•s\^V>' Sky. • ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section Number nrw* a_______ Kobm 113c, W. D., S. G. O. iro 3—10543 (ft^vised June 13, 1936) B / ANOMALIES v e / v. 6 CURIOSITIES OF MEDICINE AN ENCYCLOPEDIC COLLECTION OF RARE AND EXTRAORDINARY CASES, AND OF THE MOST STRIKING INSTANCES OF AliXOKMALITY IX ALL BRANCHES OF MEDICINE AND SURGERY, DERIVED FROM AN EXHAUSTIVE RESEARCH OF MEDICAL LITERATURE FROM ITS ORIGIN TO THE PRESENT DAY, ABSTRACTED, CLASSIFIED, ANNOTATED, AND IXDEXED BY GEORGE M. GOULD, A.M., M.D. AND WALTER L. PYLE, A.M., M.D. WITH 295 ILLUSTRATIONS IN THE TEXT, AND 12 HALF-TONE AND COLORED PLATES PHILADELPHIA W. B. SAUNDERS 1897 LIBRARY Ji:ii ■ i. m) ! i VJZ Copyright, 1896, by W. B. SAUNDERS All rights of translation reserved PRESS of W. B. SAWDERS. PHILADA. PREFATORY AND INTRODUCTORY. Since the time when man's mind first busied itself with subjects beyond his own self-preservation and the satisfaction of his bodily appetites, the anoma- lous and curious have been of exceptional and persistent fascination to him ; and especially is this true of the construction and functions of the human body. Possibly, indeed, it was the anomalous that was largely instrumental in arous- ing in the savage the attention, thought, and investigation that were finally to develop into the body of organized truth which we now call Science. As by the aid of collected experience and careful inference we to-day endeavor to pass our vision into the dim twilight whence has emerged our civilization, we find abundant hint and even evidence of this truth. To the highest type of philosophic minds it is the usual and the ordinary that demand investigation and explanation. But even to such, no less than to the most naive-minded, the strange and exceptional is of absorbing interest, and it is often through the extraordinary that the philosopher gets the most searching glimpses into the heart of the mystery of the ordinary. Truly it has been said, facts are stranger than fiction. In monstrosities and dermoid cysts, for example, we seem to catch forbidden sight of the secret work-room of Nature, and drag out into the light the evidences of her clumsiness, and proofs of her lapses of skill,—evidences and proofs, moreover, that tell us much of the methods and means used by the vital artisan of Life,—the loom, and even the silent weaver at work upon the mysterious garment of corporeality. " La premiere chose qui s'offre d PHomme quand il se regarde, c'est son corps," says Pascal, and looking at the matter more closely we find that it was the strange and mysterious things of his body that occupied man's earliest as well as much of his later attention. In the beginning/the organs and functions of generation, the mysteries of sex, not the routine of digestion or of locomotion, stimulated his curiosity, and in them he recognized, as it were, an unseen hand reaching down into the world of matter and the workings of bodily organiza- tion, and reining them to impersonal service and far-off ends. All ethnolo- gists and students of primitive religion well know the role that has been played in primitive society by the genetic instincts. Among the older naturalists, such as Pliny and Aristotle, and even in the older historians, whose scope included natural as well as civil and political history, the atypic and bizarre, and especially the aberrations of form or function of the generative organs, 1 2 PREFATORY AND INTRODUCTORY. caught the eye most quickly. Judging from the records of early writers, when Medicine began to struggle toward self-consciousness, it was again the same order of facts that was singled out by the attention. The very names applied by the early anatomists to many structures so widely separated from the organs of generation as were those of the brain, give testimony of the state of mind that led to and dominated the practice of dissection. In the literature of the past centuries the predominance of the interest in the curious is exemplified in the almost ludicrously monotonous iteration of titles, in which the conspicuous words are curiosa, rara, monstruosa, memor- abilia, prodigiosa, seleeta, exotica, miraculi, lusibus natune, oeeultis natune, etc., etc. Even when medical science became more strict, it was largely the curious and rare that were thought worthy of chronicling, and not the estab- lishment or illustration of the common, or of general principles. "With all his sovereign sound sense, Ambrose Pare has loaded his book with references to impossibly strange, and even mythologic cases. In our day the taste seems to be insatiable, and hardly any medical jour- nal is without its rare or "unique" case, or one noteworthy chiefly by reason of its anomalous features. A curious case is invariably reported, and the inser- tion of such a report is generally productive of correspondence and discus- sion with the object of finding a parallel for it. In view of all this it seems itself a curious fact that there has never been anv svstematic gathering of medical curiosities. It would have been most natural that numerous encyclopedias should spring into existence in response to such a persistently dominant interest. The forelying volume appears to be the first thorough attempt to classify and epitomize the literature of this nature. It has been our purpose to briefly summarize and to arrange in order the records of the most curious, bizarre, and abnormal cases that are found in medical literature of all ages and all languages—a thaumatographia medim. It will be readily seen that such a collection must have a function far beyond the satisfaction of mere curiosity, even if that be stigmatized with the word " idle." If, as we believe, reference may here be found to all such cases in the literature of Medicine (including Anatomy, Physiology, Surgery, Obstet- rics, etc.) as show the most extreme and exceptional departures from the ordinary, it follows that the future clinician and investigator must have use for a handbook that decides whether his own strange case has already been paralleled or excelled. He will thus be aided in determining the truth of his statements and the accuracy of his diagnoses. Moreover, to know ex- tremes gives directly some knowledge of means, and by implication and inference it frequently does more. Remarkable injuries illustrate to what extent tissues and organs may be damaged without resultant death, and thus the surgeon is encouraged to proceed to his operation with greater confidence and more definite knowledge as to the issue. If a mad cow may blindly play the part of a successful obstetrician with her horns, certainly a skilled PREFATORY AND INTRODUCTORY. 3 surgeon may hazard entering the womb with his knife. If large portions of an organ,—the lung, a kidney, parts of the liver, or the brain itself,—may be lost by accident, and the patient still live, the physician is taught the lesson of nil desperandum, and that if possible to arrest disease of these organs before their total destruction, the prognosis and treatment thereby acquire new and more hopeful phases. Directly or indirectly many similar examples have also clear medicolegal bearings or suggestions ; in fact, it must be acknowledged that much of the im- portance of medical jurisprudence lies in a thorough comprehension of the anomalous and rare cases in Medicine. Expert medical testimony has its chief value in showing the possibilities of the occurrence of alleged extreme cases, and extraordinary deviations from the natural. Every expert witness should be able to maintain his argument by a full citation of parallels to any remarkable theory or hypothesis advanced by his clients; and it is only by an exhaustive knowledge of extremes and anomalies that an authority on medical jurisprudence can hope to substantiate his testimony beyond question. In every poisoning case he is closely questioned as to the largest dose of the drug in question that has been taken with impunity, and the smallest dose that has killed, and he is expected to have the cases of reported idiosyncrasies and tolerance at his immediate command. A widow with a child of ten months' gestation may be saved the loss of reputation by mention of the authentic cases in which pregnancy has exceeded nine months' duration ; the proof of the viability of a seven months' child may alter the disposition of an estate; the proof of death by a blow on the epigastrium without external marks of violence may convict a murderer; and so it is with many other cases of a medicolegal nature. It is noteworthy that in old-time medical literature—sadly and unjustly neglected in our rage for the new—should so often be found parallels of our most wonderful and peculiar modern cases. We wish, also, to enter a mild protest against the modern egotism that would set aside with a sneer as myth and fancy the testimonies and reports of philosophers and physicians, only because they lived hundreds of years ago. "We are keenly appreciative of the power exercised by the myth-making faculty in the past, but as ap- plied to early physicians, we suggest that the suspicion may easily be too active. AVhen Par6, for example, pictures a monster, we may distrust his art, his artist, or his engraver, and make all due allowance for his primitive knowledge of teratology, coupled with the exaggerations and inventions of the wonder-lover; but when he describes in his own writing what he or his confreres have seen on the battle-field or in the dissecting room, we think, within moder- ate limits, we owe him credence. For the rest, we doubt not that the modern reporter is, to be mild, quite as much of a myth-maker as his elder brother, especially if we find modern instances that are essentially like the older cases reported in reputable journals or books, and by men presumably honest. In 4 PREFATORY AND INTRODUCTORY. our collection we have endeavored, so far as possible, to cite similar cases from the older and from the more recent literature. This connection suggests the question of credibility in general. It need hardly be said that the lay-journalist and newspaper reporter have usually been ignored by us, simply because experience and investigation have many times proved that a scientific fact, by presentation in most lav-journals, becomes in some mysterious manner, ij>s<) facto, a scientific caricature (or worse !), and if it is so with facts, what must be the effect upon reports based upon no fact whatsoever? It is manifestly impossible for us to guarantee the credibility of chronicles given. If we have been reasonably certain of unreliability, we may not even have mentioned the marvelous statement. Obviously, we could do no more with apparently credible cases, reported by reputable medi- cal men, than to cite author and source and leave the matter there, where our responsibility must end. But where our proper responsibilitv seemed likely never to end was in carrying out the enormous labor requisite for a reasonable certainty that we had omitted no searching that might lead to undiscovered facts, ancient or modern. Choice in selection is always, of course, an affair 8—Radica-Doddica, 171—Operations on conjoined twins, 172—Cranio- pagi, 17:5—Pygopagi, 174—Biddenden maids, 174—Helen and Judith, 177— Millie-Christine, 179—Rosa-Josepha Blazek, 179—Tynberg's case, IK)—Ischi- opagi, 181—Louis and Louise, 181—Marie-Louise and Hortense-Honorine, 182 —Minna and Minnie Finley, 183—Jones twins, 183—Scottish brothers, 184— Ritta-Christina, 184—Tocci brothers, 186—Marie-Rosa Drouin, 186—Bicephalic monsters, 187—Edward Mordake, 188—Fantastic monsters, 189—Parasitic terata, 189—Lazarus-Joannes Baptista Colloredo, 191—Louise L----, 192— "Laloo," 192—UA-Ke," 193—Duplication of the lower body, 193—Blanche Dumas, 194—Mrs. B----, 194—Diphallic terata, 194—Jean Baptista dos Santos, 196—Fetus in fetu, 199—Dermoid cysts, 202—Multiple dermoids, 205—Herma- phroditism, 206—Interesting instances of, 206—Catherine or Charles Hoffman, 207—Marie Madeline Lefort, 207—Spurious hermaphroditism, 211—Law of evolution in hermaphroditism, 211—Neuter hermaphrodites, 212—Marie Doro- thee, 212—Legal aspect of hermaphroditism, 212. PAOKS 113-143 TABLE OF CONTENTS. 9 CHAPTER VI MINOR TERATA ............... Ancient ideas relative to minor terata, 213—Teratoscopy, 213—Congenital defect of the epidermis, 217—Elasticity of the skin, 217—" Elastic-Skin Man," 217—Dermatolysis, 217—Abnormal development of the scalp, 218—Impervious skin, 219—Albinism, 220—Partial albinism, 221—Melanism, 222—Human horns, 222—Anomalies of the hair, 226—Congenital alopecia, 226—Sexualism and hair- growth, 228—Bearded women, 228—Hypertrichosis, 230—"Dog-face men,"231 —Naevus pilosus, 232—Hair and beard of great length, 234—Accidental growths of hair, 235—Anomalies of the color of the hair, 235—Sudden canities, 235— Temporary and partial canities, 238—Anomalous color-changes of the hair, 239 —Chemic colorations of the hair, 240—Curious causes of alopecia, 241—Anoma- lies of the nails, 241—Anomalies of dentition, 242—Triple dentition, 243—Eden- tulousness, 243—Excessive dentition, 244—Supernumerary teeth, 244—Extraoral dentition, 244—Anomalies of the head, 245—Life without a cerebrum, 246— Defective development of the cerebellum, 246—Microcephaly, 247—Artificial microcephaly, 248—Macrocephaly, 248—Largest healthy brains on record, 249— Hydrocephaly, 250—Deficiency of the cranial bones, 250—Anomalies of the maxillary bones, 251—Congenital absence of the nose, 252—Large and small noses, 252—Congenital division of the nose, 252—Macrostoma, 253—Microstoma, 252—Congenital atresia of the mouth, 253—Anomalies of the lips, 254—Hare-lip, 254—Congenital absence of the tongue, 254—Bifid and supernumerary tongues, 255—Large and small tongues, 256—Anomalies of the palate and uvula, 256— Of the epiglottis, 256—Double epiglottis and double voice, 257—Anomalies of eyes, 257—Absence of the eyes, 257—Living cyclopia, 258—"Four-eyed man of Cricklade," 258—Anomalies of lids, 259—Of the iris, 259—Of the lens, 260— Heredity in the causation of congenital defects of the eye, 260—Anomalies of the ears, 261—Absence of the limbs, 263—Supernumerary limbs, 269—Anomalies of the feet, 270—Of the hand, 270—Absence of the digits, 271—Supernumerary digits, 273—Hypertrophy of the digits, 276—Talipes, 276—Anomalies of the vertebrae, 277—Human tails, 277—Vestigial remains, 279—Anomalies of the spinal canal and contents, 280—Supernumerary ribs, 281—Fissure of the ster- num, 282—Other thoracic defects, 284—Branchial fissures, 284—Anomalies of the esophagus, 284—Anomalies of the lungs, 285—Of the diaphragm, 285—Of the stomach, 286—Of the intestines, 287—Dilatation of the colon, 287—" Bal- loon-man," 287—Imperforate anus, 288—Anomalies of the liver, 290—Of the spleen, 290—Transposition of the viscera, 291—Congenital extroversion or even- tration, 292—Anomalies of kidney, 293—Of the ureters, 294—Of the bladder, 295 —Exstrophy of the bladder, 295—Anomalies of the heart and vascular system, 296—Of the breast, 297—Amazia, 297—Micromazia, 298—Polymazia, 298— Anomalies of the hymen, 302—Of the female external genitals, 303—Absence of the vagina, 303—Duplex vagina, 304—Transverse septa of the vagina, 305— Anomalous openings of the vagina, 305—Anomalies of the labia, 306—Absence of the nymphae, 306—Enlarged nymphae, 306—Hottentot women, 307—Ceremo- nial enlargement of the nymphae, 307—Anomalies of the clitoris, 307—Circum- cision of the clitoris in Egypt, 308—Absence of the ovaries, 309—Prolapse of the ovaries, 310—Supernumerary ovaries, 310—Anomalies of the Fallopian tubes, 311—Of the uterus, 311—Absence of the uterus, 311—Double uterus, 311—Preg- nancy with double uterus, 311—Triple uterus, 313—Hernia of the uterus, 313— Absence of the penis, 314—Rudimentary development of the penis, 315—Penis palme, 316—Torsion of the penis, 316—Ossification of the penis, 316—Absence of the frenum and prepuce, 317—Anomalies of the urethra, 317—Duplication of the urethra, 317—Hypospadias and epispadias, 318—Artificial penis, 318—An- PAGES 213-323 10 TABLE OF CONTENTS. PAGES orchism, 319—Monorchism, 319—Polyorchism, 320—Cryptorchisin. 321—Anom- alous position of the testicles. 322—Inversion of the testicle, 323—Anomalies of the seminal vesicles, 323. CHAPTER VII. ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT.........324-364 Giants, 324 — Ancient giants. 324—Discoveries of giants' bones, 325—Gen- eral opinions, 326—Association of acromegaly with gigantism, 327—Celebrated giants, 32.-!—Giants of history, 333—Dwarfs, 333—Pygmies, 333—Artificial pro- duction of dwarfs, 335—Ancient popularity of dwarfs, 336—Intellectual dwarfs, 337—Women predisposed to give birth to dwarfs, 337—Species of dwarfs, 338— Celebrated dwarfs, 338—Geoffrey Hudson, 338—Gibson, 33H— Bebe, 339—Borwi- laski, 339—Great age in dwarfs, 339—Robert Skinner, 340—" Tom Thumb," 342 —Lucia Zarete, 343—Precocious development, 343—"Man-boys," 343—Small new-born infants, 347—Large new-born infants, 348—Congenital asymmetry and hemihypertrophy, 350—Obesity, 352—Fat children, 352—General remarks on obesity, 354—Treatment of obesity, 356—Remarkable instances of obesity, 356—Simulation of obesity, 360—" Adiposis dolorosa,'' 360—Abnormal leanness, 363—"Living skeletons," 364—Extreme muscular atrophy, 364. CHAPTER VIII. LONGEVITY................................365-382 Stope of the article, 365—General opinions, 365—Testimony of statistics, 365 —Natural term of life, 3(56—Censuses of centenarians, 366—Effect of class-influ- ences, occupation, etc.. 367—Longevity in ancient times, 368—Difference in chronology, 368—Alchemy and the "elixir of life," 368—Longevity in Jewish history, 369—In Egypt, 370—Among the ancient Chinese, 370—Among the Greeks, 370—Among the Romans, 370—Among hermits and ecclesiastics, 370— Among the Brahmin priests of India, 371—Influence of mental culture, 371— Compatibility of mental and physical activity with longevity, 371—Longevity among the Royalty, 372—Influence of personal habits, 372—Remarkable in- stances of longevity, 373—Henry Jenkins, 373—Thomas Parr, 373—Jean Korin, 373—Setrasch Czarten, 373—Sundry instances of great age, 374—Generative ability in old age, 376—Influence of stimulants, 377—Rejuvenescence of the senses in age, 378—Heredity in longevity, 379—Longevity among physicians, 381 —Recent instances of longevity, 382. CHAPTER IX. PHYSIOLOGIC AND FUNCTIONAL ANOMALIES .............383-526 Anomalies of the secretions, 383—Colored saliva, 383—Abnormalities of uri- nation, 383—Metastasis of tears, 384—Anomalies of the semen, 384—Blue bile, 385—Cliromidrosis, 385—Hyperidrosis, 386—Unilateral and localized sweating, 387—Bloody sweat or "stigmata," 388—Louise Lateau, 389—Postmortem sweating, 391—Anomalies of lactation, 391—Milk-metastasis, 391—Lactation in the new-born, 392—In children, 392—In the aged, 393—Prolonged lactation and galactorrhea, 394—Gynecomazia, 394—Men suckling infants, 397—Human odors, 397—Individual odors, 398—Modifying causes, 39s—Odors of races, 399—Odor of the breath after coitus, 399—Influence of the emotions, 399—Odors associated with mental and nervous diseases, 401—The odor of insanity, 400—Odors of some diseases, 401—Odor of the hair, 401—Sexual influence of odors, 401—Fetichism, 401—Sexual influence of the olfactory sense in animals. 402—Bulimia, 403— TABLE OF CONTENTS. 11 Polydipsia, 404—Polydipsia among glass-blowers, 405—Hydroadipsia, 405— Perverted appetites, 405—Anthropophagy, 406—Cannibals, 407—Ancient cus- toms, 409—Depraved appetite for human flesh in civilization, 409—Further ex- amples of depraved appetites, 411—Pica, 412—Chalk-eating, 412—Arsenic eating, 413—Fasting, 413—Older instances, 414—"Fasting girls," 418—Modern in- stances of fasting, 419—Fasting exhibitionists, 420—Anomalies of temperature, 421--H.vperthermy reaching 148° F., 423—Endurance of external heat, 424— "Human Salamanders," 424—Fire-worship, 425—Spontaneous combustion of the human body, 426—Magnetic, phosphorescent, and electric anomalies, 429— Effects of cold, 431—Effects of working in compressed air, 433—Remarkable development of the remaining senses when one or more are lost, 432—Examples of compensatory sense-development, 433—Laura Dewey Bridgman, 43—Helen Kellar, 435—Edith Thomas, 437—Remarkable blind savants, 439—Feats of memory, 439—Boy calculators, etc., 439—Jacques Inaudi, 439—Oscar Moore, 439 —Wolf-children, 444—Artificial manufacture of " wild boys," 448—Equilibrists, 449—Rope-walkers, 449—Blondin, 450—Human pyramids, 450—Jugglers, 451 —Marksmen, 452—Ventriloquists, 453—Athletic feats, 455—Public contests of Greece, 455—Runners, 455—Couriers, 456—Indian runners, 457—Jinrickisha- men, 457—Letter-carriers of India, 458—"Go-as-you-please" pedestrians, 458 —Modern records for running, 459—Long-distance traversing, 459—Riders, 460 —Influence of the spleen in running, 461—Swimming, 461—Jumpers and acro- batic tumblers, 462—Extraordinary physical development and strength, 463— Modern Hercules, 464—Strong women, 468—Strength of the jaws, 468—Strength in the hands, 470—Fraudulent "strong men," 470—Officially recorded feats of strength, 470—Contortionists, 473—Dislocationists, 473—Endurance of pain, 475 —Aissaoui, 476—Malingerers, 478—Hyperseusitiveness to pain, 480—Relation of pain to shock, 480—Morbid desire lor pain, 480—Pain as a means of sexual enjoyment, 480—Masochism, 480—Flagellation, 480—Fatal flogging, 481—Idio- syncrasies, 481—Idiosyncrasies in relation to the sense of smell, 482—Of the sense of hearing, 484—To music, 485—Therapeutic value of music, 485—Idiosyn- crasies as to vision, 487—Of the sense of touch, 488—Idiosyncrasies to foods, 489 —Eggs, 490—Parsley, 491—Rice, 491—Figs, 491—Wheat-flour, 492 -Food su- perstitions, 493—"Totemism," 494—Idiosyncrasies to drugs, 496—Acids, 497— Antimony, 499—Arsenic, 500—Belladonna, 500—Digitalis, 502—Ergot. 502— Epsom salts, 503—Iodin, 503—Iodoform, 503—Lead-poisoning, 503—Mercury, 504—Croton oil, 504—Castor oil, 504—Opium and its derivatives, 505—Chronic opium-eating, 506—Phosphorous, 508—Pilocarpin, 508—Quinin, 509—Strych- nin, 510—Idiosyncrasies in coitus, 511—Death in coitus, 513—Suspended anima- tion, 513—Prolonged submersion, 513—Divers, 514—Suspension of the cardiac movements at will, 516—Hibernation, 517—Human hibernation, 517—Fakirs of India, 517—Recovery after asphyxia from hanging and strangling, 519—Prema- ture burial, 519—Postmortem anomalies, 522—Movements of a corpse, 522— Postmortem priapism, 523—Retardation of putrefaction, 523—Postmortem growth of hair and nails, 523—Untoward effects of the emotions on the vital functions, 523—Death from joy and laughter, 524—Death from grief and sorrow, 524—Death from fear, 525—Death from shock alone following blows that cause no visible injury, 525—Death from the " wind of the cannon-ball," 526. CHAPTER X. SURGICAL ANOMALIES OF THE HEAD AND NECK...........527-587 Injuries to the eye, 527—Exophthalmos, 527—Avulsion of the eye, 527— Rupture of the eyeball, 528—Serious sequels of orbital injuries, 528—Gunshot injuries of the orbit, 529—Foreign bodies in the orbit, 531—Foreign bodies in the eyeball, 532—Dislocation of the lens, 533—Injury to the eyeball by birds, 12 TABLE OF CONTEXTS PAGES 533—Kan- accident to the eye, 533—Epistaxis through the eyes. 534—Late res- toration of sight, 535—Sight spontaneously restored, 536—Nyctalopia, 536 Hemeralopia, 536—Snow-blindness, 537—Retinal injury from exposure to intense light, 537—Electric-light injuries of the eye, 537—Injuries to the ear, .>37 Boxing the ears, 537 —Rupture of the tympanum, 537—Perforation of the tym- panum, 538—Objective tinnitus aurium, 538—Insects in the ear, 539—Other foreign bodies in the ear, 539—Scalp-injuries, 542—Cerebral injuries, 545—Pene- tration and transfixion of the brain, 545—Gunshot injuries of the brain, 549— Study of gunshot injuries of the brain, 551—Head-injuries with loss of cerebral substance, 551—"American Crow-bar Case," 551—Loss of brain-substance from cerebral tumor, 557—Extensive fractures of the cranium, 558 — Diving into shallow water, 559—Fracture of the internal table of the cranium, 559—Fracture of the cranial base, 559—Foreign bodies in the brain, 559—Injuries of the nose, 561—Nose-making, 561—Deformities of the nose, 563—Insects in the nose, 563 —Foreign bodies in the nose. 564—Tongue-swallowing, 565—Tongue-sucking, 565—Injuries to the tongue, 565—Regeneration of a severed tongue, 565—Artic- ulation without a tongue. 566—Hypertrophy of the tongue, 566—Macroglossia, 567—Living fish in the pharynx, 567—Leech in the pharynx, 569—Foreign bodies in the pharynx and esophagus, 570—Migration of foreign bodies from the esophagus, 571—Abscess or ulceration into neighboring blood-vessels, consequent upou lodgment of foreign bodies in the esophagus, 571—Esophagotomy, 574— Injuries of the neck, 574—Ligature of the common carotid artery, 575—Nonfatal perforating wounds of the trachea and esophagus, 575—Self-decapitation, 576— Cases of nonfatal cut-throat, 577—Injuries of the cervical vertebne, 578—Foreign bodies in the larynx and trachea, 580—Impaction of artificial teeth in the larynx, 582—Excision of the larynx, 584—Injuries destroying great portions of the face or jaw, but not causing death, 5H5—A curious accident, 587. CHAPTER XI. SURGICAL ANOMALIES OF THE EXTREMITIES.............588-605 Reunion of severed digits, 588—Reproduction and accidental production of nails, 588—Avulsion of a finger with the entire tendon, 589—Avulsion of the arm, 590—Avulsion of the leg, 592—Injuries to the sciatic nerve, 592—Recovery of an injured member after extensive severance and loss of substance, 593—Rup- ture of the quadriceps tendon, 594—Spontaneous fractures, 594—Evolution of the treatment of dislocations, 594—Anomalous dislocations, 594—Congenital dislocations, 595—Major amputations, 596—Multiple amputations, 596—Sponta- neous amputation, 597—Artificial limbs, 598—Dismembered athletes, 598— Foreign bodies in the extremities, 599—Osteomalacia, 600—Rachitis, 601— Achondroplasia, 602—Osteitis deformans, 603—Deformities of the articulations, 603—"Camel-boy," 603—Deformities from infantile spinal paralysis, 604— Anomalous growth of bones of the extremities, 605. CHAPTER XII. SURGICAL ANOMALIES OF THE THORAX AND ABDOMEN....... 606-666 Injuries of the lung and bronchus, 606—Loss of lung-tissue, 607—Surgery of the lung, 608—Excision of diseased portions of the lung, 608—Rupture of the lung without fracture of the rib, 608—Spontaneous rupture of the lung, 609— Penetration and transfixion of the thoracic cavity, 610—Recovery after major thoracic wounds, 611—Wounds of the diaphragm, 612—Diaphragmatic hernia, 612—Peritonitis in the thoracic cavity, 613—Foreign bodies in the thoracic cavity, 613—Foreign bodies in the bronchi, 614—Cardiac injuries, 616—Instances TABLE OF CONTENTS. 13 of survival after cardiac injuries, 617—Nonfatal cardiac injuries, 620—Foreign bodies in the heart, 624—Injuries to the pericardium, 624—Rupture of the heart, 625—Displacement of the heart, 626—Hypertrophy of the heart, 626—Wounds of the aorta, 626—Sundry cases of vascular injuries, 627—Rupture of the esoph- agus, 628—Rupture of the stomach, 629—Voluntary vomiting, 630—Wounds of the stomach, 630—Alexis St. Martin, 630—Gastric fistulae, 631—Gastrotomy performed on knife-swallowers, 633—Sword-swallowing, 633—Swallowing knives, pebbles, glass, etc., 635—Living animals in the alimentary canal, 636— Other foreign bodies in the alimentary canal, 637—Hair-swallowing, 641— Foreign bodies in the intestines, 641—Foreign bodies in the vermiform appendix, 642—Intestinal injuries, 642—Successful intestinal resection, 643—Sloughing of the intestines following intussusception, 643—Rupture of the intestines, 644— Operations upon the gastro-intestinal tract, 644—Gastrostomy, 644—Pyloro- plasty, 644—Pylorectomy, 644—Gastrectomy, 644—Enterostomy, 645—Colos- tomy, 645—Intestinal anastomosis, 645—Foreign bodies in the rectum, 645— Transfixion of the abdomen, 648—Evisceration, 650—Nonfatal perforating gun- shot wounds of the abdomen, 651—Bullets voided from the bowel and bladder, 651—Wounds of the liver, 652—Surgery of the liver, 652—Resection of the liver, 654—Floating liver, 655—Hypertrophy of the liver, 655—Rupture of the gall- bladder, 655—Cholecystotomy and cholecystectomy, 655—Rupture of the spleen, 656—Wounds of the spleen, 656—Splenectomy, 656—Hypertrophy of the spleen, 657—Inj uries of the thoracic duct, 657—Ligation of the abdominal aorta, 658— Ligation of the common iliac artery, 658—Foreign bodies loose in the abdominal cavity, 658—Foreign bodies in the skin and muscles of the back, 659—Fracture of the lower spine, 659—Laminectomy, 660—Injuries to the spinal cord, 661— Hernia, 662—Spontaneous rupture of the abdominal walls, 666. CHAPTER XIII. SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM ......667-696 Wounds of the kidney, 667—Operations on the kidney, 668—Rupture of the ureter, 668—Operations on the ureter, 669—Stricture of the ureter, 669—Rupture of the bladder, 670—Gunshot wounds of the bladder, 671—Penetration of the bladder through the anus, vagina, or buttocks, 671—Arrow-wound of the bladder through the buttocks, 672—Wounds of the bladder followed by calculi, 673— Fistulae of the bladder, 675—Worms in the bladder, 676—Foreign bodies in the bladder, 676—Hair in the bladder, 678—Foreign bodies in the pelvis, 678—Rup- ture of the urethra, 679—Fracture of the penis, 679—Urethral stricture, 680— Sundry injuries to the penis, 680—Amputation of the penis, 680—Gunshot wounds of the penis, 681—Luxation of the penis, 681—Spontaneous retraction of the penis, 681—Spontaneous gangrene of the penis, 682—Prolonged priapism, 683—Theories of priapism, 684—Injuries of the testicles and scrotum, 685— Avulsion of the male external genitalia, 686—Preservation of sexual power after injuries of the genitals, 687—Atrophy of the testicles, 687—Retraction of the testicles, 688—Ectopia of the testicles, 688—Rupture of the spermatic vessels, 689 —Hydrocele, 689—Separation of an ovary, 689—Injuries of the vagina, 689— Rupture of the clitoris, 691—Discharge of the vaginal parietes, 691—Injuries during coitus, 691—Foreign bodies in the vagina, 692—Long retention of pessa- ries, etc., 693—Leech in the vagina, 694—Foreign bodies in the uterus, 695. CHAPTER XIV. MISCELLANEOUS SURGICAL ANOMALIES...............697-758 Marvelous recoveries from multiple injuries, 697—Recoveries after injuries by machinery, with multiple fractures, etc., 699—Miscellaneous multiple frac- 14 TABLE OF CONTENTS. PAGES tures, 701—Recoveries from high falls. 703 -High dives, 701 — Resistance of children to injuries. 705—Instances of infant-vitality, 700—Operations on the extreme young and old, 706—Repeated operations, 707—Billroth's marvelous operation, 708—Self-performed surgical operations, 70>—Instances of extensive loss of blood, with recovery, 709—Extensive venesection, 709-—Spontaneous hemorrhages, 709—Arrow-wounds, 710—Arrow-poison, 711—Multiple arrow- wounds, 711—Serious insect-stings, 713—Syphilis from a flea-bite, 714—Snake- bites, 715—Hydrophobia, 719—Shark-bites, 721—Leprosy from a fish-bite, 721 Alligator-bites, 722—Animal-bites, 722—Injuries from lightning-stroke, 722 — Recovery from lightning-stroke, 723—Therapeutic effect of lightning stroke, 726 Grafting, 728—Tooth-replantation, 72<—Muscle-transplantation, 729—Tendon- transplantation, 729—Nerve-grafting, 729—Bone-grafting,729—Skin-grafting,729 —Self-mutilations, 731—Sell-castration, 732—Miscellaneous mutilations, 735— "Needle-girls," etc.,73.5—Wanderings of pins and needles in the body, 736—Prick of a pin causing death, 737—Manufacture of crippled beggars, 737—Chinese foot- binding, 737—Professional leg-breaker, 741—Anomalous suicides, 742—Religious and ceremonial mutilations, 743—Self-bleeding, 745—Exhibition of scars, 745— Cosmetic mutilations, 746—Manufacture of dimples, 716—Amputation of the fingers, 746—Knocking out the front teeth, 747—Depilatory customs, 747—Bor- ing the ear, 749—Tattooing, 749—Infection from tattooing, 751—Infibulation, 752—Chastity-girdles, 753—Infibulation to prevent masturbation, 754 -Slitting the urethra, 754 — Mutilations of the genital organs to prevent conception, 754— Circumcision, 754—Ceremonial ovariotomy, 755—Castration, 755—Eunuch- makers, 756—Castration because of excessive cupidity, 756—Castration as a re- ligious rite, 756 —The Skoptzies, 757. CHAPTER XV. ANOMALOUS TYPES AND INSTANCES OF DISEASE...........759-822 Tumors, 759—Adenoma of the breast, 759—Diffuse hypertrophy of the breast, 759 —Goiter, 761—Extirpation of the thyroid gland, 762—Fibromata, 762—Multiple fibromata of the skin, 762—Keloids, 764—Lipomata, 764—Chon- dromata, 766—Benign bone-tumors, 768—Exostoses, 768 —Gros-nez, 769—Neu- romata, 770—Carciuomata, 772—Sarcomata, 772—Osteosarcoma, 772—Varicose veins, 778—Aneurysmal varix, 778—Aneurysm, 779—Large uterine tumors 780—Ovarian cysts, 782—Enormous dropsies, 786—Ankylosis of the articula- tions, 787—" Ossified man," 787—Petrefaction, 788—Calculi, 78s—Large vesical calculi, 788—Vesical calculi in very young children, 790—Multiple vesical cal- culi, 790—Renal calculi, 790—Other extravesical calculi, 791—Retention and suppression of urine, 792—Persistent constipation, 794—Elephantiasis arabum, 795—Elephantiasis of the lower extremities, 795—Elephantiasis of the upper extremities, 798—Elephantiasis of the face and scalp, 798—Elephantiasis of the breast, 800—Elephantiasis of the scrotum, 800—Statistics of operations on ele- phantoid scroti. 803—Acromegaly, 803—Chiromegaly, 805—Megalocephaly, 805 —Cretinism, 805—Sporadic cretinism, 806—Myxedema, 807—Cagots, 808—Per- sistent hiccough, 811—Anomalous sneezing, 813—" Ear sneezing," 815-Hemo- philia, 815—Hemophilic purpura of the retina, 816—Hemorrhagic diseases of the new-born, 816—Syphilis haemorrhagica neonatorum, 816—Winckel's disease, 816—Barlow's disease, 817—Tetanus neonatorum, 817—Human parasites, 818— Tapeworms, 818—Ascarides, 819—Trichinosis, 820—Ecchinococcus, 820—Fila- ria sanguinis hominis, 820—"Eaten of worms," 821—Bot-fly, 821—Peenash, 822. TABLE OF CONTENTS. 15 CHAPTER XVI. ANOMALOUS SKIN-DISEASES ............., ........823-851 Icthyosis, 823—" Porcupine-man," 823—"Biped Armadillo," 823—"Alli- gator-boy," 824—Harlequin fetus, 825—Contagious follicular keratosis, 825— Keratodermia, 825—"Hide-bound disease," 826—Morphea, 826—Scleroderma neonatorum, 826—" Elephant-man," 827—Ainhum, 828—Sclerodactylia annu- laris ainhumoides, 832—Skin-shedding, 832—"Snake-boy," 835—Dermatitis exfoliativa neonatorum, 835—Epidemic exfoliative dermatitis, 835—Sphacelo- derma, 836—Raynaud's disease, 836—Spontaneous gangrene of the skin. 837— Neuroses of the skin, 837—Neuroma cutis dolorosum, 839—Yaws, 839—Furun- culosis orientalis, 840—Pigmentary anomalies, 841—Chloasma uterinum, 841— Acanthosis nigricans, 841—Xeroderma pigmentosum, 842—Nigrities, 842— Anomalous discolorations of the skin, 843—Metallic discolorations of the skin, 845—Melasma, 845—Leukoderma, 845—"Leopard-boy," 845—Canities un- guium, 847—Plica polonica, 848—Tinea nodosa, 849—"Hair-eaters," 849—My- cosis fungoides, 850—Universal dermatitis, 851. CHAPTER XVII. ANOMALOUS NERVOUS AND MENTAL DISEASES............852-890 Anomalous types of epilepsy, 853—The dancing mania, 853—"Tarantism," 854—Palmus, 855—Athetosis, 857—Paramyclonus multiplex, 859—Saltatoric spasm, 859—Progressive muscular atrophy, 859—Facial hemiatroph}', 859—Lin- gual hemiatrophy, 860—Astasia-abasia, 860—Meniere's disease, 861—Mery- cism, 862—Wakefulness, 863—Somnambulism, 863—Pathognomonic dreams, 867—Catalepsy, trance, and lethargy, 867—Hypnotism, 870—African sleep sick- ness, 872—Aphasia, 872—Aphasia after snake-bites, 874—Anosmia, 874—Hyper- osmia, 875—Parosmia, 875—Perversion of the tactile sense, 875—Nostalgia, 876 —Hypochondria, 876—Fear-psychoses, 877—Aichmophobia, 877—Agoraphobia, 877—Acrophobia, 877—Thalassophobia, 877—Claustrophobia, 878—Astrophobia, 878—Mysophobia, 878—Hematophobia, 878—Anthropophobia and monophobia, 879—Bacillophobia, 879—Kleptomania and kleptophobia, 879—Folie de doute, 879—Other rare fear-psychoses, 880—Demonomania, 880—Particular aversions, 880—Circular insanity, 881—Katatonia, 882—A modern Pygmalion, 882—Double consciousness, 883—Morbid sympathy of twins as illustrated in the "Corsican brothers, 887—Automatism, 887—Presentiment of approaching death, 889. CHAPTER XVIII. HISTORIC EPIDEMICS.........................891-914 Preliminary remarks on the great plagues, 891—The black death, 892— Mortality of, 893—Moral effect of, 894—The great plague of London, 895— Modern bubonic plague in China, 896—Sweating sickness, 896—Mortality of, 897 —Chronologic table of the principal plagues, 898—Small-pox, 903—Inoculation, 905—Lady Montagu, 905—Vaccination, 906—Edward Jenner, 906—Asiatic cholera, 908—Typhus fever, 910—Yellow fever, 910—Leprosy, 911—Syphilis, 912—Tuberculosis, 913—Modern mortality from infectious diseases, 913. BIBLIOGRAPHIC INDEX INDEX ........ 915-929 931-968 ANOMALIES AND CURIOSITIES OF MEDICINE. CHAPTER I. GENETIC ANOMALIES. Menstruation has always been of interest, not only to the student of medicine, but to the lay-observer as well. In olden times there were many opinions concerning its causation, all of which, until the era of physiologic investigation, Mere of superstitious derivation. Believing menstruation to be the natural means of exit of the feminine bodily impurities, the ancients always thought a menstruating woman was to be shunned ; her very presence was deleterious to the whole animal economy, as, for instance, among the older writers we find that Pliny a remarks : " On the approach of a woman in this state, must will become sour, seeds which are touched by her become sterile, grass withers away, garden plants are parched up, and the fruit will fall from the tree beneath which she sits." He also says that the menstruating women in Cappadocia were perambulated about the fields to preserve the vegetation from worms and caterpillars. According to Flem- ming,b menstrual blood was believed to be so powerful that the mere touch of a menstruating woman would render vines and all kinds of fruit-trees sterile. Among the indigenous Australians, menstrual superstition was so intense that one of the native blacks, who discovered his wife lying on his blanket during her menstrual period, killed her, and died of terror himself in a fortnight. Hence, Australian women during this season are forbidden to touch anything that men use.c Aristotle said that the very look of a men- struating woman would take the polish out of a mirror, and the next person looking in it would be bewitched. Frommannd mentions a man who said he saw a tree in Goa which withered because a catamenial napkin was hung on it. Bourke remarks that the dread felt by the American Indians in this respect corresponds with the particulars recited by Pliny. Squaws at the time of menstrual purgation are obliged to seclude themselves, and in most instances to occupy isolated lodges, and in all tribes are forbidden to a 636, L. xxviii., cap. 23. b de Remediis, 16 and 17. c Frazer, "The Golden Bough." d " Tractatus de Fascinatione," Nuremberg, 1675. 2 17 18 GENETIC ANOMALIES. prepare food for anyone save themselves. It was believed that, were a men- struating woman to step astride a rifle, a bow, or a lance, the weapon would have no utility. Medicine men are in the habit of making a " protective clause whenever they concoct a "medicine," which is to the effect that the " medicine " will be effective provided that no woman in this condition is allowed to approach the tent of the official in charge. Kmpiricism had doubtless taught the ancient husbands the dangers of sexual intercourse during this period, and the after-results of many such con- nections were looked upon as manifestations of the contagiousness of the evil excretions issuing at this period. Hence at one time menstruation was held in much awe and abhorrence. On the other hand, in some of the eastern countries menstruation was regarded as sacred, and the first menstrual discharge Mas considered so valua- ble that premenstrual marriages Mere inaugurated in order that the first ovum might not be Masted, but fertilized, because it Mas supposed to be the purest and best for the purpose. Such customs are extant at the present day in some parts of India, despite the efforts of the British Government to sup- press them, and descriptions of child-marriages and their evil results have often been given by missionaries. As the advances of physiology enlightened the mind as to the true nature of the menstrual period, and the age of superstition gradually disappeared, the intense interest in menstruation vanished, and noMr, rather than being held in fear and a^e, the physicians of to-day constantly see the results of copulation during this period. The uncontrollable desire of the husband and the mercenary aims of the prostitute furnish examples of modern disregard. The anomalies of menstruation must naturally have attracted much attention, and Mre find medical literature of all times replete with examples. While some are simply examples of vicarious or compensatory menstrua- tion, and Mere so explained even by the older writers, there are many that are physiologic curiosities of considerable interest. Lheritier 485 furnishes the oft-quoted history of the case of a young girl mIio suffered from suppression of menses, which, instead of flowing through the natural channels, issued periodically from vesicles on the leg for a period of six months, M'hen the seat of the discharge changed to an eruption on the left arm, and con- tinued in this location for one year ; then the discharge shifted to a sore on the thumb, and at the end of another six months again changed, the next location being on the upper eyelid ; here it continued for a period of two years. Brierre de Boismont and Meisner describe a case apparentlv identical with the foregoing, though not quoting the source. Haller, 40° in a collection of physiologic curiosities covering a period of a century and a half, cites is instances of menstruation from the skin. Parrot has also mentioned several cases of this nature. Chambers a speaks a 476, 1861, i., 207. MENSTRUATION FROM THE SKIN. 19 of bloody sweat occurring periodically in a woman of twentv-seven ; the intervals, however, were occasionally but a week or a fortnight, and the exu- dation was not confined to any one locality. Van Swieten755 quotes the history of a case of suppression of the menstrual function in which there were convulsive contractions of the body, followed by paralvsis of the right arm. Later on, the patient received a blow on the left eve causing amaurosis; swelling of this organ followed, and one month later blood issued from it, and subsequently blood oozed from the skin of the nose, and ran in jets from the skin of the fingers and from the nails. D'Andradea cites an account of a healthy Parsee lady, eighteen years of age, MTho menstruated regularly from thirteen to fifteen and a half years ; the catamenia then became irregular and she suffered occasional hemorrhages from the gums and nose, together with attacks of hematemesis. The men- struation returned, but she never became pregnant, and, later, blood issued from the healthy skin of the left breast and right forearm, recurring every month or two, and finally additional dermal hemorrhage developed on the fore- head. Microscopic examination of the exuded blood showed usual constituents present. There are two somewhat similar cases spoken of in French literature^ The first M^as that of a young lady, who, after ten years' suppression of the menstrual discharge, exhibited the flow from a vesicular eruption on the finger. The other case was quite peculiar, the woman being a prostitute, who menstruated from time to time through spots, the size of a five-franc piece, developing on the breasts, buttocks, back, axilla, and epigastrium. Barham c records a case similar to the foregoing, in which the menstru- ation assumed the character of periodic purpura. Duchesne d mentions an instance of complete amenorrhea, in Mrhich the ordinary flow Mas replaced by periodic sweats. Parrot speaks of a woman Mrho, Mrhen seven months old, suffered from strumous ulcers, which left cicatrices on the right hand, from Avhence, at the age of six years, issued a sanguineous discharge with associate convulsions. One day, while in violent grief, she shed bloody tears. She menstruated at the age of eleven, and was temporarily improved in her condition; but after any strong emotion the hemorrhages returned. The subsidence of the bleed- ing followed her first pregnancy, but subsequently on one occasion, MThen the menses Mere a few days in arrears, she exhibited a blood-like exudation from the forehead, eyelids, and scalp. As in the case under D'Andrade's obser- vation, the exudation M'as found by microscopic examination to consist of the true constituents of blood. An additional element of complication in this case M'as the occurrence of occasional attacks of hematemesis. Menstruation from the Breasts.—Being in close sympathy M-ith the generative function, we Mrould naturally expect to find the female mamma? a 772, 1862. b 162, 1829, 212, 236. C656, 1847. d Monit. d' hop., 1856, iv., 661. 20 GENETIC ANOMALIES. involved in cases of anomalous menstruation, and the truth of this supposi- tion is substantiated in the abundance of such cases on record. Sehcnck a reports instances of menstruation from the nipple; and Hichter, de 1< onte- chia, Laurentius,b Marcellus I)onatus,c Amatus Lusitanus,d and Bierling are some of the older M'riters who have observed this anomaly. Pare e says the wife of Pierre de Feure, an iron merchant, living at Chasteaudun, menstruated such quantities from the breasts each month that several ser- viettes were necessary to receive the discharge. Cazenave f details the his- tory of a case in M'hich the mammary menstruation Mas associated M'ith a similar exudation from the face, and Wolff*-' saM' an example associated M'ith hemorrhage from the fauces. In the Lancet (1S40-1841) is an instance of monthly discharge from beneath the left mamma. Finlev'1 also M'rites of an example of mammary hemorrhage simulating menstruation. Barnes saw a case in St. George's Hospital, London, 18783. f 462, T. x., 23. B Obs. med.-chir., L. i., n. 20. b 256, 1825. i 476. 1882. i., 786. J 476, 1840-41, i., 493. k 454. 1828. xxxi., 83-85. 1 Gaz. med. de Nantes, 1883-4, ii. 39. m 789. 1872, xiv., 845. n Southern Jour, of Med. and Pharm., Charleston, March 184~ Plate i. ■^*fc®** Menstruation from the breast (Baker). MENSTRUATION FROM THE BREASTS. 23 matter were made to exude. This discharge, however, was not offensive to the smell. On March 17, 1846, the breast became much enlarged and con- gested, as portrayed in Plate 1 (Fig. 1). The ulcer was much inflamed and painful, the veins corded and deep colored, and there was a free discharge of sanguineous yellowish matter. When the girl's general health improved and menstruation became more natural, the vicarious discharge diminished in proportion, and the ulcer healed shortly afterward. Every month this breast had enlarged, the ulcer became inflamed and discharged vicariously, continuing in this manner for a few days, M'ith all the accompanying mens- trual symptoms, and then dried up gradually. It Mas stated that the ulcer M'as the result of the girl's stooping over some bushes to take an egg from a hen's nest, when the point of a palmetto stuck in her breast and broke off. The ulcer subsequently formed, and ultimately discharged a piece of pal- metto. This happened just at the time of the beginning of the menstrual epoch. The accompanying figures, Plate 1 (Figs. 1, 2), show the breast in the ordinary state and at the time of the anomalous discharge. Hancocka relates an instance of menstruation from the left breast in a large, otherwise healthy, Englishwoman of thirty-one, mIio one and a half years after the birth of the youngest child (now ten years old) commenced to have a discharge of fluid from the left breast three days before the time of the regular period. As the fluid escaped from the nipple it became changed in character, passing from a M'hitish to a bloody and to a yelloM- ish color respectively, and suddenly terminating at the beginning of the real flow from the uterus, to reappear again at the breast at the close of the flow, and then lasting two or three days longer. Some pain of a lancinating type occurred in the breast at this time. The patient first discovered her peculiar condition by a stain of blood upon the night-gown on awakening in the morning, and this she traced to the breast. From an examination it ap- peared that a neglected lacerated cervix during the birth of the last child had given rise to endometritis, and for a year the patient had suffered from severe menorrhagia, for M'hich she was subsequently treated. At this time the menses became scantv, and then supervened the discharge of bloody fluid from the left breast, as heretofore mentioned. The right breast remained always entirely passive. A remarkable feature of the case was that some escape of fluid occurred from the left breast during coitus. As a possible means of throwing light on this subject it may be added that the patient was unusually vigorous, and during the nursing of her two children she had more than the ordinary amount of milk (galactorrhea), which poured from the breast constantly. Since this time the breasts had been quite normal, except for the tendency manifested in the left one under the conditions given. Cases of menstruation through the eyes are frequently mentioned by the older writers. Bellini,b Helhvig,414 and Dodonseus all speak of menstrua- a533, 1895, May 11th. b Zodiacus, etc., 1680. 24 GENETIC A NOMA LIES. tion from the eye. Jonston447 quotes an example of ocular menstruation m a young Saxon girl, and Bartholinus 190 an instance associated Mith bloody dis- charge of the foot. Guepina has an example in a case of a girl of eighteen, who commenced to menstruate when three years old. The menstruation was tolerably regular, occurring every thirty-two or thirty-three days, and lasting from one to six days. At the cessation of the menstrual flow, she generally had a supplementary epistaxis, and on one occasion, M'hen this Mas omitted, she suffered a sudden effusion into the anterior chamber of the eye. The discharge had only lasted two hours on this occasion. He also relates an example of hemorrhage into the vitreous humor in a case of amenorrhea. Conjunctival hemorrhage has been noticed as a manifestation of vicarious menstruation by several American observers. Liebreich found examples of retinal hemorrhage in suppressed menstruation, and Sir James Paget b says that he has seen a young girl at Moorfields mIio had a small effusion of blood into the anterior chamber of the eye at the menstrual period, which became absorbed during the intervals of menstruation. Blairc relates the history of a case of vicarious menstruation attended with conjunctivitis and opacity of the cornea. LaM'd speaks of a plethoric woman of thirty mIio bled freely from the eyes, though menstruating regularly. Relative to menstruation from the ear, Spindleiy Paullini/ and Ali- bertg furnish examples. In Paullini's ease the discharge is spoken of as very foul, M'hich makes it quite possible that this was a case of middle-ear disease associated M'ith some menstrual disturbance, and not one of true vicarious menstruation. Alibert's case Mas consequent upon suppression of the menses. Lawh cites an instance in a woman of twenty-three, in M'hom the menstrual discharge Mas suspended several months. She experienced fulness of the head and bleeding (largely from the ears), M'hich subse- quently occurred periodically, being preceded by much throbbing ; but the patient finally made a good recovery. Barnes,1 Stepanoff,J and Fieldk ad- duce examples of this anomaly. Jouilleton1 relates an instance of men- struation from the right ear for five years, folloM'ing a miscarriage. Hemorrhage from the mouth of a vicarious nature has been frequently observed associated M'ith menstrual disorders. The Ephemerides,104 Mei- bomius,561 and Rhodius mention instances. The case of Meibomius Mas that of an infant, and the ease mentioned by Rhodius was associated M'ith hemor- rhages from the lungs, umbilicus, thigh, and tooth-cavity. Allportm reports the history of a case in M'hich there Mas recession of the gingival margins and alveolar processes, the consequence of amenorrhea. Cason has an in- a 145, vol. xlvi. b 476, 18*2, i., 786. c Oglethorpe Med. and Surg. Jour., Savannah, 1858-9, i., 11. d 224. 1869. e 74s. n. 63. f 620, cent, iv., obs. 56. g Jour, de Med. et Chir. de Toulouse, 1845-6. b 313, 1867. i 317, 1826-7. J 557, 1885, xxiv., 588-595. ^ 536, xxiii., 115. U61, 1813, 330. m450, 1885, iv., 147. n 538, 1-78. MENSTRUATION FROM ULCERS, ETC. 25 stance of menstruation from the gums, and there is on record the description of a woman, aged thirty-two, who had bleeding from the throat preceding men- struation ; later the menstruation ceased to be regular, and four years pre- viously, after an unfortunate and violent connection, the menses ceased, and the woman soon developed hemorrhoids and hemoptysis. Henrv a speaks of a woman who menstruated from the mouth ; at the necropsy 207 stones were found in the gall-bladder. Krishaber speaks of a case of lingual men- struation at the epoch of menstruation. Descriptions of menstruation from the extremities are quite numer- ous. Pechlin b offers an example from the foot; Boerhaave from the skin of the hand ; Ephemerides104 from the knee; Albertus from the foot; Zacutus Lusitanus c from the left thumb ; Bartholinusd a curious instance from the hand ; and the Ephemerides e another during pregnancy from the ankle. Postf speaks of a very peculiar case of edema of the arm alternating M'ith the menstrual discharge. Sennert M-rites of menstruation from the groin associated M'ith hemorrhage from the umbilicus and gums. Moses § offers an example of hemorrhage from the umbilicus, doubtless vicarious. Verduc details the history of two cases from the top of the head, and Kerck- ringh cites three similar instances, one of which was associated M'ith hemor- rhage from the hand. A peculiar mode is vicarious menstrual hemorrhage through old ulcers, wounds, or cicatrices, and many examples are on record, a few of which Mrill be described. Calder1 gives an excellent account of menstrua- tion at an ankle-ulcer, and Brincken-" says he has seen periodical bleeding from the cicatrix of a leprous ulcer. In the Lancetk is an account of a case in the ATienna Hospital of simulated stigmata ; the scar opened each month and a menstrual flow proceeded therefrom ; but by placing a plaster-of-Paris bandage about the wound, sealing it so that tampering M'ith the M'ound could be easily detected, healing soon ensued, and the imposture Mas thus exposed. Such would likely be the result of the investigation of most cases of " bleed- ing wounds " Mrhich are exhibited to the ignorant and superstitious for relig- ious purposes. Hogg! publishes a report describing a young lady who injured her leg with the broken steel of her crinoline. The wound healed nicely, but ahvays burst out afresh the day preceding the regular period. Forster m speaks of a menstrual ulcer of the face, and Moses n two of the head. White, quoted by Barnes, cites an instance of vicarious hemorrhage from five deep fissures a 663, 1757, 384. d 190, cent, i., hist. 13. e 124, 1859. J Christiania, 1834. ^490, 1851, xlvii. b 622, L. i. e 104, dec. i., ann. i., obs. 96. b 473, obs. 60, 85. M76, 1879, i., 593. c 831, L. ix., obs. 13. f 595, 1841, iv., 215. i 527, 1735, iii., 380. 1 476, 1885, ii., 515. n 124, 1859. 26 GENETIC ANOMALIES of the lips in a girl of fourteen ; the hemorrhage M'as periodical and could not be checked. At the advent of each menstrual period the lips became much congested, and the recently-healed menstrual scars burst open anew. Knaggsa relates an interesting account of a sequel to an operation for ovarian disease. Following the operation, there Mas a regular, painless menstruation every month, at M'hich time the lower part of the Mound re- opened, and blood issued forth during the three days of the eatamenia. McGraM'b illustrates vicarious menstruation by an example, the discharge issuing from an ovariotomy-sear, and Hooper c cites an instance in M'hich the vicarious function Mas performed by a sloughing ulcer. Buchanand and Simpson e describe " amenorrheal ulcers." Dupuytrenf speaks of denuda- tion of the skin from a burn, M'ith the subsequent development of vicarious eatamenia from the seat of the injury. There are cases on record in M'hich the menstruation occurs by the rectum or the urinary tract. Barbee & illustrates this by a case in M'hich cholera morbus occurred monthly in lieu of the regular menstrual discharge. Barretth speaks of a ease of vicarious menstruation by the rectum. Ast- bury :us says he has seen a case of menstruation by the hemorrhoidal vessels, and instances of relief from plethora by vicarious menstruation in this manner are quite common. Rosenbladt691 cites an instance of menstruation by the bladder, and Salmuth1 speaks of a pregnant woman M'ho had her monthly Aom' by the urinary tract. Ford J illustrates this anomaly by the case of a woman of thirty-two, Mrho began normal menstruation at four- teen ; for quite a period she had vicarious menstruation from the urinary tract, M'hich ceased after the birth of her last child. The coexistence of a floating kidney in this case may have been responsible for this hemorrhage, and in reading reports of so-called menstruation due consideration must be given to the existence of any other than menstrual derangement before M'e can accept the cases as true vicarious hemorrhage. Tarnier cites an instance of a girl M'ithout a uterus, in M'hom menstruation proceeded from the vagina. Zacutus Lusitanus k relates the history of a case of uterine occlusion, with the floM' from the lips of the cervix. There is mentioned an instance of menstruation from the labia. The occurrence of menstruation after removal of the uterus or ovaries is frequently reported. Storer,1 Clay,m Tait,n and the British and Foreign Medico-Chirurgical RevieM' ° report cases in which menstruation took place with neither uterus nor ovary. Doubtless many authentic instances like the preceding could be found to-day. Menstruation after a 310, 1873. b 125, 1884, 912-914. 0547, 1882-3. d 381,1879. e Month. Jour. Med. Sci., Lond., 1855. xx., 347. f 363, 1828. i., 85. g 511, 1840. b809, 1875. i 7<)ti, cent, iii., obs. 36. J 125, vol. xxii., 154. *831, L. ix., obs. 4. ' 476, 1866. ii., 471. m476, 1880, i., 15. n 548, 1884, i., 662. o 22, 1673, i., 296. MENSTRUATION IN MAN. 27 hysterectomy and ovariotomy has been attributed to the incomplete removal of the organs in question, yet upon postmortem examination of some cases no vestige of the functional organs in question has been found. Hematemesis is a means of anomalous menstruation, and several instances are recorded. Marcellus Donatus a and Benivenius l97 exemplify this with cases. Instances of vicarious and compensatory epistaxis and hemoptysis are so common that any examples would be superfluous. There is recorded15 an inexplicable case of menstruation from the region of the sternum, and among the curious anomalies of menstruation must be men- tioned that reported by Parvinc seen in a woman, mIio, at the menstrual epoch, suffered hemoptysis and oozing of blood from the lips and tongue. Occa- sionally there was a substitution of a great swelling of the tongue, rendering mastication and articulation very difficult for four or five days. Parvin gives portraits showing the venous congestion and discoloration of the lips. Instances of migratory menstruation, the flow moving periodically from the ordinary passage to the breasts and mammae, are found in the older writers.5 Salmuth speaks of a womane on M'hose hands appeared spots immediately before the establishment of the menses. Cases of semimonthly menstruation104 and many similar anomalies of periodicity are spoken of. The Ephemerides contains f an instance of the simulation of menstrua- tion after death, and Testa g speaks of menstruation lasting through a long sleep. Instances of hlack menstruation are to be found, described in full, in the Ephemerides, by Paullini11 and by Schurig,1 and in some of the later works ; it is possible that an excess of iron, administered for some menstrual disorder, may cause such an alteration in the color of the menstrual fluid. Suppression of menstruation is brought about in many peculiar Mays, and sometimes by the slightest of causes, some authentic instances being so strange as to seem mythical. Through the Ephemerides104 we constantly read of such causes as contact with a corpse, the sight of a serpent or mouse, the sight of monsters, etc. Lightning stroke and curious neuroses have been reported as causes. Many of the older books on obstetric subjects are full of such instances, and modern illustrations are constantly reported. Menstruation in Man.—Periodic discharges of blood in man, constitut- ing M'hat is called " male menstruation," have been frequently noticed and are particularly interesting when the discharge is from the penis or urethra, furnishing a striking analogy to the female function of menstruation. The older authors quoted several such instances, and Mehliss says that in the ancient days certain M'riters remarked that catamenial lustration from the penis Mas inflicted on the JeMS as a divine punishment. Bartholinus•> a 306. L. iv., 19. b 108, dec. i., vol. iv., 69. c 764. 1877. d 282, 1733, 359 ; and 105, vol. iii., app., 168. e 706, cent, iii., obs. 18. f 104, dec. iii., ann. iv., obs. 18. 8 758, 215. b 620, cent, ii., obs. 8. i 724, 217. J 190, cent, v., hist. 33. 28 GENETIC ANOMALIES. mentions a case in a youth ; the Ephemerides several instances ; Zacutus Lusitanus, Salmuth,a Hagedorn, Fabricius Hildanus, Vesalius, b Mead,c and Acta Eruditorumd all mention instances. F<>ivl e saw menstruation in a man. (rloningerf tells of a man of thirty-six, who, since the age of seventeen years and five months, had had lunar manifestations of menstrua- tion. Each attack Mas accompanied by pains in the back and hypogastric region, febrile disturbance, and a sanguineous discharge from the urethra, M'hich resembled in color, consistency, etc., the menstrual flux. Kingg re- lates that M'hile attending a course of medical lectures at the Universitv of Louisiana he formed the acquaintance of a young student mIio possessed the normal male generative organs, but in whom, the simulated function of men- struation Mas periodically performed. The cause Mas inexplicable, and the unfortunate victim Mas the subject of dee}) chagrin, and Mas afflicted M'ith melancholia, lie had menstruated for three years in this manner: a fluid exuded from the sebaceous glands of the deep fossa behind the corona glandis ; this fluid Mas of the same appearance as the menstrual flux. The quantity Mas from one to two ounces, and the discharge lasted from three to six days. At this time the student Mas twenty-two years of age, of a lymphatic temperament, not particularly lustful, and Mas never the victim of any venereal disease. The author gives no account of the after-life of this man, his whereabouts being, unfortunately, unknown or omitted. Vicarious Menstruation in the Male.—This simulation of menstrua- tion by the male assumes a vicarious nature as well as in the female. Van Swieten,h quoting from Benivenius, relates a case of a man Mho once a month sweated great quantities of blood from his right flank. Pinel mentions a case of a captain in the army (M. Regis), mIio Mas wounded by a bullet in the body and who afterward had a monthly discharge from the urethra. Pinel calls attention particularly to the analogy in this case by mentioning that if the captain were exposed to fatigue, privation, cold, etc., he exhibited the ordinary symptoms of amenorrhea or suppression. Founder1 speaks of a man over thirty years old, who had been the subject of a menstrual evacua- tion since puberty, or shortly after his first sexual intercourse. He Mould experience pains of the premenstrual type, about twenty-four hours before the appearance of the flow, M'hich subsided when the menstruation began. He M'as of an intensely voluptuous nature, and constantly gave himself up to sexual excesses. The flow Mas abundant on the first day, diminished on the second, and ceased on the third. Halliburton^ Jouilleton, and Rayman also record male menstruation. Cases of menstruation during pregnancy and lactation are not rare. a 706, cent, iii., obs. 47. d 106, ann. 1688. 228. g 251, 1867. » 302, iv., 192. b 803, L. v., cap. 15. c 515, 369 e 239, 1869. f 129, 1819. h 755, vol. xiii., sect. 1286. J Weekly Med. Rev., Chicago, 18*4, xii., 392. PRECOCIOUS MENSTRUATION. 29 It is not uncommon to find pregnancy, lactation, and menstruation coexist- ing. No careful obstetrician will deny pregnancy solely on the regular occurrence of the menstrual periods, any more than he M'ould make the diag- nosis of pregnancy from the fact of the suppression of menses. Blake a reports an instance of eatamenia and mammary secretion during pregnancy. Denaux de Breyne mentions a similar case. The child Mas born by a face- presentation. De Saint-Moulin b cites an instance of the persistence of men- struation during pregnancy in a woman of twenty-four, Mrho had never been regular; the child was born at term. Gelly speaks of a case in M'hich menstruation continued until the third month of pregnancy, when abortion occurred. Post,c in describing the birth of a tMro-pound child, mentions that menstruation had persisted during the mother's pregnancy. Roussetd reports a peculiar case in M'hich menstruation appeared during the last four months of pregnancy. There are some cases on record of child-bearing after the menopause, as, for instance, that of Pearson,e of a woman who had given birth to nine children up to September, 1836 ; after this the menses appeared only slightly until July, 1838, when they ceased entirely. A year and a half after this she was delivered of her tenth child. Other cases, somewhat similar, Mill be found under the discussion of late conception. Precocious menstruation is seen from birth to nine or ten years. Of course, menstruation before the third or fourth year is extremely rare, most of the cases reported before this age being merely accidental sanguineous discharges from the genitals, not regularly periodical, and not true eatamenia. However, there are many authentic cases of infantile menstruation on record, which were generally associated M'ith precocious development in other parts as well. Billard says that the source of infantile menstruation is the lining membrane of the uterus ; but Camerer explains it as due to ligature of the umbilical cord before the circulation in the pulmonary vessels is thoroughly established. In the consideration of this subject, we must bear in mind the influence of climate and locality on the time of the appearance of menstruation. In the southern countries, girls arrive at maturity at an earlier age than their sisters of the north. Medical reports from India show early puberty of the females of that country. Campbell remarks that girls attain the age of puberty at twelve in Siam, M^hile, on the contrary, some observers report the fact that menstruation does not appear in the Esquimaux women until the age of twenty-three, and then is very scanty, and is only present in the summer months. Cases of menstruation commencing M'ithin a few days after birth and exhibiting periodical recurrence are spoken of by Penada,f Neues Han- *2lS, 1856-7, lv., 508. c286, 1885-6, i., 543. e 476, 1836. b Jour, d'accouch., Liege, 1888, ix., 205. d Jour, de med. de Bordeaux, 1856. f Saggio d'osservazioni, iii. 30 GENETIC ANOMALIES. noverischcs Magazin,a Drummond,b Buxtorf,0 Arnold,'1 The Lancet,e and the British Medical Journal.f Cecil « relates an instance of menstruation on the sixth day, continuing for five days, in M'hich six or eight drams of blood M'ere lost. Peeplesh cites an instance in Texas in an infant at the age ot five days, M'hich Mas associated M'ith a remarkable development of the genital organs and breasts. Van Swieten offers an example at the first month ; the British Medical Journal' at the second month; Conarmond at the third month. Ysabel, a young slave girl belonging to Don Carlos Pedro of Havana, •> began to menstruate soon after birth, and at the first year M'as regular in this function. At birth her mamma* Mere well developed and her axilhe Mere slightly cov- ered M'ith hair. At the age of thirty-two months she Mas three feet ten inches tall, and her genitals and mammae resembled those of a girl of thir- teen. Her voice \\as grave and sonorous ; her moral inclinations M'ere not known. Deever358 records an instance of a child two years and seven months old M'ho, M'ith the exception of three months only, had menstruated regularly since the fourth month. Harle k speaks of a child, the youngest of three girls, M'ho had a bloody discharge at the age of five months M'hich lasted three days and recurred every month until the child Mas Meaned at the tenth month. At the eleventh month it returned and continued periodically until death, occasioned by diarrhea at the fourteenth month. The necropsy shoM'ed a uterus If inches long, the lips of M'hich were congested ; the left ovary Mas twice the size of the right, but displayed nothing strikingly abnormal. Baillot and the British Medical Journall cite instances of men- struation at the fourth month. A case is on record111 of an infant M'ho menstru- ated at the age of six months, and M'hose menses returned on the twentv- eighth day exactly. Clark, "Wall, and the Lancetn give descriptions of cases at the ninth month. Xaegele has seen a case at the eighteenth month, and Schmidt and Colly ° in the second year. Another case p is that of a child, nineteen months old, M'hose breasts and external genitals M'ere fully de- veloped, although the child had shoMrn no sexual desire, and did not exceed other children of the same age in intellectual development. This prodigy Avas symmetrically formed and of pleasant appearance. Warner mentions a case in M'hich menstruation did not commence until the seventieth year, and Hover a mentions one delayed to the seventy-sixth year. Marx of Krakaub speaks of a woman, aged forty-eight, M'ho had never menstruated ; until forty-tMO years old she had felt no symptoms, but at this time pain began, and at forty-eight regular menstruation ensued. At the time of report, four years after, she Mas free from pain and amenorrhea, and her floMr Mas regular, though scant. She had been married since she M'as twenty-eight years of age. A someMrhat similar case is mentioned by Gregory0 of a mother of 7 children M'ho had never had her menstrual floM\ There are two instances of delayed menstruation quoted :d the first, a woman of thirty, M'ell formed, healthy, of good social position, and M'ith all the signs of puberty except menstruation, M'hich had never appeared ; the second, a married woman of forty-tMo, who throughout a healthy connubial life had never menstruated. An instance is known to the authors of a woman of forty M'ho has never menstruated, though she is of exceptional vigor and development. She has been married many years without pregnancy. The medical literature relative to precocious impregnation is full of marvelous instances. Individually, many of the cases would be bevond credibility, but M'hen instance after instance is reported by reliable authori- ties Mre must accept the possibility of their occurrence, even if Mre doubt the statements of some of the authorities. Xo less a medical celebrity than the illustrious Sir Astley Cooper remarks that on one occasion he saw a girl in Scotland, seven years old, M'hose pelvis Mas so fully developed that he Mas sure she could easily give birth to a child ; and Warner's case of the Jewish girl three and a half years old, M'ith a pelvis of normal width, more than substantiates this supposition. Similar examples of precocious pelvic and sexual development are on record in abundance, and nearly every medi- cal man of experience has seen cases of infantile masturbation. The ordinary period of female maturity is astonishingly late when com- pared M'ith the loM'er animals of the same size, particularly M'hen viewed M'ith cases of animal precocity on record. Bertholde speaks of a kid four- teen days old M'hich was impregnated by an adult goat, and at the usual period of gestation bore a kid, which was mature but M-eak, to M'hich it gave milk in abundance, and both the mother and kid greM' up strong. Compared M'ith the above, child-bearing by women of eight is not extraordinary. a 108. 1712. b 657. 1-S9. 9. c 124,1853. d 302, iv., 193. e 202, 32. PRECOCIO US IMPREGNA TION 35 The earliest case of conception that has come to the authors' notice is a quotation in one of the last century books from von Mandelsloa of impreg- nation at six ; but a careful search in the British Museum failed to confirm this statement, and, for the present, we must accept the statement as hearsay and M'ithout authority available for reference-purposes. Molitorb gives an instance of precocious pregnancy in a child of eight. It Mas probably the same case spoken of by Lefebvre c and reported to the Belgium Academy : A girl, born in Luxemborg, well developed sexually, having hair on the pubis at birth, who menstruated at four, and at the age of eight Mas impregnated by a cousin of thirty-seven, M'ho Mas sentenced to five years' imprisonment for seduction. The pregnancy terminated by the expulsion of a mole containing a well-characterized human embryo. Schmidt's case in 1779 d Mas in a child who had menstruated at two, and bore a dead fetus when she was but eight years and ten months old. She had all the appearance and development of a girl of seventeen. Kussmaul gives an example of conception at eight. Dodde speaks of a child who menstruated early and continued up to the time of impregnation. She Mas a hard worker and did all her mother's washing. Her labor pains did not continue over six hours, from first to the last. The child Mas a large one, Meighing 7 pounds, and afterward died in convulsions. The infant's left foot had but 3 toes. The young mother at the time of delivery was only nine years and eight months old, and consequently must have been impreg- nated before the age of nine. Meyer gives an astonishing instance of birth in a Swiss girl at nine. Cam describes a case of a child who menstruated at two, became pregnant at eight, and lived to an advanced age. Ruttel reports con- ception in a girl of nine, and as far north as St. Petersburg a girl has become a mother before nine years. The Journal de Sea vans, 1684,470 contains the report of the case of a boy, Mrho survived, being born to a mother of nine years. Beck has reported an instance of delivery in a girl a little over ten years of age. There are instances of fecundity at nine years recorded by Ephemeri- des, Wolffius/ Savonarola,s and others.h Gleaves* reports from AVytheville, Ya., the history of Mdiat he calls the case of the youngest mother in Virginia —Annie H.—M'ho Mas born in Bland County, July 15, 1885, and, on Sep- tember 10, 1895, M'as delivered of a Mell-formed child weighing 5 pounds. The girl had not the development of a woman, although she had menstruated regularly since her fifth year. The labor Mas short and uneventful, and, two hours afterM'ard, the child-mother wanted to arise and dress and would have done so had she been permitted. There Mere no developments of the mammae nor secretion of milk. The baby Mas nourished through its short a 505. b ni, 1378-9. c 362, March 8, 1878. d 753, vol. ii. e 476, 1881, i., 601. f Lect. Memorabilia, T. i., 620. g 714, cap. 21, n. 6. h 45s, T. xxxvii., 542. i 538, Nov. 16, 1895. 36 G ENE TI< * A NOMALIES. existence (as it only lived a week) by its grandmother, M'ho had a child only a few months old. The parents of this child were prosperous, intelligent, and worthy people, and there Mas no doubt of the child's age. " Annie is now well and plays about with the other children as if nothing had happened." Harris refers to a Kentucky woman, a mother at ten years, one in Massachu- setts a mother at ten years, eight months, and seventeen days, and one in Phila- delphia at eleven years and three months. The first case Mas one of infantile precocity, the other belonging to a much later period, the menstrual function having been established but a few months prior to conception. All these girls had M'ell-developed pelves, large mammae, and the general marks of womanhood, and bore living children. It has been remarked of 3 very markedly precocious eases of pregnancy that one Mas the daughter of very humble parents, one born in an almshouse, and the other raised by her mother in a house of prostitution. The only significance of this statement is the greater amount of vice and opportunity for precocious sexual intercourse to M'hich they M'ere exposed ; doubtless similar cases under more favorable con- ditions Mould never be recognized as such. The instance in the Journal speaks of a girl M'ho became pregnant at twelve years and nine months, and Mas delivered of a healthy, ii-jMmnd boy before the physician's arrival; the placenta came away afterM'ard, and the mother made a speedy recovery. She Mas thought to have had " dropsy of the abdomen," as the parents had lost a girl of about the same age M'ho Mas tapped for ascites. The father of the child M'as a boy only fourteen years of age. Marvelous to relate, there are on record several cases of twins being born to a child mother. Kay reports a case of tw ins in a girl of thirteen ; Montgomery, at fourteen ; and Meigs reports the case of a young girl, of Spanish blood, at Maracaibo, M'ho gave birth to a child before she Mas twelve and to twins before reaching fourteen years. In the older works, the following authors have reported cases of preg- nancy before the appearance of menstruation: Ballonius, Vogel, Mor- gagni, the anatomist of the kidney, Sehenck, Bartholinus, Bierling, Zaechias, (1harleton, Mauriceau, Ephemerides, and Fabricius Hildanus. In some cases this precocity seems to be hereditary, being transmitted from mother to daughter, bringing about an almost incredible state of affairs, in which a girl is a grandmother about the ordinary age of maternity. Kay says that he had reported to him, on "pretty good" authority, an instance of a Damascus Jewess M'ho became a grandmother at twenty-one years. In France c they record a young grandmother of tMenty-eight. Ketchumd speaks of a negress, aged thirteen, M'ho gave birth to a Mrell-developed child M'hich began to menstruate at ten years and nine months and at thirteen became pregnant; hence the negress Mas a grandmother at tM'enty-five years and nine months. She had a second child before she was sixteen, M'ho began to menstruate at seven years and six months, thus proving the inheritance of this precocity, and leaving us at sea to figure what degree of grandmother she may be if she lives to an advanced age. Another interesting case of this nature is that of Mrs. C.,e born 18o4, married in 1867, and M'ho had a daughter ten months after. This daughter married in 1882, and in March 18S.°>, gave birth to a 9-pound boy. The youthful grandmother, not twenty- nine, Mas present at the birth. This case was remarkable, as the children were both legitimate. Fecundity in the old seems to have attracted fully as much attention among the older observers as precocity. Pliny 636 speaks of Cornelia, of the family of Serpios, who bore a son at sixty, M'ho Mas named Yolusius Saturnius; and Marsa, a physician of Venice, Mas deceived in a pregnancy a 490, 1848. b 224, 1885, ii., 913. c 365, 1867, No. 291. d 770, 1849. e 49^ june 9 1883 FECUNDITY IN THE OLD. 39 in a woman of sixty, his diagnosis being " dropsy." Tarenta records the history of the case of a woman M'ho menstruated and bore children when past the age of sixty. Among the older reports are those of Blanchard a of a woman mIio bore a child at sixty years; Fielitz,160 one at sixty ; Ephemerides, one at sixty-two ; Rush,b one at sixty ; Bernstein,201 one at sixty years ; Schoepfer, at seventy years ; and, almost beyond belief, Debesc cites an instance as tak- ing place at the very advanced age of one hundred and three. AVallaced speaks of a woman in the Isle of Orkney bearing children when past the age of sixty. AVe would naturally expect to find the age of child-bearing prolonged in the northern countries M'here the age of maturity is later. Capuron cites an example of child-birth in a woman of sixty ; Haller, cases at fifty-eight, sixty-three, and seventy; Dewees, at sixty-one ; and Thibaut de Chauvalon, in a Monian of Martinique aged ninety years. There Mas a woman delivered in Germany, in 1723, at the age of fifty-five ; one at fifty-one in Kentucky ;e and one in Russia at fifty .f Depasse s speaks of a woman of fifty-nine years and five months old who was delivered of a healthy male child, which she suckled, weaning it on her sixtieth birthday. She had been a M'idow for twenty years, and had ceased to menstruate nearly ten years before. In St. Peter's Church, in East Oxford, is a monument bearing an inscription re- cording the death in child-birth of a woman sixty-two years old. Cachoth relates the case of a woman of fifty-three, who M'as delivered of a living child by means of the forceps, and a year after bore a second child M'ithout instrumental interference. She had no milk in her breasts at the time and no signs of secretion. This aged mother had been married at fifty-two, five years after the cessation of her menstruation, and her husband Mas a young man, only twenty-four years old. Kennedy1 reports a delivery at sixty-two years, and the Cincinnati Enquirer, January, 1863, says : " Dr. \V\ McCarthy was in attendance on a lady of sixty-nine years, on Thursday night last, M'ho gave birth to a fine boy. The father of the child is seventy-four years old, and the mother and child are doing well." Quite recently there died in Great Britain a Mrs. Henry of Gortree at the age of one hundred and twelve, leaving a daughter of nine years. MayhamJ saM' a woman seventy-three years old M'ho recovered after delivery of a child. A most peculiar case is that of a M'idow, seventy years old, a native of Garches.k She had been in the habit of indulging freely in wine, and, during the last six months, to decided excess. After an unusually prolonged libation she found herself unable to walk home ; she sat doM'n by the roadside M'aiting until she could proceed, and Mas so found by a young man who knew her and M'ho proposed helping her home. By the time her a 213, cent, iv., n. 71. b 696, ii. c 290, 248. d 629, vol. xxii., 543. o 133, 1872, vi., 138. f 811, 1881, vi. g 364, Oct. 1, 1891. b 616, 1883-4, xxvi., 394. i 769, 1881. J 542, Jan., 1891. k 789, Dec. 3, 1881. 40 GENE TIC A N OMA LIES house Mas reached night Mas M'ell advanced, and she invited him to stop over night; finding her more than affable, he stopped at her house over four nights, and the result of his visits Mas an ensuing pregnancy for Madame. Multiple births in the aged have been reported from authentic sources. The Lancet a quotes a rather fabulous account of a lady over sixty-two years of age mIio gave birth to triplets, making her total number of children 13. Montgomery, Colomb, and Knehel, each, have recorded the birth of twins in M'oinen beyond the usual age of the menopause, and there is a case recorded of a woman of fifty-two M'ho Mas delivered of twins. Impregnation without completion of the copulative act by reason of some malformation, such as occlusion of the vagina or uterus, fibrous and unruptured hymen, etc., has been a subject of discussion in the M'orks of medical jurisprudence of all ages; and cases of conception M'ithout entrance of the penis are found in abundance throughout medical literature, and may have an important medicolegal bearing. There is little doubt of the possibility of spermatozoa deposited on the genitalia making progress to the seat of fer- tilization, as their poM'er of motility and tenacity of life have been well dem- onstrated. Percy c reports an instance in M'hich semen Mas found issuing from the os uteri eight and one-half days after the last intercourse ; and a microscopic examination of this semen revealed the presence of living as M'ell as dead spermatozoa. We have occasional instances of impregnation by rectal coitus, the semen finding its May into an occluded vaginal canal by a fistulous communication. Guillemeau,d the surgeon of the French king, tells of a girl of eighteen, M'ho Mas brought before the French officials in Paris, in 1607, on the cita- tion of her husband of her inability to allow him completion of the marital function. He alleged that he had made several unsuccessful attempts to enter her, and in doing so had caused paraphimosis. On examination by the surgeons she Mas found to have a dense membrane, of a fibrous nature entirely occluding the vagina, M'hich they incised. Immediately afterward the woman exhibited morning sickness and the usual signs of pregnancy and Avas delivered in four months of a full-term child, the results of an impreg- nation occasioned by one of the unsuccessful attempts at entrance. Such instances are numerous in the older literature, and a mere citation of a few- is considered sufficient here. Zacchias,e Amand, Fabricius Hildanus, Graaf the discoverer of the follicles that bear his name, Borellus, Blegnv, Blanchard f Diemerbroeck,g Duddell, Mauriceau, a Reyes, Riolan,h Harvev, the discoverer of the circulation of the blood,1 AVolfius, AValther, Rongier,j Ruysch For- estus, Ephemerides,k and Schurig all mention cases of conception with intact a 476, 1867, i., 727. b ,33s, 1889. c 130, March 9, 1861. d 389. L. ii., chap. 8. fol. 108. e 830, n. 42. f 213, cent, iii.' g 303, L. i., c. 23. h 686. L. ii., c. 37. i 405, L. ii., c. 11. J 462, T. xlix., 358. k 104, Dec. 1, ann. iii., obs. 273. IMPREGNATION AFTER INCOMPLETE COPULATION. 41 hymen, and in which there was no entrance of the penis. Tolberg 762 has an example of hymen integrum after the birth of a fetus five months old, and there is recordeda a case of tubal pregnancy in M'hich the hymen Mas intact. Gilbert b gives an account of a case of pregnancy in an unmarried woman, who successfully resisted an attempt at criminal connection and yet became impregnated and gave birth to a perfectly formed female child. The hymen Mas not ruptured, and the impregnation could not have preceded the birth more than thirty-six weeks. Unfortunately, this poor woman was infected with gonorrhea after the attempted assault. Simmons of St. Louisc gives a curious peculiarity of conception, in which there was complete closure of the vagina, subsequent conception, and delivery at term. He made the patient's acquaintance from her application to him in regard to a malcondi- tion of her sexual apparatus, causing much domestic infelicity. Lawsond speaks of a woman of thirty-five, who had been married ten months, and whose husband could never effect an entrance ; yet she became pregnant and had a normal labor, despite the fact that, in addition to a tough and unruptured hymen, she had an occluding vaginal cyst. Hickinbotham of Birmingham e reports the history of two cases of labor at term in females whose hymens were immensely thickened. H. Grey Edwards has seen a case of imperforate hymen which had to be torn through in labor; yet one single act of copulation, even with this obstacle to entrance, sufficed to impregnate. Champion speaks of a woman who became pregnant although her hymen Mas intact. She had been in the habit of having coitus by the urethra, and all through her pregnancy continued this practice. Houghtonf speaks of a girl of twenty-five into whose vagina it was impossible to pass the tip of the first finger on account of the dense cicatricial membrane in the orifice, but who gave birth, M'ith comparative ease, to a child at full term, the only interference necessary being a few slight incisions to permit the passage of the head. Tweedieg saw an Irish girl of twenty- three, M'ith an imperforate os uteri, who had menstruated only scantily since fourteen and not since her marriage. She became pregnant and went to term, and required some operative interference. He incised at the point of usual location of the os, and one of his incisions Mas followed by the flow of liquor amnii, and the head fell upon the artificial opening, the diameter of which proved to be one and a half or two inches ; the birth then progressed promptly, the child being born alive. Guerardh notes an instance in which the opening barely admitted a hair ; yet the patient reached the third month of pregnancy, at which time she induced abortion in a manner that could not be ascertained. Roe gives a a Collect. Acad, de Med., Paris, 1756, xii., 151. b 218, 1872, 298. c 703, 1847, 62-69. d 224, 1885, i., 1202. e 224, 1881, i., 1001. f 313, 1862. g 490, vol. xx., 202. h 261, 1895, No. 15. 42 GENETIl' ANOMALIES. case of conception in an imperforate uterus,;l and Duncanb relates the history of a case of pregnancy in an unruptured hymen, characterized by an extra- ordinary ascent of the uterus. Among many, the following modern observers have also reported instances of pregnancy with hymen integrum : Braun,c 3 cases; Francis,d Horton,e Oakman/ Brill,e 2 cases; Burgess,h Haig,! Hav,J and Smith.k Instances in M'hich the presence of an unruptured hymen has complicated or retarded actual labor are quite common, and until the membrane is rup- tured by external means the labor is often effectually obstructed. Among others reporting cases of this nature are Beale,1 Carey,"1 Davis, Emond,n Fetherston, Leiseuring,0 Mackinlay,P Martinelli, Palmer,q Rousseau, Ware, and Yale.1" There are many cases of stricture or complete occlusion of the vagina, con- genital or acquired from cicatricial contraction, obstructing delivery, and in some the impregnation seems more marvelous than cases in which the obstruc- tion is only a thin membranous hymen. Often the obstruction is so dense as to require a large bistoury to divide it, and even that is not always suffi- cient, and the Cesarean operation only can terminate the obstructed delivery ; we cannot surmise how conception could have been possible. Stapless records a ease of pregnancy and parturition M'ith congenital stricture of the vagina. Maisonneuve* mentions the successful practice of a Cesarean operation in a case of congenital occlusion of the vagina forming a complete obstruction to delivery. Yerdileu records an instance of imperforate vagina in which the rectovaginal M'all Mas divided and the delivery effected through the rectum and anus. Lombard v mentions an observation of complete occlusion of the vagina in a woman, the mother of 4 living children and pregnant for the fifth time. Thus, almost incredible to relate, it is possible for a woman to become a mother of a living child and yet preserve all the vaginal evidences of virginity. ('olew describes a woman of twenty-four who Mas delivered without the rupture of the hymen, and Meek x remarks on a similar case. We can readily see that, in a case like that of A'erdile, in M'hich rectal deliv- ery is effected, the hymen could be left intact and the product of conception be born alive. A natural sequence to the subject of impregnation M'ithout entrance is that of artificial impregnation. From being a matter of Monder and a 476, 1851, i., 564. b 769, 1875, iii., 91-93. c Wien. Med. Wochen., 1876. xxvi., 289-316. d 4:35, isil, vi., 253. e 545. Mill, xxi., :U4. *' 476, 1851, i., 569. g 812, 1882. b 476, 1876. ii.. 237. i 180, 1870. J 547, 1873. k 592, 1858-9. 1 476, 1859. ii., 98. m 525, 1855, i., 97. n 363, 1862, xxxv., 214. 0 547. 187(1-1, i., 395. P 476, 1840-1, i., 847. q 778. iv., 211. r 218, ls.-)!)-60, lxi., 295. s Northwest Med. and Surg. Jour.. St. Paul, 1870-71, i. 183. t 363, 1^49, i., 451. u Morgagni, Xapoli, 1875, xvii., 747. v 368, is:5l. ^Western Lancet, Sau Francisco, 1873-4, ii., 705. x 176. 1874-5, xii. 457. ARTIFICIAL IMPREGNATION. 43 hearsay, it has been demonstrated as a practical and useful method in those eases in which, by reason of some unfortunate anatomic malformation on either the male or the female side, the marriage is unfruitful. There are many cases constantly occurring in M'hich the birth of an heir is a most desirable thing in a person's life. The historic instance of Queen Mary of England, whose anxiety and efforts to bear a child Mere the subject of public comment and prayers, is but an example of a fact that is occurring every day, and doubtless some of these cases could be righted by the pursuance of some of the methods suggested. There have been rumors from the beginning of the century of women being impregnated in a bath, from contact with cloths containing semen, etc., and some authorities in medical jurisprudence have accepted the possibility of such an occurrence. It is not in the province of this work to speculate on M'hat may be, but to give authoritative facts, from which the reader may draw his own deductions. Fertilization of plants has been thought to have been known in the oldest times, and there are some who believe that the library at Alexandria must have contained some information relative to it. The first authentic account that we have of artificial impregnation is that of Sehwammerdam, Mrho in 1<>8() attempted it M'ithout success by the fecunda- tion of the eggs of fish. Roesel, his scholar, made an attempt in 1690, but also failed ; and to Jacobi, in 1700, belongs the honor of success. In 1780, Abbe Spallanzani, following up the success of Jacobi, artificially impreg- nated a bitch, who brought forth in sixty-two days 3 puppies, all resembling the male. The illustrious John Hunter advised a man afflicted with hypospadias to impregnate his wife by vaginal injections of semen in water with an ordinary syringe, and, in spite of the simplicity of this method, the attempt was followed by a successful issue. Since this time, Nicholas of Xancy and Lesueur have practised the simple vaginal method ; while Gigon, d'Angouleme (14 cases), Girault (10 cases), Marion Sims, Thomas, Salmon, Pajot, Gallard, Courty, Roubaud, Dehaut, and others have used the more modern uterine method with success. A dog-breeder,a by syringing the uterus of a bitch, has succeeded in im- pregnating her. Those who are desirous of full information on this subject, as regards the modus operandi, etc., are referred to Girault ;b this author reports in full several examples. One case M'as that of a woman, aged twenty-five, afflicted with blenorrhea, who, chagrined at not having issue, made repeated forcible injections of semen in water for two months, and finally succeeded in impregnating herself, and Mas delivered of a living child. Another case was that of a female, aged twenty-three, who had an extra long vaginal canal, probably accounting for the absence of pregnancy. She made injec- tions of semen, and was finally delivered of a child. He also reports the case of a distinguished musician who, by reason of hypospadias, had never as<)6, 1884. b100, 1868, 409. 44 GENETIC ANOMALIES. impregnated his M'ife, and had resorted to injection- of semen with a favor- able result. Thi- latter case seems hardly warranted M'hen we consider that men afflicted M'ith hypospadias and epispadias have become fathers. Percy a gives the instance of a gentleman whom he had known for some time, whose urethra terminated a little below the frenum, as in other persons, but whose glans bulged quite prominently beyond it, rendering urination in the forward direction impossible. Despite the fact that this man could not perform the ejaculatory function, lie was the father of three children, two of them inheriting his penile formation. The fundamental condition of fecundity being the union of a spermato- zoid and an ovum, the object of artificial impregnation is to further this union by introducing semen directly to the fundus of the uterus. The operation is quite simple and as follows : The husband, having been found perfectly healthy, is directed to cohabit with his wife, using a condom. The semen ejaculated is sucked up by an intrauterine syringe (Fig. 1) M'hich has been properly disinfected and kept warm. The os uteri is now- exposed and wiped off M'ith some cotton M'hich has been dipped in an antiseptic fluid ; the nozzle of the syringe is introduced to the fundus of the uterus, and some drops of the fluid slowly expressed into the uterus. The woman Fig. L-Apparatus for artificial impregnation. is then kept in bed on her back. This operation is best carried out immediately before or immediately after the menstrual epoch, and if not successful at the first attempt should be repeated for several months. At the present dav artificial impregnation in pisciculture is extensively used with great success.b a 130, 1861. b The following extraordinary incident of accidental impregnation, quoted from the American Medical Weekly1 by the Lancet,2 is given in brief, not because it bears any sem- blance of possibility, but as a curious example from the realms of imagination in medicine. L. G. Capers of Vicksburg, Miss., relates an incident during the late Civil War, as fol- lows : A matron and her two daughters, aged fifteen and seventeen years, filled with the enthusiasm of patriotism, stood ready to minister to the wounds of their countrymen in their fine residence near the scene of the battle of E------. May 12. 1*6.'». between a portion of Grant's army and some Confederates. During the fray a gallant and noble young friend of the narrator staggered and fell to the earth ; at the same time a piercing cry was heard in the house near by. Examination of the wounded soldier showed that a bullet had passed through the scrotum and carried away the left testicle. The same bullet had apparently penetrated the left side of the abdomen of the elder young lady, midway between the umbilicus and the anterior superior spinous process of the ilium, and had become lost in the abdomen. This 1131, Nov. 7, 1874. " 476, 1875, i., 35. CONCEPTION WITH DEFICIENT ORGANS. 45 Interesting as are all the anomalies of conception, none are more so than those of unconscious impregnation ; and some well-authenticated cases can be mentioned. Instances of violation in sleep, M'ith subsequent preg- nancy as a result, have been reported in the last century by Yalentini,793 Gen- selius,'-1 and Selmrig. Reports by modern authorities seem to be quite scarce, though there are several cases on record of rape during anesthesia, followed by impregnation. Capuron b relates a curious instance of a woman who M'as raped during lethargy, and who subsequently became pregnant, though her condition was not ascertained until the fourth month, the peculiar abdominal sensation exciting suspicion of the true nature of the case, which had pre- viously been thought impossible. There is a record of a case c of a young girl of great moral purity M'ho became pregnant without the slightest knowledge of the source ; although, it might be remarked, such cases must be taken " cum grano *«//*." Cases of conception without the slightest sexual desire or pleasure, either from fright, as in rape, or naturally deficient constitution, have been recorded ; as well as conception during intoxication and in a hypnotic trance, which latter has recently assumed a much mooted legal aspect. As far back as KiSO,215 Duverney speaks of conception without the slightest sense of desire or pleasure on the part of the female. Conception with Deficient Organs.—Having spoken of conception with some obstructive interference, conception wdth some natural or acquired deficiency of the functional, organic, or genital apparatus must be considered. It is a well-known fact that women exhibiting rudimentary development of the uterus or vagina are still liable to become pregnant, and many such cases have been recorded ; but the most peculiar cases are those in M'hich pregnancy has appeared after removal of some of the sexual apparatus. Pregnancy going to term M'ith a successful delivery frequently folloMs the performance of ovariotomy with astonishing rapidity. 01ierd cites an daughter suffered an attack of peritonitis, but recovered in two mouths under the treatment administered. Marvelous to relate, just two hundred and seventy-eight days after the reception of the minie-ball, she was delivered of a fine boy, weighing 8 pounds, to the surprise of herself and the mortification of her parents and friends. The hymen was intact, and the young mother strenu- ously insisted on her virginity and innocence. About three weeks after this remarkable birth Dr. Capers was called to see the infant, and the grandmother insisted that there was something wrong with the child's genitals. Examination showed a rough, swollen, and sensitive scrotum, containing some hard substance. He operated, and extracted a smashed and battered minie- ball. The doctor, after some meditation, theorized in this manner : He concluded that this was the same ball that had carried away the testicle of his young friend, that had penetrated the ovary of the young lady, and, with some spermatozoa upon it, had impregnated her. With this conviction he approached the young man and told him the circumstances ; the soldier appeared skeptical at first, but consented to visit the young mother ; a friendship ensued which soon ripened into a happy marriage, and the pair had three children, none resembling, in the same degree as the first, the heroic pafer families. a 104, 1715. t>254, 86. c fy25, 1S55. d 363, xlv., 1140. 46 G ENE TIC A NOMA LIES. instance of ovariotomy M'ith a pregnancy of twins three months afterM'ard, and accouchement at term of two well-developed boys. Polaillon a speak.- of a pregnancy consecutive to ovariotomy, the accouchement being normal at term. Crouchb reports a case of successful parturition in a patient M'ho had previously undergone ovariotomy by a large incision. Parsons0 mentions a case of twin pregnancy two years after ovariotomy attended M'ith abnormal development of one of the children. Cutterd speaks of a case in which a woman bore a child one year after the performance of ovariotomy, and Pippingskold e of two cases of pregnancy after ovariotomy in which the stump as Mell as the remaining ovary Mere cauterized. BroM'nf relates a similar instance with successful delivery. Bixbv,s Harding,b Walker (187K-!)), and Mears1 all report cases, and others are not at all rare. In the cases following shortly after operation, it has been suggested that they may be explained by the long retention of the ova in the uterus, deposited there prior to operation. In the presence of such facts one can but wonder if artificial fecundation of an ovum derived from another woman may ever be brought about in the uterus of a sterile woman ! Conception Soon After a Preceding Pregnancy.—Conception some- times follows birth (or abortion) M'ith astonishing rapidity, and some women seem for a period of their lives either always pregnant or M'ith infants at their breasts. This prolificity is often alluded to, and is not confined to the lower classes, as often stated, but is common even among the nobility. Illustrative of this, we have examples in some of the reigning families in Europe to-day. A peculiar instance is given by SparkmanJ in M'hich a woman conceived just forty hours after abortion. Rice k mentions the case of a woman who M'as confined M'ith her first child, a boy, on July 31, 1870, and M'as again delivered of another child on June 4, 1871. She had become pregnant tMenty-eight days after delivery. He also mentions another ease of a Mrs. C, M'ho, at the age of twenty-three, gave birth to a child on September 13, 1880, and bore a second child on July 2, 1881. She must have become pregnant twenty-one days after the delivery of her first child. Superfetation has been known for many centuries ; the Konians had laws prescribing the laws of succession in such cases, and many medical M'riters have mentioned it. Hippocrates and Aristotle M'rote of it, the former at some length. Pliny speaks of a slave M'ho bore two infants, one resembling the master the other a man M'ith M'hom she had intercourse, and cites the case as one of super- fetation. Schenck1 relates instances, and Zacchias, Velchius, and Sinibaldus mention cases. Pare seemed to be well conversant with the possibility as Mell as the actuality of superfetation ; and Harvey m reports that a certain a 168, 1879, vi., 243. b 550, xxxv., 71. c 476, 1866, i., 2s4. d 533, 1867-8. e 321, 1880. f 54S. 1854, ix., 566. g 476. 18=1. M76, 1880, i., 93. i 547, 1879. J 264, 1876. k 122, 1881, 206. 1 L. iv., De Superfetation, 617. m404, fol. 479. SUPERFETA TION. 47 maid, gotten with child by her master, in order to hide her knavery came to London in September, where she lay in by stealth, and being recovered, returned home. In December of the same year she was unexpectedly deliv- ered of another child, a product of superfetation, which proclaimed the crime that she had so cunningly concealed before. Marcellus Donatus, Goret, Schacher,717 and Mauriceau a mention super- fetation. In the Aeademie des Sciences, at Paris, in 1702, there Mas men- tioned the case of a woman who Mas delivered of a boy ; in the placenta was discovered a sort of bladder M'hich Mas found to contain a female fetus of the age of from four to five months ; and in 1729, before the same society, there M'as an instance in which two fetuses M'ere born a day apart, one aged forty days and the other at full term. From the description, it does not seem pos- sible that either of these were blighted twin pregnancies. Ruyschb gives an account of a surgeon's wife at Amsterdam, in 1686, who was delivered of a strong child which survived, and, six hours after, of a small embryo, the funis of M'hich was full of hydatids and the placenta as large and thick as one of three months. Ruysch accompanies his description with an illustrative figure. At Lyons, in 1782, Benoite Franquet Mas unexpectedly delivered of a child seven months old ; three wreeks later she experienced symptoms indicative of the existence of another fetus, and after five months and six- teen days she was delivered of a remarkably strong and healthy child. Baudeloquec speaks of a case of superfetation observed by Desgranges in Lyons in 1780. After the birth of the first infant the lochia failed to flow, no milk appeared in the breasts, and the belly remained large. In about three weeks after the accouchement she had connection M'ith her hus- band, and in a few days felt fetal movements. A second child M'as born at term, sixty-eight days after the first; and in 1782 both children were living. A woman of Ariesd was delivered on November 11, 1796, of a child at term ; she had connection with her husband four days after ; the lochia stopped, and the milk did not flow after this intercourse. About one and a half months after this she felt quickening again, and naturally sup- posed that she had become impregnated by the first intercourse after confine- ment ; but five months after the first accouchement she Mas delivered of another child at term, the result of a superfetation. Milk in abundance made its appearance, and she Mas amply able to nourish both children from the breasts. Lachausse e speaks of a woman of thirty M'ho bore one child on April 30, 1748, and another on September 16th in the same year. Her breasts were full enough to nourish both of the children. It might be remarked in comment on this case that, according to a French authority, the woman died in 1755, and on dissection Mas found to have had a double uterus. a 513, app. i., 65. b 698, Tome i., obs. 14. c Traite de l'Art des Accouchemens, ii. d 302, iv., 181. e De superfetation vera in utero simplici, Argentor., 1?">5. 48 GENETIC ANOMALIES. A peculiar instance of superfetation was reported by Langmore;l in which there was an abortion of a fetus between the third and fourth months, appar- ently dead some time, and thirteen hours later a second fetus ; an ovum of about four M'eeks and of perfect formation was found adherent near the fundus. Tyler Smithb mentions a lady pregnant for the first time who miscarried at five months and some time afterward discharged a small clot containing a perfectly fresh and healthy ovum of about four weeks' forma- tion. There was no sign of a double uterus, and the patient menstruated regularly during pregnancy, being unwell three M'eeks before the abortion. Harlcy and Tanner c speak of awonian of thirty-eight M'ho never had borne tM'ins, and mIio aborted a fetus of four months'gestation ; serious hemorrhage accompanied the removal of the placenta, and on placing the hand in the uter- ine cavity an embryo of five or six M'eeks was found inclosed in a sac and floating in clear liquor amnii. The patient was the mother of nine children, the youngest of M'hich M'as three years old. Young d speaks of a woman M'ho three months previously had aborted a three months' fetus, but a tumor still remained in the abdomen, the auscultation of which gave evidence of a fetal heart-beat. Vaginal examination revealed a dilatation of the os uteri of at least one inch and a fetal head pressing out; subsequently a living fetus of about six months of age was delivered. Se- vere hemorrhage complicated the case, but was controlled, and convales- cence speedily ensued. Husee cites an instance of a mother bearing a boy on November 4, 1834, and a girl on August 3, 1835. At birth the boy looked premature, about seven months old, which being the case, the girl must have been either a superfetation or a seven months' child also. Aran Bibber of Baltimore says he met a young lady who was born five months after her sister, and M'ho was still living. The most curious and convincing examples of superfetation are those in which children of different colors, either twins or near the same age, are born to the same woman,—similar to that exemplified in the case of the mare who M'as covered first by a stallion and a quarter of an hour later bv an ass, and gave birth at one parturition to a horse and a mule/ Parsons s speaks of a case at Charleston, S. C, in 1714, of a M'hite woman who gave birth to tM'ins, one a mulatto and the other white. She confessed that after her husband left her a negro servant came to her and forced her to comply with his M'ishes by threatening her life. Smellie mentions the case of a black woman M'ho had twins, one child black and the other almost M'hite. She confessed having had intercourse M'ith a white overseer immediately after her husband left her bed. Deweesh reports a similar case. Newlin of Nashville * speaks of a negress who bore twins, one distinctly black M'ith the a 778, iv., 135. b 476, April 12, 1856. c 77s. Lond., 1863, iv., 165-169. a 124, 1868. e 218, 1856, liv. 294. f Acad, de Med., Aug., 1*25. g 629, Oct., 1745. b 301, 1805, T. clxxiv. i Quoted in 300, Sept.,' 1887. CHILDREN OF DIFFERENT COLORS. 49 typical African features, while the other M'as a pretty mulatto exhibiting the distinct characters of the Caucasian race. Both the parents were perfect types of the black African negro. The mother, on being questioned, frankly acknowledged that shortly after being M'ith her husband she had lain a night with a white man. In this case each child had its own distinct cord and placenta. Archera gives facts illustrating and observations showing: "that a white woman, by intercourse with a white man and negro, may conceive twins, one of M'hich shall be M'hite and the other a mulatto; and that, vice versa, a black woman, by intercourse M'ith a negro and a M'hite man, may conceive twins, one of which shall be a negro and the other a mulatto." Wightb narrates that he was called to see a woman, the wife of an East Indian laborer on the Isle of Trinidad, who had been delivered of a fetus 6 inches long, about four months old, and having a cord of about 18 inches in length. He removed the placenta, and in about half an hour the woman was delivered of a full-term white female child. The first child was dark, like the mother and father, and the mother denied any possibility of its being a Mrhite man's child; but this Mas only natural on her part, as East Indian husbands are so intensely jealous that they would even kill an un- faithful M'ife. Both the mother and the mysterious white baby are doing well. Bouillon0 speaks of a negress in Guadeloupe who bore twins, one a negro and the other a mulatto. She had sexual congress with both a negro and a M'hite man. Delmas,d a surgeon of Rouen, tells of a woman of thirty-six who was delivered in the hospital of his city on February 26, 1806, of tM'o children, one black and the other a mulatto. She had been pregnant eight months, and had had intercourse M'ith a negro twice about her fourth month of preg- nancy, though living with the M'hite man who first impregnated her. Two placentae were expelled some time after the twins, and showed a mem- branous junction. The children died shortly after birth. Pregnancy often takes place in a unicorn or bicorn uterus, leading to sim- ilar anomalous conditions. Galle, Hoffman, Massen, and Sanger give inter- esting accounts of this occurrence, and Rosse relates an instance of triple pregnancy in a double uterus. Clevelandf describes a discharge of an anomalous deciduous membrane during pregnancy M'hich Mas probably from the unimpregnated half of a double uterus. a 541, 1809-10. b 124, July 6, 1895, 14. c Bull, de la Societe de Med., 1821. d 302, iv., 181. e Medicin, Paris, 1879, v., No. 43. * 778, 1884, xxvi., 117. 4 CHAPTER II. PRENATAL ANOMALIES. Extrauterine Pregnancy.—In the consideration of prenatal anomalies, the first to be discussed will be those of extrauterine pregnancy. This abnormalism has been knoM'n almost as long as there has been any real knowledge of obstetrics. In the writings of A Ibueasis,115 during the eleventh century, extrauterine pregnancy is discussed, and later the works of N. Polinus and Cordaeus, about the sixteenth century, speak of it; in the case of Cordams the fetus was converted into a lithopedion and carried in the abdomen twenty-eight years. Horstius in the sixteenth century relates the history of a woman who conceived for the third time in March, 1547, and in 1563 the remains of the fetus were still in the abdomen. Israel Spach, in an extensive gynecologic work published in 1557, fig- ures a lithopedion drawn in situ in the case of a woman with her belly laid open. He dedicated to this calcified fetus, M'hich he regarded as a reversion, the following curious epigram, in allusion to the classical myth that after the flood the world was repopulated by the two survivors, Deucalion and Pyrrha, M'ho walked over the earth and cast stones behind them, which, on striking the ground, became people. Roughly translated from the Latin, this epigram read as follows : " Deucalion cast stones behind him and thus fashioned our tender race from the hard marble. How comes it that nowadays, by a reversal of things, the tender body of a little babe has limbs nearer akin to stone ? " a Manv of the older Mritcrs mention this form of fetation as a curiosity, but offer no explanation as to its cause. Mauriceau 513 and de Graaf384 discuss in full extrauterine pregnancy, and Salmuth, Hannseus, and Bartholinus describe it. From the beginning of the eighteenth century this subject always demanded the attention and interest of medical observers. In more modern times, Campbell and Geoffroy-Saint-Hilaire, M'ho named it " Grossesse Path- ologique," have carefully defined and classified the forms, and to-day every text-book on obstetrics gives a scientific discussion and classification of the different forms of extrauterine pregnancy. The site of the conception is generally the wall of the uterus, the Fallo- pian tube, or the ovary, although there are instances of pregnancy in the vagina, as for example when there is scirrhus of the uterus ;b and again, cases a 844, 274. b 462, T. Ii.. 55. 50 TERMINATION OF EXTRAUTERINE PREGNANCY. 51 supposed to be only extrauterine have been instances simply of double uterus, with single or concurrent pregnancy. Ross a speaks of a woman of thirty- three who had been married fourteen years, had borne six children, and who on July 16, 1870, miscarried with twins of about five months' develop- ment. After a wreek she declared that she was still pregnant with another child, but as the physician had placed his hand in the uterine cavity after the abortion, he knew the fetus must be elsewhere or that no pregnancy existed. We can readily see how this condition might lead to a diagnosis of extra- uterine pregnancy, but as the patient insisted on a thorough examination, the doctor found by the stethoscope the presence of a beating fetal heart, and by vaginal examination a double uterus. On introducing a sound into the new aperture he discovered that it opened into another cavity ; but as the woman was pregnant in this, he proceeded no further. On October 31st she Mas delivered of a female child of full growth. She had menstruated from this bipartite uterus three times during the period between the miscarriage of the twins and the birth of the child. Both the mother and child did Mell. In most cases there is rupture of the fetal sac into the abdominal cavity or the uterus, and the fetus is ejected into this location, from thence to be removed or carried therein many years ; but there are instances in which the conception has been found in situ, as depicted in Figure 2. A sturdy woman b of thirty was executed on January 16,1735, for the murder of her child. It was ascertained that she had passed her eatamenia about the first of the month, and thereafter had sexual intercourse M'ith one of her fellow-prisoners. On dissection both Fallopian tubes Merc found distended, and the left ovary, which bore signs of conception, was twice as large as the right. Campbell248 quotes another such case in a woman of thirty-eight who for twenty years had practised her vocation as a Cyprian, and who unexpectedly conceived. At the third month of pregnancy a hard extrauterine tumor was found, which was gradually increasing in size and extending to the left side of the hypogastrium, the associate symptoms of pregnancy, sense of pressure, pain, tormina, and dysuria, being unusually severe. There Mas subsequently an attack of inflammatory fever, followed by tumefaction of the abdomen, con- vulsions, and death on the ninth day. The fetus had been contained in the peritoneal coat of the ovary until the fourth month, M'hen one of the feet passed through the cyst and caused the fatal result, Signs of acute peritonitis were seen postmortem, the abdominal cavity Mas full of blood, and the ovary much lacerated. The termination of extrauterine pregnancy varies ; in some cases the fetus is extracted by operation after rupture ; in others the fetus has been delivered alive by abdominal section ; it may be partially absorbed, or carried many years in the abdomen ; or it may ulcerate through the confining walls, enter the bowels or bladder, and the remnants of the fetal body be discharged. a 476, 1871, ii., 189. b 527, vol. v., 277. 52 PR EN 1 TA L A NOM. 1 LIES. The curious cases mentioned by older writers, and called abortion by the mouth, etc., are doubtless, in many instances, remnants of extra- uterine pregnancies or dermoid cysts. Maroldus 5()T speaks in full of such cases; Bartholinus, Salmuth,a and a Reyesb speak of women vomiting remnants of fetuses. In Germany,0 in the seventeenth century, there lived a woman M'ho on three different occasions is said to have vomited a fetus. 1 he last miscarriage in this manner was of eight months' growth and was acconi- Fig. 2 -Pregnant Fallopian tube laid open, showing the fetus killed by hemorrhage into its membranes but without the escape of the fetus from the tube (Tuttle aud Cragin). panied by its placenta. The older observers thought this woman must have had two orifices to her womb, one of M'hich had some connection M'ith the stomach, as they had records of the dissection of a female in whom Mas found a conformation similar to this. Discharge of the fetal bones or even the whole of an extrauterine fetus by the rectum is not uncommon. There are two early cases mentioned d in a 706, cent, iii., No. 94. b Campus Elys. Jncund., Qugest 41 90 c 302, iv., 180. d 629, 1748. 1015. DISCHARGE OF FETUS FROM ABDOMINAL WALLS. 53 which the bones of a fetus were discharged at stool, causing intense pain. Armstrong* describes an anomalous case of pregnancy in a syphilitic patient who discharged fetal bones by the rectum. Bubendorf b reports the sponta- neous elimination of a fetal skeleton by the rectum after five years of reten- tion, with recovery of the patient. Butcherc speaks of delivery through the rectum at the fourth month, with recovery. Depaul mentions a similar ex- pulsion after a pregnancy of about two months and a half. Jackson d reports the dissection of an extrauterine sac which communicated freely with the large intestine. Peck e has an example of spontaneous delivery of an extra- uterine fetus by the rectum, with recovery of the mother. Skippon,f in the early part of the last century, reports the discharge of the bones of a fetus through an " imposthume " in the groin. Other cases of anal discharge of the product of extrauterine conception are recorded by Winthrop, AVoodbury, Tuttle, Atkinson, Browne, Weinlechner, Gibson, Littre, Magruder, Gilland, and many others. De Brun du Bois-Noir s speaks of the expulsion of extra- uterine remains by the anus after seven years, and Heyerdahlh after thirteen years. Benhami mentions the discharge of a fetus by the rectum; there was a stricture of the rectum associated with syphilitic patches, necessitating the performance of colotomy. Bartholinus 190 and Rosseus 692 speak of fetal bones being discharged from the urinary passages. Ebersbach, in the Ephemerides of 1717, describes a necropsy in which a human fetus was found contained in the bladder. In 1878 AVhitej reported an instance of the discharge of fetal remains through the bladder. Discharge of the Fetus through the Abdominal Walls.—Margaret Parry of Berkshirek in 1668 voided the bones of a fetus through the flesh above the os pubis, and in 1684 she Mas alive and well, having had healthy children afterward. Brodiel reports the history of a case in a negress who voided a fetus from an abscess at the navel about the seventeenth month of conception. Modern instances of the discharge of the extrauterine fetus from the walls of the abdomen are frequently reported. Algora m speaks of an abdominal pregnancy in which there was spontaneous perforation of the anterior abdominal parietes, followed by death. Bouzaln cites an extraor- dinary case of ectopic gestation in M^hich there was natural expulsion of the fetus through abdominal Malls, with subsequent intestinal strangulation. An artificial anus was established and the mother recovered. Brodie, Dunglison, Erich, Rodbard, Fox, and AVilson are among others reporting the expulsion of remnants of ectopic pregnancies through the abdominal parietes. Camp- bell quotes the case of a Polish woman, aged thirty-five,0 the mother of nine a 490, 1835, xvi., 51. b 140, 1886, xxvi., 269. c Am. Med. Jour., St. Louis, 1886. d 21S, 1865. e 218, 1870, lxxxiii., 22. t 629, 1731. 8 242, 1883. b 603, 1847. ' 224, 1876. J 764 (1878), 1879, iii., 101. k 629, 1700, 219. 1 Ibid. mClinica, Zaragoza, 1878, ii., 221. n 497, 1884, 513. o 504, vol. xix., No. 2. 54 PRENA TA L A NOMA LIES children, most of whom M'ere stillborn, M'ho conceived for the tenth time, the gestation being normal up to the lying-in period. She had pains followed by extraordinary effusion and some blood into the vagina. After various protracted complaints the abdominal tumor became painful and inflamed m the umbilical region. A breach in the M'alls soon formed, giving exit to purulent matter and all the bones of a fetus. During this process the patient received no medical treatment, and frequently no assistance in dressing the opening. She recovered, but had an artificial anus all her life. Sarah McKinna* was married at sixteen and menstruated for the first time a month thereafter. Ten months after marriage she showed signs of preg- nancy and was delivered at full term of a living child ; the second child was born ten months after the first, and the second month after the second birth she again showed signs of pregnancy. At the close of nine months these symptoms, with the exception of the suppression of menses, subsided, and in this state she continued for six years. During the first four years she felt discomfort in the region of the umbilicus. About the seventh year she suffered tumefaction of the abdomen and thought she had conceived again. The abscess burst and an elbow of the fetus protruded from the wound. A butcher enlarged the wound and, fixing his finger under the jaw of the fetus, extracted the head. On looking into the abdomen he perceived a black object, whereupon he introduced his hand and extracted piecemeal an entire fetal skeleton and some decomposed animal-matter. The abdomen Mas bound up, and in six M'eeks the woman Mas enabled to superintend her domestic affairs ; excepting a ventral hernia she had no bad after-results. Kimura,b quoted by Whitney, speaks of a case of extrauterine pregnancy in a Japanese woman of forty-one similar to the foregoing, in which an arm protruded through the abdominal Mall above the umbilicus and the remains of a fetus were removed through the aperture. The accompanying illustra- tion (Fig. 3) shoM's the appearance of the arm in situ before extraction of the fetus and the location of the Mround. Bodinierc and Lusk d report instances of the delivery of an extrauterine fetus by the vagina ; and Mathieson e relates the history of the delivery of a living ectopic child by the vagina, M'ith recovery of the mother. Gordonf speaks of a curious case in a negress, six months pregnant, in M'hich an extra- uterine fetus passed down from the posterior culdesac and occluded the uterus. It Mas removed through the vagina, and two days later labor-pains set in, and in two hours she Mas delivered of a uterine child. The placenta M'as left behind and drainage established through the vagina, and the woman made complete recovery. Combined Intrauterine and Extrauterine Gestation.—Many M-ell- authenticated cases of combined pregnancy, in which one of the products of a 629, viii., 517. b 791; 1393. c 616, v., 79- d 125, xix., 242. e 224, 1884, i., 99. f 817, October, 1848. COMBINED ECTOPIC AND UTERINE GESTATION. 55 conception was intrauterine and the other of extrauterine gestation, have been recorded. Clark and Ramsbothama report instances of double conception, one fetus being born alive in the ordinary manner and the other located extrauterine. Chasserb speaks of a case in M'hich there was concurrent pregnancy in both the uterus and the Fallopian tube. Smith0 cites an instance of a woman of twenty-three M'ho became pregnant in August, 1870. In the following December she passed fetal bones from the rectum, and a month later gave birth to an intrauterine fetus of six months' growth. McGee d mentions the case of a woman of twenty-eight M'ho became pregnant in July, 1872, and on October 20th and 21st passed several fetal bones by the rectum, and about four months later expelled some from the uterus. From this time she rapidly recovered her strength and health. Devergiee quotes an instance of a woman of thirty who had several children, but M'ho died sud- Fig. 3.—A, protrusion of an arm in ectopic gestation; B, after operation (Kimura). denly, and being pregnant was opened. In the right iliac fossa was found a male child weighing 5 pounds and 5 ounces, 8} inches long, and of about five months' growth. The uterus also contained a male fetus of about three months' gestation. Figure 4 shows combined intrauterine and extra- uterine gestation. Hodgenf speaks of a woman of twenty-seven, M'ho was regular until November, 1872; early in January, 1873, she had an attack of pain M'ith peritonitis, shortly after M'hich what Mas apparently an extra- uterine pregnancy gradually diminished. On August 17,1873, after a labor of eight hours, she gave birth to a healthy fetus. The hand in the uterus detected a tumor to the left, M'hich M'as reduced to about one-fourth the former size. In April, 1874, the woman still suffered pain and tenderness a 548, 1856, 591- b 463, Aout., 1812, 415. c 481, February, 1873. d 681, March, 1875. e Medecine Legale, i., 508. * 703, August, 1874. 56 PRENA TAL ANOMALIES. in the tumor. Hodgen believed this to have been originally a tubal preg- nancy, M'hich burst, causing much hemorrhage and the death of the fetus, together M'ith a limited peritonitis. Beacha has seen a twin compound pregnancy in M'hich after connection there M'as a miscarriage in six M'eeks, and four years after delivery of an extrauterine fetus through the abdominal M'alls. Cooke cites an example of intrauterine and extrauterine pregnancy progressing simultaneously to full period of gestation, M'ith resultant death. Rossetb reports the case of a woman of twenty-seven, who menstru- ated last in November, 1878, and on August 5, 1879, was delivered of a well-developed dead female child weighing seven pounds. The uterine contractions were feeble, and the attached placenta was removed only with difficulty; there was considerable hemorrhage. The hemorrhage continued to occur at intervals of two weeks, and an extrauterine tumor re- mained. Two weeks later septicemia supervened and life Mas despaired of. On the loth of October a portion of a fetus of five months' growth in an ad- vanced stage of decomposition protruded from the vulva. After the escape of this putrid mass her health returned, and in four months she M'as again robust and healthy. Whinery c speaks of a young woman who at the time of her second child-birth observed a tumor in the ab- domen on her right side and felt motion in it. In about a month she was seized with severe pain which continued a week and then ceased. Health soon improved, and the woman afterward gave birth to a third child ; subsequently she noticed that the tumor had enlarged since the first birth, and she had a recur- rence of pain and a slight hemorrhage every three weeks, and distinctly felt motion in the tumor. This continued for eighteen months, when, after a most violent attack of pain, all movement ceased, and, as she expressed it, she knew the moment the child died. The tumor lost its natural consistence and felt flabby and dead. An incision M'as made through the linea alba, and the knife came in contact M'ith a hard, gritty substance, three or four lines thick. The escape of several quarts of dark brown fluid followed the incision, and the operation had to be discontinued on account of the ensuing syncope. About six weeks aftenvard a bone presented at the orifice, M'hich the woman extracted and this Mras soon followed by a mass of bones, hair, and putrid matter. The discharge was small, and gradually grew less in quantity and offensiveness, a 459, 1871. b 133, April, 1878. c 124, 1846. Fig. 4.—Combined intrauterine and extrauterine gestation (Brit. Med. Jour., May 12, 1894). DELIVERY OF A VIABLE ECTOPIC FETUS. 57 soon ceasing altogether, and the wound closed. By December health M'as good and the menses had returned. Ahlfeld, Ambrosioni, Galabin, Packard, Thiernesse, Maxson, de Belami- zaran, Dibot, and Chabert are among others recording the phenomenon of coexisting extrauterine and intrauterine pregnancy. Arglesa mentions simultaneous extrauterine fetation and superfetation. Sangerb mentions a triple ectopic gestation, in which there was twin pregnancy in the Mall of the uterus and a third ovum at the fimbriated end of the right tube. Careful examination showed this to be a case of intramural twin pregnancy at the point of entrance of the tube and the uterus, while at the abdominal end of the same tube there was another ovum,—the whole being an example of triple unilateral ectopic gestation. The instances of delivery of an extrauterine fetus, with viability of the child, from the abdomen of the mother would attract attention from their rarity alone, but when coupled with associations of additional interest they surely deserve a place in a work of this nature. Osiander615 speaks of an abdominal fetus being taken out alive, and there is a similar case on record in the early part of this century.c The London Medical and Physical Journal, in one of its early numbers, contained an account of an abdominal fetus penetrating the Malls of the bladder and being extracted from the walls of the hypogastrium ; but Sennertus gives a case M'hich far eclipses this, both mother and fetus surviving. He says that in this case the*woman, while pregnant, received a blow on the lower part of her body, in consequence of M'hich a small tumor appeared shortly after the accident. It so happened in this case that the peritoneum was extremely dilatable, and the uterus, with the child inside, made its May into the peritoneal sac. In his presence an incision Mas made and the fetus taken out alive. Jessopd gives an ex- ample of extrauterine gestation in a woman of twenty-six, M'ho had pre- viously had normal delivery. In this case an incision was made and a fetus of about eight months' growth Mas found lying loose in the abdominal cavity in the midst of the intestines. Both the mother and child Mere saved. This is a very rare result. Campbell, in his celebrated monograph, in a total of 51 operations had only seen recorded the accounts of two children saved, and one of these Mas too marvelous to believe. Lawson Tait reports a case in M'hich he saved the child, but lost the mother on the fourth day. Parvin describes a case in M'hich death occurred on the third day. Brownee quotes Parry as saying that there is one twin pregnancy in 23 extrauterine concep- tions. He gives 24 cases of tM'in conception, one of which Mas uterine, the other extrauterine, and says that of 7 in the third month, M'ith no opera- tion, the mother died in 5. Of 6 cases of from four and a half to seven months' duration, 2 lived, and in 1 case at the fifth month there Mas an a 476, 1871, ii., 394- b 261, 1893. c 559, 1809, 414. d778, xviii., 261; and 610, December, 1876. e 764, 1882, vi., 444-462. 58 PRENATAL ANOMALIES. intrauterine fetus delivered M'hich lived. Of 11 such cases at nine months, 6 mothers lived and 6 intrauterine fetuses lived. In 6 of these cases no operation M'as performed. In one case the mother died, but both the uterine and the extrauterine conceptions lived. In another the mother and intra- uterine fetus died, and the extrauterine fetus lived. Wilson a gives an instance of a woman delivered of a healthy female child at eight months M'hich lived. The after-birth came away without assistance, but the woman still pre- sented every appearance of having another child within her, although ex- amination by the vagina revealed none. Wilson called Chatard in consulta- tion, and from the fetal heart-sounds and other symptoms they decided that there Mas another pregnancy wholly extrauterine. They allowed the case to go twenty-three days, until pains similar to those of labor occurred, and then decided on celiotomy. The operation Mas almost bloodless, and a living child M'eighing eight pounds was extracted. Unfortunately, the mother succumbed after ninety hours, and in a month the intrauterine child died from inanition, but the child of extrauterine gestation thrived. Sales'' gives the case of a negress of twenty-two, M'ho said that she had been " tricked by a negro," and had a large snake in the abdomen, and could dis- tinctly feel its movements. She stoutly denied any intercourse. It Mas decided to open the abdominal cyst; the incision Mas followed by a gush of blood and a placenta came into view, M'hich M'as extracted with a living child. To the astonishment of the operators the uterus M'as distended, and it Mas decided to open it, when another living child Mas seen and extracted. The cyst and the uterus m ere cleansed of all clots and the wound closed. The mother died of septicemia, but the children both lived and were doing well six M'eeks after the operation. A curious case Mras seen in 1814° of a woman M'ho at her fifth gestation suffered abdominal uneasiness at the third month, and this became intolerable at the ninth month. The head of the fetus could be felt through the abdomen ; an incision was made through the parietes ; a fully developed female child Mas delivered, but, unfortunately, the mother died of septic infection. The British Medical Journal quotes : " Pinard (Bull, de PAcad. de Med., August 6, 1895) records the folloM'ing, M'hich he describes as an ideal case. The patient was aged thirty-six, had had no illness, and had been regular from the age of fourteen till July, 1894. During August of that year she had nausea and vomiting; on the 22d and 23d she lost a fluid M'hich Mas just pink. The symptoms continued during September, on the 2 2d and 23d of M'hich month there was a similar loss. In October she Mas kept in bed for two days by abdominal pain, M'hich reappeared in November, and Mas then associated with pain in micturition and defecation. From that time till February 26, 1895, when she came under Pinard's care, she Mas attended by several doctors, each of M'hom adopted a different a 125, 1880, xiii., 821-836. b 593) October, 1870. c 460, XV-) 51 IDEAL CASE OF ECTOPIC GESTATION. 59 diagnosis and treatment. One of them, thinking she had a fibroid, made her take in all about an ounce of savin poM'der, M'hich did not, however, pro- duce any ill effect. AVhen admitted she looked ill and pinched. The left thigh and leg were painful and edematous. The abdomen looked like that of the sixth month of pregnancy. The abdominal wall Mas tense, smooth, and M'ithout lineae albicantcs. Palpation revealed a cystic immobile tumor, extending 2 inches above the umbilicus and apparently fixed by deep adhesions. The fetal parts could only be made out with difficulty by deep palpation, but the heart-sounds were easily heard to the right of and below the umbilicus. By the right side of this tumor one could feel a small one, the size of a Tangerine orange, M'hich hardened and softened under examina- tion. AVhen contracted the groove between it and the large tumor became evident. Vaginal examination showed that the cervix, which was slightly deflected forward and to the right and softened, as in uterine gestation, Mas continuous M'ith the smaller tumor. Cephalic ballottement Mas obtained in the large tumor. Xo sound Mas passed into the uterus for fear of setting up reflex action; the diagnosis of extrauterine gestation at about six and a half months with a living child Mas established M'ithout requiring to be clinched by proving the uterus empty. The patient Mas kept absolutely at rest in bed and the edema of the left leg cured by position. On April 30th the fundus of the tumor M'as 35 cm. above the symphysis and the uterus 1H cm.; the cervix Mas soft as that of a primipara at term. Operation, May 2d : Uterus found empty, cavity 14| cm. long. Median incision in abdominal wall; cyst walls exposed ; seen to be very slight and filled with enormous vessels, some greater than the little finger. On seizing the wall one of these vessels burst, and the hemorrhage Mas only rendered greater on attempting to secure it, so great M'as the friability of the M'alls. The cyst was therefore rapidly opened and the child extracted by the foot. Hemorrhage was re- strained first by pressure of the hands, then by pressure-forceps and ligatures. The walls of the cyst M'ere sewn to the margins of the abdominal Mound, the edge of the placenta being included in the suture. A wound was thus formed 10 cm. in diameter, with the placenta for its base; it M'as filled M'ith iodo- form and salicylic gauze. The operation lasted an hour, and the child, a boy weighing 5J pounds, after a brief period of respiratory difficulties, M-as perfectly vigorous. There Mas at first a slight facial asymmetry and a depression on the left upper jaw caused by the point of the left shoulder, against M'hich it had been pressed in the cyst; these soon disappeared, and on the nineteenth day the boy weighed 12 pounds. The maternal wound was not dressed till May 13th, M'hen it Mas Mashed with biniodid, 1 : 4000. The placenta came away piecemeal between May 25th and June 2d. The wound healed up, and the patient got up on the forty-third day, having suckled her infant from the first day after its birth." Date of opera- tion. Name of operator. Aug. 11, 187"). July 9, 1881. June 6, 1885. Nov. 4, 1885. Mav 211, 1887. Oct. 20, 1887. July 10, 1X88. Nov. 1, 18SS. Mr. T. R. Jessup, Leeds, Eng- land. Dr. A. Martin, Berlin. John Williams, London. J. Lazarewitch, Kharkof, Russia Hector Treub, Leyden. Aug. Breisky, Vienna. Joseph East- man, Indian- apolis. R. Olshauscn, Berlin. i) | Feb. 11, Carl Braun von 1889. | Fermvald, Vi- enna. 39 39 30 is p.p< Period of gestation. 33d to 34th week. 7 months. 35th week 9 months. 2 to 3 weeks before end of term. End of 8th month. 7 months. 9 months. End of term. Result to child. Living, but died at eleven months from croup. Alive, cord pulsating, but did not breathe ; had a large encephalocele. Died in a few minutes. Lived 26 days. Living, weight over 4 pounds. A year later a strong, healthy boy. Alive and well, weight 5 pounds, but died 3 weeks later from phle- bitis of umbilical vein. Living, weight 4 pounds. Died at eight and a half months from pneumo- nia. Living, weight 5 pounds. When a year old, weight 14 pounds. Living, weight over 6 pounds. Died seventy- two hours after birth from lobular pneumo- nia due to inspiration of amniotic fluid. Details of operation. Placenta not removed; no sac, fetus free in abdominal cavity among intestines. Placenta removed after ligation at three points. Placenta not removed, sac drained. Placenta and cyst drawn out, pressed up in the abdominal wound, ligated, and large portion removed. After incision of the sac, which bled freely, placenta was perfor- ated with hand, and after extracting child bleeding was con- trolled by compressing each half of placenta by the hand of operator and assistant until removed : portion of sac extirpated, the rest,intimately adherent to intestines, sewed to abdominal wound and packed with Mikulicz dressing. Supposed to have been an ovarian pregnancy or a pregnancy in a tuboovarian cyst. Tubal intraligamentous pregnancy. After removing child from the sac, the latter was drawn out, ligated at its juncture with the uterus, and removed, containing placenta and membranes, and cavity drained. Mother recovered perfectly in three weeks. Intraligamentous tubal pregnancy. Clamped uterine end of tube and broad ligament, and enucleated fetal sac containing pla- centa intact, and quilted the pedicle with cobbler's stitch, using iron-dyed silk. Fetus free in abdominal cavity, also largest part of placenta, between loops of intestines; the latter adherent to right broad ligament with only about one-third of its periphery. This last portion was easily surrounded, and proved so thin that two mass ligatures of silk were sufficient to securely tie off the pla- centa with attached portion of broad ligament. * Only shreds of fetal membranes were attached to placenta. Child free in abdominal cavity; placenta adherent to posterior surface of uterus and right broad ligament, extends deep into Douglas's culdesac, and firmly attached to descending colon. After ligating right broad ligament in number of places pla- centa can be detached in a number of places without much hemorrhage. Removal of sac necessitated elastic ligature around uterus to check bleeding, and supravaginal hysterec- tomy. References. Tait on Diseases of Women and Abdominal Surgery, vol. i. p. 495. Berlin, klin. W'och., De- cember 2t'>, 1881; Harris, " Intrauterine Preg- nancy," Am. Jour. Med. Sci., September, 1888. Hrit. Med Jour., Decem- ber 3, 1887 ; Harris, ibid. Vrach.St. Petersburg,1886; Harris, ibid. Zeitschrift fiir Oeburtsh. unil Oynak., Band xv. S. 384, 1888. Wiener mcd. W'ochcn- schrift, 1887, N'os. -18, -19, and .r>(',; and Eastman, in Am. Jour. Obstet., vol. xxi., 18NX. Am. Jour. Obstet., 188-H, p. 929. Deutsche med. W'ochen- schrift, 1890, p. 171. Archiv f. Gynak., Heft ii., 1890. 10 Feb. 27, R. Olshausen, 1889. Berlin. 11 Feb. 4, 1890. 12 13 1891. G. Rein, Kiew, Russia. John W.Taylor, Birmingham, Eng. Jan. 10, Prof. Schauta, 1891. Vienna. 14 Oct. 23, 1892. 15 16 Aug. 19, 1893. 1894. Dr. Mordecai Price, Phila- delphia. Wm. T. Lusk, New York. Hector Trcub, Leyden April 4, X. O. Wcrder, 1894. Pittsburgh. 32 35 4 9 months. 37th week. 7 months. 33 1 6 months. 1 fore term 2 weeks be fore term Alive, but very much de- formed. Died one and half hours after birth. Living, weight 6 pounds; slight asymmetry of head. Two years after operation was hearty and well. Living. Living. Living. Lived twenty-four hours. Lived several weeks. Lived four days. sac and placenta left undisturbed and drained with iodoform- Deutsche _ mcd. gauze packing. Spontaneous expulsion of placenta on thirty- 1890, p. 171. fourth day. Interesting is the daily copious discharge of fluid from the vagina during the eighth month, which was undoubt- edly amniotic fluid draining away through tube. No amniotic fluid present during operation. Intraligamentous tubal pregnancy. Sac, placenta, and fetal Centralblatt membrane removed entire by enucleation from the peritoneum, No. 50, 1892. in the same manner as practised in removal of intraligament- ous ovarian cyst. Woch., f. Gynak., Fetus free in abdominal cavity ; placenta left behind and drain- age-tube introduced, and umbilical cord drawn out of the lower angle of the wound. Patient recovered after very protracted convalescence, complicated by sepsis, thrombosis of left iliac, the inferior cava, the right iliac, and right renal veins. After tying ovarian artery at the peritoneal fold, which con- stituted the residue of the infundibulopelvic ligament, he in- cised the peritoneal covering in a circular line corresponding nearly to the largest circumference of the sac. The enuclea- tion of the latter was readily accomplished without rupture of sac-walls. Considerable hemorrhage resulted from detach- ment of the ovum from the uterus, which was temporarily controlled by pressure and later by sutures. The peritoneal borders of the cavity were then sutured to the parietal perito- neum, and the cavity itself was drained by a Mikulicz tampon. Placenta attached to uterine attachment of left tube and the entire pelvic viscera of the left side from the spine, and extend- ing up to the kidney posteriorly and covering the descending colon. It was slightly wounded in the abdominal incision and the cause of considerable hemorrhage ; this was controlled by clamping-forceps, which were allowed to remain until first dressing. The child was enveloped only by amniotic sac, to which were attached the transverse colon and also small in- testines to a slight extent. Placenta left and sac packed with iodoform-gauze. Last portion of placenta removed on thirty- fifth day. Pregnancy started in right tube, and subsequently developed to a great extent between the folds of broad ligaments. Tied ovarian and uterine arteries of right side, and then enucle- ated entire sac with placenta. Fetus free in abdominal cavity. Supravaginal amputation of uterus; removal of placenta and sac. (Private communication from R. P. Harris.) Child enveloped in amniotic sac and also partly by folds of broad ligaments. Placenta removed after clamping'and subsequently tying ovarian and uterine arteries of left side. Part of sac incised, but portion had to be left on account of tirm intestinal adhesion. Edges of sac and stump of left broad ligament drawn together by sutures and attached to parietal peritoneum, and drained by Mikulicz gauze packing. Obstet. Trans, of London for 1891, p. 1151 ; and Lusk, in New York Jour, of Gvnecol. and Obstet., July, 1893. Beitriige f. Casuistik Prog- nose und Therapie der Extrauterine Schwan- ger«chaft, Prag, 1891; c Lusk, in New York Jour, of Gvnecol. and Obstet,, July, 1893. Transactions of the State Medical Society of Penn- sylvania, 1893, p. 152. Lusk, "Technique of Pri- mary Celiotomy in Ad- vanced Ectopic Gesta- tion," in N. V. Jour, of Gynecol, and Obstet., July, 1893. Bulletin Mem. Soc. Obstet. et Gvnecol. de Paris, 1894. " Med. Rec, Nov. 24,1894. &5 s 3 © 62 PRENATAL ANOMALIES. Quite recently AVerdera has investigated the question of the ultimate fate of ectopic children delivered alive. lie has been able to obtain the record of 40 cases. Of these, 18 died within a week after birth ; 5 within a month ; 1 died at six months of bronchopneumonia; 1 at seven months of diarrhea ; 2 at eleven months, 1 from croup ; 1 at eighteen months from cholera infantum—making a total of 26 deaths and leaving 14 children to be ac- counted for. Of these, 5 were reported as living and Mell after operation, M'ith no subsequent report; 1 was strong and healthy after three M'eeks, but there has been no report since ; 1 Mas M'ell at six months, then M'as lost sight of; 1 Mas Mell at the last report; 2 lyye and are well at one year ; 2 are living and M'ell at two years ; 1 (Beisone's case) is well at seven years ; and 1 (Tait's case) is well at fourteen and one-half years. The list given on pages 60 and 61 has been quoted by Hirst and Dorland.b It contains data relative to 17 cases in which abdominal section has been successfully performed for advanced ectopic gestation M'ith living children. Long Retention of Extrauterine Pregnancy.—The time of the reten- tion of an extrauterine gestation is sometimes remarkable, and it is no un- common occurrence for several pregnancies to successfully ensue during such retention. The Ephemerides contains examples of extrauterine pregnancy remaining in the abdomen forty-six years ;c Hannseusd mentioned an in- stance remaining ten years, the mother being pregnant in the meantime ; Primperosius speaks of a similar instance ; de Blegny,e one of twenty-five years in the abdomen; Birch, a case of eighteen years in the abdomen, the M'oman bearing in the meantime; Bayle/ one of twenty-six years, and the Ephemerides, another. In a woman of forty-six,s the labor pains inter- vened M'ithout expulsion of the fetus. Impregnation ensued twice after- ward, each followed by the birth of a living child. The woman lived to be ninety-four, and was persuaded that the fetus M'as still in the abdomen, and directed a postmortem examination to be made after her decease, which Mas done, and a large cyst containing an ossified fetus was discovered in the left side of the cavity. In 1716 h a woman of Joigny when thirty years old, having been married four years, became pregnant, and three months later felt movements and found milk in her breasts. At the ninth month she had labor-pains, but the fetus failed to present; the pains ceased, but recurred in a month, still M'ith a negative result. She fell into a most sickly condition and remained so for eighteen months, M'hen the pains returned again, but soon ceased. Menstruation ceased and the milk in her breasts remained for thirty years. She died at sixty-one of peripneumonia, and on postmortem examination a tumor M'as found occupying part of the hypogas- tric and umbilical regions. It weighed eight pounds and consisted of a male a 538, Nov. 24, 1894. b 843, 372. c 104, cent, x., obs. 48. d Prod. Act., Havn., 107. e 215, Ann. I., obs. 9, Jan.; obs. 8, Feb. f 629, London, xii. S 418, 1721, 422. l»302, iv.,233. LONG RETENTION OF UTERINE PREGNANCY. 63 fetus of full term M'ith six teeth ; it had no odor and its sac contained no liquid. The bones seemed better developed than ordinarily; the skin Mas thick, callous, and yellowish. The chorion, amnion, and placenta were ossi- fied and the cord dried up. AValther a mentions the case of an infant which remained almost petrified in the belly of its mother for tMenty-three years. No trace of the placenta, cord, or enveloping membrane could be found. Cordierb publishes a paper on ectopic gestation, M'ith particular reference to tubal pregnancy, and mentions that when there is rupture between the broad ligaments hemorrhage is greatly limited by the resistance of the sur- rounding structures, death nirely resulting from the primary rupture in this location. Cordier gives an instance in which he successfully removed a full- grown child, the result of an ectopic gestation M^hich had ruptured intraliga- mentally and had been retained nearly two years. Lospichlerus c gives an account of a mother carrying twins, extrauterine, for six years. Mounsey of Riga, physician to the army of the Czarina, sent to the Royal Society in 1748 the bones of a fetus that had been extracted from one of the fallopian tubes after a lodgment of thirteen years. Starkey Middlcton d read the report of a case of a child M'hich had been taken out of the abdomen, having lain there nearly sixteen years, during M'hich time the mother had borne four children. It Mas argued at this time that boys were conceived on the right side and girls on the left, and in commenting on this Middlcton remarks that in this case the woman had three boys and one girl after the right fallopian tube had lost its function. Chester6 cites the instance of a fetus being retained fifty-two years, the mother not dying until her eightieth year. Margaret Mathewf carried a child weighing eight pounds in her abdomen for twenty-six years, and which after death was extracted. Aubreyg speaks of a woman aged seventy years unconsciously carrying an extrauterine fetus for many years, which M'as only discovered postmortem. She had ceased to menstruate at forty and had borne a child at twenty-seven. AVatkinsh speaks of a fetus being retained forty-three years; James, others for twenty-five, thirty, forty-six, and fifty years; Murfee,1 fifty-five years; Cunningham,J forty years; Johnson,kforty-four years; Josephi,1 fifteen years (in the urinary bladder); Craddock,mtwenty- two years, and da Costa Simoes,n twenty-six years. Long Retention of Uterine Pregnancy.—Cases of long retained intra- uterine pregnancies are on record and deserve as much consideration as those that were extrauterine. Albosius speaks of a mother carrying a child in an ossified condition in the uterus for twenty-eight years.0 Cheselden speaks a Mem. de Berlin, 1774. b Annals of Gynaecol, and Paediatry, Aug., 1893. c Opera, 1737, iii., 89. d 629, 1748, 1018. e 550, vol. v., 104. f 629, 1700, 217. g 162, March, 1842. 1778, viii., 106. i 774, 1886. J 810, 1855. k Med. Times and Gaz., London, 1872. 1 535, 1805. m 526, 1846. n 278, 1H86. ° Observatio Lithopaedii Senonensis, 1682. 64 PRENA TAL ANOMALIES. of a case in which a child was carried many years in the uterus, being con- verted into a clay-like substance, but preserving form and outline. Cald- well a mentions the case of a woman who carried an ossified fetus in her uterus for sixty years. Camererb describes the retention of a fetus in the uterus for forty-six years ; Stengel,0 one for ten years, and Storer and Buzzell, for twenty- two months. Hannseus, in Hi SO, issued a paper on such a case under the title, " Mater, Infantis Mortui Vivum Sepulchrum," which may be found in French translation.'1 Buchner e speaks of a fetus being retained in the uterus for six years, and Horstius423 relates a similar case. Schmidt's Jahrbucherf contain the report of a woman of forty-nine, M'ho had borne two children. While threshing corn she felt violent pain like that of labor, and after an illness suffered a constant fetid discharge from the vagina for eleven years, fetal bones being discharged with occasional pain. This poor creature worked along for eleven years, at the end of which time she M'as forced to bed, and died of symptoms of purulent peritonitis. At the necropsy the uterus Mas found adherent to the anterior wall of the abdomen and containing rem- nants of a putrid fetus with its numerous bones. There is an instance re- corded g of the death of a fetus occurring near term, its retention and subsequent discharge being through a spontaneous opening in the abdominal wall one or two months after. Meigs h cites the case of a woman M'ho dated her pregnancy from March, 1848, and M'hich proceeded normally for nine months, but no labor super- vened at this time and the menses reappeared. In March, 1849, she passed a few fetal bones by the rectum, and in May, 1855, she died. At the necropsy the uterus was found to contain the remains of a fully developed fetus, minus the portions discharged through a fistulous connection between the uterine cavitv and the rectum. In this case there had been retention of a fully developed fetus for nine years. Coxi describes the case of a woman M'ho M-as pregnant seven months, and who was seized M'ith convulsions ; the sup- posed labor-pains passed off, and after death the fetus M-as found in the womb, having lain there for five years. She had an early return of the menses, and these recurred regularly for four years. DeMees 419 quotes two cases, in one of M'hich the child was carried twenty months in the uterus ; in the other, the mother was still living tMro years and five months after fecundation. Another caseJ" Mas in a woman of sixty, who had conceived at twenty-six, and M'hose fetus Mas found, partly ossified, in the uterus after death. There are many narratives of the long continuation of fetal move- ments, and during recent years, in the Southern States, there was quite a a 318, 1806, ii., 22-24. b 280, 1774, v., 338. c Eyr, Christiania, 1827, ii., 134. d 280, 1755, iii., 695. e Miscellan., 1728, 822. * 720, Nov. 9, 1848. g 124, v., 530. h 124, xxv., 541. i 271, 1867, ii., 385. j 318, ii., 22. SHORT PREGNANCIES. 65 prevalence of this kind of impostors. Many instances of the exhibition of fetal movements in the bellies of old negro women have been noticed by the lay journals, but investigation proves them to have been nothing more than an exceptional control over the abdominal muscles, with the ability to simulate at will the supposed fetal jerks. One old woman M'ent so far as to show the fetus dancing to the music of a banjo with rhythmical move- ments. Such impostors flourished best in the regions given to " voodooism." We can readily believe how easy the deception might be M'hen we recall the exact simulation of the fetal movements in instances of pseudocyesis. The extraordinary diversity of reports concerning the duration of preg- nancy has made this a much mooted question. Many opinions relative to the longest and shortest period of pregnancy, associated M'ith viability of the issue, have been expressed by authors on medical jurisprudence. There is perhaps no information more unsatisfactory or uncertain. Mistakes are so easily made in the date of the occurrence of pregnancy, or in the date of conception, that in the remarkable cases we can hardly accept the proposi- tions as worthy evidence unless associated with other and more convincing facts, such as the appearance and stage of development of the fetus, or cir- cumstances making conception impossible before or after the time mentioned, etc. It will be our endeavor to cite the more seemingly reliable instances of the anomalies of the time or duration of pregnancy reported in reputable periodicals or books. Short Pregnancies.—Haseneta speaks of the possibility of a living birth at four months ; Capuron relates the instance of Fortunio Liceti, who M'as said to have been born at the end of four and a half months and lived to complete his twrentv-fourth year. In the case of the Marechal de Richelieu, the Parli- ament of Paris decreed that an infant of five months possessed that capability of living the ordinary period of existence, /. e., the " viabilite," which the law of France requires for the establishment of inheritance. In his seventh book Pliny gives examples of men who Mere born out of time. Jonston b gives instances of births at five, six, seven, and eight months. Bonnar ° quotes 5 living births before the one hundred and fiftieth day; 1 of one hundred and twenty-five days ; 1 of one hundred and twenty days ; 1 of one hundred and thirty-three days, surviving to twenty-one months ; and 1 of one hundred and thirty-five days' pregnancy surviving to eighty years. Maisonneuve462 de- scribes a case in which abortion took place at four and a half months ; he found the fetus in its membranes two hours after delivery, and, on laying the mem- branes open, saw that it was living. He applied M-armth, and partly succeeded in restoring it; for a few minutes respiratory movements were performed regu- larly, but it died in six hours. Taylor757 quotes Carter concerning the case of a fetus of five months which cried directly after it was born, and in the half hour it lived it tried frequently to breathe. He also quotes Davies, a Jena, 1705. b 447, 465. <= 393, 133-4. 5 66 PRENATAL ANOMALIES. mentioning an instance of a fetus of five months, which lived twelve hours, weighing 2 pounds, and measuring 12 inches, and which cried vigorously. The pupillary membrane was entire, the testes had not descended, and the head was well covered with hair. Ushera speaks of a woman who in 1876 was delivered of 2 male children on the one hundred and thirty-ninth day ; both lived for an hour; the first weighed 10 ounces 6 drams and meas- ured 9f inches; the other 10 ounces 7 drams, M'ith the same length as the first. Routhb speaks of a Mrs. F-----, aged thirty-eight, who had borne 9 children and had had 3 miscarriages, the last conception terminating as such. Her husband M-as aM'ay, and returned October 9, 1869. She did not again see her husband until the 3d or 4th of January. The date of quickening was not observed, and the child Mas born June 8, 1870. Dur- ing gestation she M^as much frightened by a rat. The child M'as weak, the testes undescended, and it lived but eighteen days, dying of symptoms of atrophy. The parents were poor, of excellent character, and although, according to the evidence, this pregnancy lasted but twenty-two weeks and two days, there Mas absolutely no reason to suspect infidelity. Ruttel speaks of a child of five months who lived twenty-four hours ; and he saw male twins born at the sixth month weighing 3 pounds each who Mere alive and healthy a year after. Barker c cites the case of a female child born on the one hundred and fifty-eighth day that weighed 1 pound and Mas 11 inches long. It had rudimentary nails, very little hair on the head, its eyelids Mere closed, and the skin much shriveled ; it did not suckle properly, and did not M'alk until nineteen months old. Three and a half years after, the child Mas healthy and thriving, but weighed only 29^ pounds. At the time of birth it Mas wrapped up in a box and placed before the fire. Brouzet speaks of living births of from five to six months' preg- nancy, and Kopp d speaks of a six months' child which lived four days. The Ephemerides contains accounts of living premature births. Newinton describes a pregnancy of five months terminating with the birth of twins, one of whom lived twenty minutes and the other fifteen. The first was 11J inches long, and weighed 1 pound 3 J ounces, and the other M-as 11 inches long, and weighed 1 pound. There is a recent instance of premature birthe following a pregnancy of between five and a half and six months, the infant weighing 955 grams. One month after birth, through the good offices of the wet-nurse and M. Villemin, who attended the child and mIio invented a "couveuse" for the occasion, it measured 38 cm. long. Mooref is accredited with the trustworthy report of the case of a woman M'ho bore a child at the end of the fifth month weighing 1J pounds and measuring 9 inches. It was first nourished by dropping liquid food into its mouth; and at the age of fifteen months it was healthy and M-eighed 18 a 180, 1886, 366. b 778, xiii., 132. c 546, 1850, ii., 249, and 392. d 444^ j^ 129. e 674, 1895, Jan., p. 22. f 545, 1180; and quoted by 548, 1880, ii., 8. SHORT PREGNANCIES. 67 pounds. Eikama saw a case of abortion at the fifth month in M'hich the fetus Mas 6 inches in length and weighed about 8 ounces. The head was sufficiently developed and the cranial bones considerably advanced in ossifi- cation. He tied the cord and placed the fetus in warm Mater. It drew up its feet and arms and turned its head from one side to the other, opening its mouth and trying to breathe. It continued in this M'ise for an hour, the action of the heart being visible ten minutes after the movements ceased. From its imperfectly developed genitals it was supposed to have been a female. Professor J. Miiller, to M'hom it was shown, said that it Mas not more than four months old, and this coincided with the mother's calculation. Villeminb before the Societe Obstetricale et Gynecologique reported the case of a two-year-old child, born in the sixth month of pregnancy. That the child had not had six months of intrauterine life he could vouch, the statement being borne out by the last menstrual period of the mother, the date of the first fetal movements, the child's weight, which was 30 J ounces, and its appearance. Budin had had this infant under observation from the beginning and corroborated Villemin's statements. He had examined infants of six or seven months that had cried and lived a few days, and had found the alveolar cavities filled with epithelial cells, the lung sinking M'hen placed in a vessel of water. Charpentier reported a case of premature birth in his practice, the child being not more than six and a half months and M-eighing 33J ounces. So sure Mras he that it would not live that he placed it in a basin while he attended to the mother. After this had been done, the child being still alive, he M'rapped it in cotton and was surprised next day to find it alive. It was then placed in a small, well-heated room and fed with a spoon on human milk ; on the twelfth day it could take the breast, since which time it thrived and grew. There is a case on record0 of a child viable at six months and twenty days. The mother had a miscarriage at the beginning of 1877, after which menstruation became regular, appearing last from July 3 to 9, 1877. On January 28, 1878, she gave birth to a male infant, which was wrapped in M'adding and kept at an artificial temperature. Being unable to suckle, it Mas fed first on diluted com's milk. It M'as so small at birth that the father passed his ring over the foot almost to the knee. On the thirteenth day it weighed 1250 grams, and at the end of a week it M'as taking the breast. In December, 1879, it had 16 teeth, weighed 10 kilograms, walked with agility, could pronounce some words, and was especially intelligent. Capuron 254 relates an instance of a child born after a pregnancy of six and a half months and in excellent health at two years, and another living at ten years of the same age at birth. Taitd speaks of a living female child, born on the one hundred and seventy-ninth day, with no nails on its fingers or toes, no hair, the extremities imperfectly developed, and the skin florid and thin. It a 558. B. v., H. 2. b 791, March, 1895. c 168, Dec, 1879. d 476, April 23, 1842. 68 PRENATAL ANOMALIES. was too feeble to grasp its mother's nipple, and was fed for three M'eeks by milk from the breast through a quill. At forty days it Meighed 3 pounds and measured 13 inches. Before the expiration of three months it died of measles. Dodd a describes a case in M'hich the eatamenia were on the 24th of June, 1838, and continued a week ; the woman bore twins on January 11, 1839, one of which survived, the other dying a few minutes after birth. She Mas never irregular, prompt to the hour, and this fact, coupled with the diminutive size of the children, seemed to verify the dura- tion of the pregnancy. In 1825, Baber of Buxur, India, spoke of a child born at six and a half months, who at the age of fifty days Meighed 1 pound and 13 ounces and was 14 inches long. The longest circumference of the head was 10 inches and the shortest 9.1 inches. The child suckled freely and readily. In Spaeth's clinic b there Mas a viable infant at six and a half months weighing 900 grams. Spaeth says that he has known a child of six months to surpass in eventual development its brothers born at full term. In some cases there seems to be a peculiarity in women M'hich manifests itself by regular premature births. La Motte, van Swieten, and Fordere mention females who always brought forth their conceptions at the seventh month. The incubator seems destined to be the future means of preserving these premature births. Several successful cases have been noticed, and by means of an incubator Tarnier succeeded in raising infants which at the age of six months were above the average. A full description of the incu- bator may be found.0 The modified Auvard incubator is easily made ; the accompanying illustrations (Figs. 5, 6, and 7) explain its mechanism. Several improved incubators have been described in recent years, but the Auvard ap- pears to be the most satisfactory. The question of retardation of labor, like that of premature birth, is open to much discussion, and authorities differ as to the limit of protraction with viability. Aulus Gellius d says that, after a long conversation M'ith the physicians and wise men, the Emperor Adrian decided in a case before him, that of a woman of chaste manners and irreproachable character, the child born eleven months after her husband's death was legitimate. Under the Roman law the Decemviri established that a woman may bear a viable child at the tenth month of pregnancy. Paulus Zacchias,830 physician to Pope Innocent X., declared that birth may be retarded to the tenth month, and sometimes to a longer period. A case was decided in the Supreme Court of Friesland, a province in the northern part of the Netherlands, October, 1634, in Mrhich a child born three hundred and thirty-three days after the death of the husband was pronounced legitimate. The Parliament of Paris was gallant enough to come to the rescue of a widow and save her a 656, 1841. b 118, May 16, 1882. c 536, 1883, i., 39. d L. iii., chap. 16. L ONG PREGNA NCIES. 69 reputation by declaring that a child born after a fourteen months' gestation was legitimate. Bartholinus speaks of an unmarried woman of Leipzig M'ho was delivered after a pregnancy of sixteen months. The civil code of France provides that three hundred days shall constitute the longest period Fig. 5.—Modified Auvard incubator; v, glass plate of the movable lid, 6; H, ventilating tube containing small rotary fan; K, ventilating slide ; M, hot-water cans ; O, slide closing hot-air chamber. of the legitimacy of an infant; the Scottish law, three hundred days ; and the Prussian law, three hundred and one days. There are numerous cases recorded by the older writers. Amman 128 has one of twelve months' duration; Enguin,3 one of twelve months'; Fig. 6.—Interior view of a modified Auvard incubator. Buchner,b a case of twelve months'; Benedictus,196 one of fourteen months'; de Blegny,0 one of nineteen months'; Marteau,d Osiander, and others of forty-two and forty-four weeks' ; and Stark's Archives,*5 one of forty-five a 462, T. lxi., 163. d 462, T. xxv. bMiscel., 1727, 170. o 215, Ann. i., 23. e 162, L. ii., 3 st. n. 2. 70 PRENATAL ANOMALIES. weeks', living, and also another case of forty-four M'eeks'. An incredible case is recorded51 of an infant M'hich lived after a three years' gestation. Instances of twelve months' duration are also recorded.401' 172 b Jonston 447 quotes Paschal in relating an instance of birth after pregnancy of twenty- three months ; Aventium, one after two years ; and Mercurial is, a birth after a four years' gestation—M'hich is, of course, beyond belief. Thormeau writes from Tours, 1580, of a case of gestation prolonged to the twenty-third month, and Santorini, at Venice, in 1721, describes a similar case, the child reaching adult life. El vertc records a case of late pregnancy, and Henschel495 one of forty-six weeks, but the fetus Mas dead. Schneiderd cites an instance of three hundred and eight days' duration. Campbell says e that Simpson had cases of three hundred and nineteen, three hundred and thirty-two, and three hundred and thirty-six days'; Meigs had one of four hundred and twenty. James Reid, in a table of 500 mature births, gives 14 as being from three hundred and two to three hundred and fifteen days'. Not so long ago a jury rendered a verdict of guilty of fornication and bastardy when it was alleged that the child Mas born three hundred and seventeen days after intercourse. Taylor relates a case of pregnancy in which the wife of a laborer went to America three hundred and twenty-two days before the birth. Jaffef describes an instance of the prolongation of pregnancy for three hundred and sixty-five days, in M'hich the developments and measurements corresponded to the length of protraction. Bryang speaks of a woman of twenty-five M'ho became pregnant on February 10, 1876, and on June 17th felt motion. On July 28th she Mas threatened with miscar- riage, and by his advice the woman weaned the child at the breast. She expected to be confined the middle of November, 1876, but the expected event did not occur until April 26, 1877, nine months after the quickening and four hundred and forty days from the time of conception. The boy was active and weighed nine pounds. The author cites Meigs' case, and also one of Atlee's, at three hundred and fifty-six days. Talcott,h Superintendent of the State Homeopathic Asylum for the Insane, explained the pregnancy of an inmate who had been confined for four years in this institution as one of protracted labor. He said that many such cases have been reported, and that something less than two years before he had charge of a case in which the child was born. He made the report to the New York Senate Commission on Asylums for the Insane as one of three years' protraction. Tiddi speaks of a woman M'ho Mas delivered of a male child at term, and again in ten months delivered of a Mell-developed male child weighing 7£ pounds ; he relates the history of another case in Clifton, \V. Va., of a woman expecting confinement on June 1st going over a 418, 1753, 206. b 462, T. xxvii., 4*. c 137, b. iii., 257. d Annalen der Heilk., 1811, Oct., 87. e 512, iss, viii., 145, 149. f 261, 1890. g 703, 1877, n. s. xiv., 345. h 224, 1883, ii., 665. i 299, xi., 798. LONG PREGNANCIES. 71 to September 15th, the fetus being in the uterus over twelve months, and nine months after quickening Mas felt. Two extraordinary cases are mentioned,81 one in a woman of thirty-five, who expected to be confined April 24, 1883. In May she had a feM' labor- pains that passed away, and during the next six months she remained about as large as usual, and Mas several times thought to be in the early stages of labor. In September the os dilated until the first and second fingers could be passed directly to the head. This condition lasted about a month, but passed away. At times during the last nine months of pregnancy she was almost unable to endure the movements of the child. Finally, on the morn- ing of November 6th, after a pregnancy of four hundred and seventy-six days, she was delivered of a male child weighing 13 pounds. Both the mother and child did well despite the use of chloroform and forceps. The other case M'as one lasting sixteen months and twenty days. In a rather loose argument, Carey reckons a case of three hundred and fifty days. Menzieb gives an instance in a woman aged twenty-eight, the mother of one child, in whom a gestation was prolonged to the seventeenth month. The pregnancy was complicated by carcinoma of the uterus. Bal- lard0 describes the case of a girl of sixteen years and six months, whose pregnancy, the result of a single intercourse, lasted three hundred and sixty days. Her labor Mas short and easy for a primipara, and the child was of the average size. Mackenzied cites the instance of a woman aged thirty- two, a primipara, M'ho had been married ten years and who always had been regular in menstruation. The menses ceased on April 28, 1888, and she felt the child for the first time in September. She had false pains in January, 1889, and labor did not begin until March 8th, lasting sixty-six hours. If all these statements are correct, the probable duration of this pregnancy Mas eleven months and ten days. Lundiee relates an example of protracted gestation of eleven months, in which an anencephalous fetus Mas born ; and Martin of Birmingham de- scribes a similar case often and a half months' duration. Raux-Tripierf has seen protraction to the thirteenth month. Enguing reports an observa- tion of an accouchement of tM'ins after a pregnancy that had been prolonged for eleven months. Resnikoffh mentions a pregnancy of eleven months' duration in an anemic secundipara. The case had been under his observa- tion from the beginning of pregnancy ; the patient M'ould not submit to artificial termination at term, which he advised. After a painful labor of twcntv-four hours a macerated and decomposed child M'as born, together with a closely-adherent placenta. Tarjiier1 reports an instance of partus serotinus in which the product of conception was carried in the uterus forty a 790, Dec. 27, 1884. b 381, 1853-4. ° 224, 1884, i., 56. A 536, 1889. ii., 522. « 759, April, 1895. f 233, 1847. g 460, 1784, 163. h 261, No. 24, 1894. * Jour, des Sages-Femmes, May 1, 1894. 72 PRENATAL ANOMALIES. days after term. The fetus Mas macerated but not putrid, and the placenta had undergone fatty degeneration. At a recent meeting of the Chicago Gynecological Society, Dr. F. A. Stahl reported the case of a German-Bohe- mian woman in which the fifth pregnancy terminated three hundred and tM'o days after the last menstruation. Twenty days before there had occurred pains similar to those of labor, but they gradually ceased. The sacral prom- ontory Mas exaggerated, and the anteroposterior pelvic diameter of the inlet in consequence diminished. The fetus was large and occupied the first posi- tion. Version Mas M'ith difficulty effected and the passage of the after- coming head through the superior strait required expression and traction, during which the child died. The mother suffered a deep laceration of the perineum involving an inch of the wall of the rectum. Among others reporting instances of protracted pregnancy are Collins,a eleven months; Desbrest,beighteen months; Henderson,0 fifteen months; Jefferies,d three hundred and fifty-eight days, and De la Vergnee gives the history of a woman who carried an infant in her womb for twenty-nine months; this case may possibly belong under the head of fetus long retained in the uterus. Unconscious Pregnancy.—There are numerous instances of women M'ho have had experience in pregnancy unconsciously going almost to the moment of delivery, yet experiencing none of the usual accompanying symptoms of • this condition. Crowellf speaks of a woman of good social position who had been married seven years, and who had made extensive preparations for a long journey, when she was seized with a " bilious colic," and, to her dismay and surprise, a child was born before the arrival of the doctor summoned on account of her sudden colic and her inability to retain her water. A peculiar feature of this case was the fact that mental disturbance set in immediately afterward, and the mother became morbid and had to be removed to an asy- lum, but recovered in a few months. Tanner s saw a woman of forty-two who had been suffering with abdominal pains. She had been married three years and had never been pregnant. Her eatamenia were very scant, but this Mas attributed to her change of life. She had conceived, had gone to the full term of gestation, and Mas in labor ten hours without any suspicion of preg- nancy. She was successfully delivered of a girl, which occasioned much rejoicing in the household. Tasker of Kendall's Mills, Me., reports the case of a young married woman calling him for bilious colic. He found the stomach slightly distended and questioned her about the possibility of pregnancy. Both she and her hus- band informed him that such could not be the case, as her courses had been regular and her waist not enlarged, as she had worn a certain corset all the time. There Mere no signs of quickening, no change in the breasts, and, a 318, 1826, xxv., 245. b 453, 1769. c 125, 1879, xii., 393. d Trans. M. Soc. Penna., Phila., 1879. e 458, 1761. f 218, 1878. g 778, 1864. PSEUD OCYESIS. 73 in fact, none of the usual signs of pregnancy present. He gave her an opiate, and to her surprise, in about six hours she was the mother of a boy Meigh- ing five pounds. Both the mother and child made a good recovery. Duke a cites the instance of a woman who supposed that she Mas not pregnant up to the night of her miscarriage. She had menstruated and Mas suckling a child sixteen months old. During the night she Mas attacked with pains resem- bling those of labor and a fetus slipped into the vagina without any hemor- rhage ; the placenta came away directly afterward. In this peculiar case the woman was menstruating regularly, suckling a child, and at the same time was unconsciously pregnant. Isham b speaks of a case of unconscious pregnancy in which extremely small twins were delivered at the eighth month. Fox ° cites an instance of a woman who had borne eight children, and yet unconscious of pregnancy. Merrimand speaks of a woman forty years of age who had not borne a child for nine years, but who suddenly gave birth to a stout, healthy boy without being cognizant of pregnancy. Dayrale tells of a woman who carried a child all through pregnancy, unconscious of her condition, and who was greatly surprised at its birth. Among the French observers speak- ing of pregnancy remaining unrecognized by the mother until the period of accouchement, Lozes and Rhades record peculiar cases; and Mourtni- val8 relates an instance in which a woman who had borne three children completely ignored the presence of pregnancy until the pains of labor were felt. Fleishmanh and Miinzenthaler also record examples of unconscious pregnancy. Pseudocyesis.—On the other hand, instances of pregnancy with imaginary symptoms and preparations for birth are sometimes noticed, and many cases are on record. In fact, nearly every text-book on obstetrics gives some space to the subject of pseudocyesis. Suppression of the menses, enlargement of the abdomen, engorgement of the breasts, together with the symptoms produced by the imagination, such as nausea, spasmodic contraction of the abdomen, etc., are for the most part the origin of the cases of pseudo- cyesis. Of course, many of the cases are not examples of true pseudocyesis, with its interesting phenomena, but instances of malingering for mercenary or other purposes, and some are calculated to deceive the most expert obstetricians by their tricks. Weir Mitchell1 delineates an interesting case of pseudocyesis as follows : "A woman, young, or else, it may be, at or past the climacteric, eagerly desires a child or is horribly afraid of becoming pregnant. The menses become slight in amount, irregular, and at last cease or not. Meanwhile the abdomen and breasts enlarge, owing to a rapid taking on of fat, and this is far less visible elseMrhere. There comes M'ith this excess of fat the most profound conviction of the fact of pregnancy. By a 312, 1846. b 124, 1874. c 649, 1888. d 218, 1828. e 146, 1865. f 146, 1865. g 454, 1825, xxiii., 281. b 834, 1839. i 533, 1895, 393. 74 PR EN A TA L ANOMA LIES. and by the child is felt, the physician takes it for granted, and this goes on until the great diagnostician, Time, corrects the delusion. Then the fat disappears with remarkable speed, and the reign of this singular simulation is at an end." In the same article, Dr. Mitchell cites the two following cases under his personal observation : "I was consulted by a lady in regard to a woman of thirty years of agre, a nurse in M'hom she Mas interested. This person had been married some three years to a very old man possessed of a considerable estate. He died, leaving his M'ife her legal share and the rest to distant cousins, unless the M'ife had a child. For tM'O months before he died the woman, who was very anemic, ceased to menstruate. She became sure that she was pregnant, and thereupon took on flesh at a rate and in a way M'hich seemed to justify her belief. Her breasts and abdomen Mere the chief seats of this overgrowth. The menses did not return, her pallor in- creased ; the child Mas felt, and every preparation made for delivery. At the eighth month a physician made an examination and assured her of the absence of pregnancy. A second medical opinion confirmed the first, and the tenth month found her of immense size and still positive as to her con- dition. At the twelfth month her menstrual flow returned, and she became sure it Mas the early sign of labor. When it passed over she became con- vinced of her error,' and at once dropped Meight at the rate of half a pound a day despite every effort to limit the rate of this remarkable loss. At the end of twro months she had parted M'ith fifty pounds and was, on the whole, less anemic. At this stage I Mas consulted by letter, as the woman had be- come exceedingly hysteric. This briefly stated case, which occurred many years ago, is a fair illustration of my thesis. " Another instance I saw when in general practice. A lady who had several children and suffered much in her pregnancies passed five years without becoming impregnated. Then she missed a period, and had, as usual, vomiting. She made some Muld efforts to end her supposed pregnancy, and failing, acquiesced in her fate. The menses returned at the ninth month and were presumed to mean labor. Meanwhile she vomited, up to the eighth month, and ate little. Nevertheless, she took on fat so as to make the abdo- men and breasts immense and to excite unusual attention. No physician examined her until the supposed labor began, when, of course, the truth came out. She was pleased not to have another child, and in her case, as in all the others knoM'n to me, the fat lessened as soon as the mind Mas satisfied as to the non-existence of pregnancy. As I now recall the facts, this woman Mas not more than two months in getting rid of the excess of adipose tissue. Dr. Hirst tells me he has met M'ith cases of women taking on fat with cessation of the menses, and in M'hich there Mas also a steady belief in the existence of pregnancy. He has not so followed up these cases as to know if in them the fat fell away with speed M'hen once the patient Mas as- sured that no child existed M'ithin her." PLATE 2. Conditions simulating pregnancy (pseudocyesis) (Hirst) : 1. Pendulous belly of rachitis. 2. Normal distention in a primipara at term. 3. Normal distention, seventh month. 4. Pen- dulous belly of rachitis (Cesarean section). 5. Twins. 6. Pendulous belly of rachitis ; fat and tympany. 7. Hydramnios. PSEUDOCYESIS. 77 Hirst,a in an article on the difficulties in the diagnosis of pregnancy, gives several excellent photographs showing the close resemblance between several pathologic conditions and the normal distention of the abdomen in preg- nancy (Plate 2). A womanb who had several children fell sick with a chest-affection, followed by an edema. For fifteen months she was con- fined to her bed, and had never had connection with her husband during that time. Her menses ceased ; her mammae became engorged and discharged a serous lactescent fluid ; her belly enlarged, and both she and her phy- sician felt fetal movements in her abdomen. As in her previous pregnancies, she suffered nausea. Naturally, a suspicion as to her virtue came into her husband's mind, but Mrhen he considered that she had never left her bed for fifteen months he thought the pregnancy impossible. Still the M'ife insisted that she was pregnant and was confirmed in the belief by a midwife. The belly continued to increase, and about eleven months after the cessation of the menses she had the pains of labor. Three doctors and an accoucheur were present, and Mrhen they claimed that the fetal head presented the hus- band gave up in despair ; but the supposed fetus was born shortly after, and proved to be only a mass of hydatids, M'ith not the sign of a true pregnancy. Girard of Lyons0 speaks of a female who had been pregnant several times, but again experienced the signs of pregnancy. Her mammas were engorged with a lactescent fluid, and she felt belly-movements like those of a child ; but during all this time she had regular menstruation. Her abdo- men progressively increased in size, and between the tenth and eleventh months she suffered what she thought to be labor-pains. These false pains ceased upon taking a bath, and with the disappearance of the other signs was dissipated the fallacious idea of pregnancy. There is mentioned d an instance of medicolegal interest of a young girl who showed all the signs of pregnancy and confessed to her parents that she had had commerce with a man. The parents immediately prosecuted the seducer by strenuous legal methods, but M'hen her ninth month came, and after the use of six baths, all the signs of pregnancy vanished. Harvey cites sev- eral instances of pseudocyesis, and says we must not rashly determine of the the inordinate birth before the seventh or after the eleventh month. In 1646 a woman, after having laughed heartily at the jests of an ill-bred, covetous clown, M'as seized Math various movements and motions in her belly like those of a child, and these continued for over a month, M'hen the courses appeared again and the movements ceased. The woman was certain that she Mas pregnant. The most noteworthy historic case of pseudocyesis is that of Queen Mary of England, or " Bloody Marv," as she Mas called. To insure the succession of a Catholic heir, she Mas most desirous of having a son by her consort, Philip, and she constantly prayed and M'ished for pregnancy. Finally her a 792, May, 1895. b 302, iv., 235. c Ibid. d Ibid. 78 PRENATAL ANOMALIES. menses stopped ; the breasts began to enlarge and became discolored around the nipples. She had morning-sickness of a violent nature and her abdomen enlarged. On consultation with the ladies of her court, her opinion of preg- nancy was strongly confirmed. Her favorite amusement then Avas to make baby-clothes and count on her fingers the months of pregnancy. When the end of the ninth month approached, the people Avere awakened one night by the joyous peals of the bells of London announcing the new heir. An am- bassador had been sent to tell the Pope that Mary could feel the new life within her, and the people rushed to St. Paul's Cathedral to listen to the venerable Archbishop of Canterbury describe the baby-prince and give thanks for his deliverance. The spurious labor pains passed aAvay, and after being assured that no real pregnancy existed in her case, Mary Avent into violent hysterics, and Philip, disgusted with the whole affair, deserted her ; then commenced the persecution of the Protestants, which blighted the reign. Putnam a cites the case of a healthy brunet, aged forty, the mother of three children. She had abrupt vertical abdominal movements, so strong as to cause her to plunge and sway from side to side. Her breasts were enlarged, the areolae dark, and the uterus contained an elastic tumor, heavy and roll- ing under the hand. Her abdomen progressively enlarged to the regular size of matured gestation ; but the extrauterine pregnancy, Avhich Avas sup- posed to have existed, was not seen at the autopsy, nothing more than an enlarged liver being found. The movement Avas due to spasmodic move- ments of the abdominal muscles, the causes being unknoAvn. Madden b gives the history of a primipara of twenty-eight, married one year, to whom he was called. On entering the room he Avas greeted by the midAvife, Avho said she expected the child about 8 p. m. The woman was lying in the usual obstetric position, on the left side, groaning, crying loudly, and pulling hard at a strap fastened to the bed-post. She had a partial cessation of menses, and had complained of tumultuous movements of the child and overfloAV of milk from the breasts. Examination showed the cer\Tix Ioav doAvn, the os small and circular, and no signs of pregnancy in the uterus. The abdomen Avas distended Avith tympanites and the rectum much dilated Avith accumulated feces. Dr. Madden left her, telling her that she Avas not pregnant, and Avhen she reappeared at his office in a few days, he reassured her of the nonexist- ence of pregnancy ; she became very indignant, triumphantly squeezed lac- tescent fluid from her breasts, and, insisting that she could feel fetal moAre- ments, left to seek a more sympathetic accoucheur. Underbill,0 in the words of Hamilton, describes a woman as "having acquired the most accurate description of the breeding symptoms, and with wonderful facility imagined that she had felt every one of them." He found the Avoman on a bed com- plaining of great labor-pains, biting a handkerchief, and pulling on a cloth a 218, 1870. b 310, 1872, liii., 255. e 318, 1873-4, xix., ii., 844. SYMPATHETIC MALE NAUSEA OF PREGNANCY. 79 attached to her bed. The finger on the abdomen or vulva elicited symptoms of great sensitiveness. He told her she Avas not pregnant, and the next day she was sitting up, though the discharge continued, but the simulated throes of labor, Avhich she had so graphically pictured, had ceased. Haultaina gives three examples of pseudocyesis, the first Avith no apparent cause, the second due to carcinoma of the uterus, Avhile in the third there Avas a small fibroid in the anterior Avail of the uterus. Some cases are of purely nervous origin, associated Avith a purely muscular distention of the abdomen. Clay reported a case due to ascites. Cases of pseudocyesis in Avomen con- victed of murder are not uncommon, though most of them are impostors hoping for an extra lease of life. Croon b speaks of a child seven years old on Avhom he performed ovari- otomy for a round-celled sarcoma. She had been Avell up to May, but since then she had several times been raped by a boy, in consequence of which she had constant uterine hemorrhage. Shortly after the first coitus her abdomen began to enlarge, the breasts to develop, and the areolae to darken. In seven months the abdomen presented the signs of pregnancy, but the cervix Avas soft and patulous ; the sound entered three inches and was folloAved by some hemor- rhage. The child was well developed, the mons was covered with hair, and all the associate symptoms tended to increase the deception. Sympathetic Male Nausea of Pregnancy.—Associated Avith preg- nancy there are often present morning-nausea and \Tomiting as prominent and reliable symptoms. Vomiting is often so excessiA'e as to be pro- vocative of most serious issue and even warranting the induction of abortion. This fact is well known and has been thoroughly discussed, but with it is associated an interesting point, the occasional association of the same symptoms sympathetically in the husband. The belief has long been a superstition in parts of Great Britain, descending to America, and even exists at the present day. Sir Francis Bacon has Avritten on this subject, the substance of his argument being that certain loving husbands so sympathize Avith their pregnant Avives that they suffer morning-sickness in their own person. No less an authority than S. Weir Mitchell called attention to the interesting subject of sympathetic vomiting in the husband in his lectures on nervous maladies some years ago. He also quotes the folloAving case associated Avith pseudocyesis :— " A Avoman had given birth to two female children. Some years passed, and her desire for a boy was ungratified. Then she missed her flow once, and had thrice after this, as always took place with her when pregnant, a very small but regular loss. At the second month morning-vomiting came on as usual with her. Meanwhile she became very fat, and as the growth Avas largely, in fact excessively, abdominal, she became easily sure of her condi- tion. She was not my patient, but her husband consulted me as to his OAvn a 124, April, 1891. b 318, Feb., 1893. 80 PRENATAL ANOMALIES. morning-sickness, Avhich came on with the first occurrence of this sign in his Avife, as had been the case tAvice before in her former pregnancies. I advised him to leave home, and this proved effectual. I learned later that the Avoman continued to gain flesh and be sick every morning until the seventh month. Then menstruation returned, an examination was made, and when sure that there was no possibility of her being pregnant she began to lose flesh, and Avithin a few months regained her usual size." Hamill* reports an instance of morning-sickness in a husband two Aveeks after the appearance of menstruation in the wife for the last time. He had daily attacks, and it Avas not until the failure of the next menses that the woman had any other sign of pregnancy than her husband's nausea. His nausea continued for two months, and Avas the same as that Avhich he had suffered during his Avife's former pregnancies, although not until both he and his Avife became aware of the existence of pregnancy. The Lancetl) describes a case in which the husband's nausea and vomiting, as well as that of the wife, began and ended simultaneously. Judkins ° cites an instance of a man Avho was sick in the morning while his Avife was carrying a child. This occurred during every pregnancy, and the man related that his own father was simi- larly affected while his mother Avas in the early months of pregnancy Avith him, showing an hereditary predisposition. The perverted appetites and peculiar longings of pregnant women furnish curious matter for discussion. From the earliest times there are many such records. Borellus cites an instance, and there are many others, of pregnant women eating excrement with apparent relish. Tulpius, Sennert, Langius, van Swieten, a Castro, and seA^eral others report depraved appe- tites. SeAeral writers haA'e seen aA'idity for human flesh in such females. Founderd kneAV a woman with an appetite for the blood of her husband. She gently cut him Avhile he lay asleep by her side and sucked blood from the wounds—a modern " Succubus." Paree mentions the perverted appetites of pregnant women, and says that they have been known to eat plaster, ashes, dirt, charcoal, flour, salt, spices, to drink pure vinegar, and to indulge in all forms of debauchery. Plot637 gives the case of a woman Avho would gnaw and eat all the linen off her bed. Hufeland's Journal452 records the history of a case of a Avoman of thirty-two, Avho had been married ten years, who acquired a strong taste for charcoal, and was ravenous for it. It seemed to cheer her and to cure a supposed dyspepsia. She devoured enormous quantities, preferring hard-Avood charcoal. Bruyesinus228 speaks of a Avoman who had a most perverted appetite for her own milk, and constantly drained her breasts ; Krafft-Ebing cites a similar case. Another case280 is that of a pregnant Avoman Avho had a desire for hot and pungent articles of food, and who in a short time devoured a pound of pepper. Scheidemantel cites a a 780, 1888 ; and 596, 1888, lvii., 635. b 476, 1878, 66. c 272, 1892. d302, xiv.,624. e 618, 992. MA TERNAL IMPRESSIONS. 81 case in Avhich the perverted appetite, originating in pregnancy, became permanent, but this is not the experience of most observers. The pregnant wife of a farmer in Hassfort-on-the-Main ate the excrement of her husband.3 Many instances could be quoted, some in Avhich extreme cases of poly- dipsia and bulimia developed; these can be readily attributed to the in- creased call for liquids and food. Other cases of diverse neAV emotions can be recalled, such as lasciviousness, dirty habits, perverted thoughts, and, on the other hand, extreme piety, chastity, and purity of the mind. Some of the best-natured Avomen are Avhen pregnant extremely cross and irritable, and many perA'crsions of disposition are commonly noticed in pregnancy. There is often a longing for a particular kind of food or dish for Avhich no noticeable desire had been displayed before. Maternal Impressions.—Another curious fact associated with pregnancy is the apparent influence of the emotions of the mother on the child in utero. Every one knoAVS of the popular explanation of many birth-marks, their supposed resemblance to some animal or object seen by the mother during pregnancy, etc. The truth of maternal impressions, however, seems to be more firmly established by facts of a substantial nature. There is a natural desire to explain any abnormality or anomaly of the child as due to some incident during the period of the mother's pregnancy, and the truth is often distorted and the imagination heavily draAvn upon to furnish the satisfactory explanation. It is the customary speech of the dime-museum lecturer to attribute the existence of some " freak" to an episode in the mother's pregnancy. The poor " Elephant-man " firmly believed his peculiarity was due to the fact that his mother Avhile carrying him in utero was knocked down at the circus by an elephant. In some countries the exhibition of monstrosi- ties is forbidden because of the supposed danger of maternal impression. The celebrated " Siamese TAvins " for this reason Avere forbidden to exhibit themselves for quite a period in France. We shall cite only a feAV of the most interesting cases from medical litera- ture. Hippocrates saved the honor of a princess, accused of adultery Avith a negro because she bore a black child, by citing it as a case of maternal impression, the husband of the princess having placed in her room a paint- ing of a negro, to the vieAV of Avhich she Avas subjected during the Avhole of her pregnancy. Then, again, in the treatise " De Superfcetatione " there occurs the folloAving distinct statement: "If a pregnant Avoman has a long- ing to eat earth or coals, and eats of them, the infant which is born carries on its head the mark of these things." This statement, hoAveA'er, occurs in a work Avhich is not mentioned by any of the ancient authorities, and is rejected by practically all the modern ones; according to Ballantyne, there is, there- fore, no absolute proof that Hippocrates Avas a believer in one of the most popular and long-persisting beliefs concerning fetal deformities. a Ephem. Physico-Medicorum, Leipzig, 1694, 212. 6 82 PRENA TA L A NOMA LIES. in the explanation of heredity, Hippocrates a states " that the body of the male as Avell as that of the female furnishes the semen. That which is weak (unhealthy) is derived from weak (unhealthy) parts, that which is strong (healthy) from strong (healthy) parts, and the fetus will correspond to the quality of the semen. If the semen of one part come in greater quantity from the male than from the female, this part will resemble more closely the father; if, however, it comes more from the female, the part Avill rather resemble the mother. If it be true that the semen comes from both parents, then it is impossible for the Avhole body to resemble either the mother or the father, or neither the one nor the other in anything, but necessarily the child will resemble both the one and the other in something. The child Avill most resemble the one Avho contributes most to the formation of the parts." Such was the Hippocratic theory of generation and heredity, and it Avas ingen- iously used to explain the hereditary nature of certain diseases and mal- formations. For instance, in speaking of the sacred disease (epilepsy), Hippocrates says : " Its origin is hereditary, like that of other diseases ; for if a phlegmatic person be born of a phlegmatic, and a bilious of a bilious, and a phthisical of a phthisical, and one having spleen disease of another having disease of the spleen, Avhat is to hinder it from happening that Avhere the father and mother Avere subject to this disease certain of their offspring should be so affected also ? As the semen comes from all parts of the body, healthy particles will come from healthy parts, and unhealthy from unhealthy parts." According to Pare,618 Damascene saw a girl with long hair like a bear, whose mother had constantly before her a picture of the hairy St. John. Pare also appends an illustration showing the supposed resemblance to a bear. Jonston u1 quotes a case of Heliodorus; it Avas an Ethiopian, who bv the effect of the imagination produced a Avhite child. Pare 618 describes this case more fully: " Heliodorus says that Persina, Queen of Ethiopia, being impregnated by Hydustes, also an Ethiopian, bore a daughter with a Avhite skin, and the anomaly Avas ascribed to the admiration that a picture of Andro- meda excited in Persina throughout the Avhole of the pregnancy." Van Helmont 413 cites the case of a tailor's Avife at INIechlin, Avho during a conflict outside her house, on seeing a soldier lose his hand at her door, gave birth to a daughter with one hand, the other hand being a bleeding stump ; he also speaks of the case of the Avife of a merchant at Antwerp, Avho after seeing a soldier's arm shot off at the siege of Ostend gave birth to a daughter with one arm. Plot 637 speaks of a child bearing the figure of a mouse ; Avhen pregnant, the mother had been much frightened by one of these animals. Gassondus 356 describes a fetus Avith the traces of a Avound in the same location as one received by the mother. The Lancetb speaks of several cases__ one of a child with a face resembling a dog whose mother had been bitten ; one a 759, Oct., 1895. b 476) 1863 y 27 MATERNAL IMPRESSIONS. 83 of a child with one eye blue and the other black, whose mother during con- finement had ^ecn a person so marked; of an infant with fins as upper and loAver extremities, the mother haA'ing seen such a monster; and another, a child born Avith its feet covered Avith scalds and burns, Avhose mother had been badly frightened by fireworks and a descending rocket. There is a the history of a Avoman who while pregnant at seven months Avith her fifth child was bitten on the right calf by a dog. Ten Aveeks after, she bore a child Avith three marks corresponding in size and appearance to those caused by the dog's teeth on her leg. Kerrb reports the case of a woman in her seATenth month Avhose daughter fell on a cooking stove, shocking the mother, who suspected fatal burns. The Avoman was delivered two months later of an infant blistered about the mouth and extremities in a manner similar to the burns of her sis- ter. This infant died on the third day, but another Avas born fourteen months later with the same blisters. Inflammation set in and nearly all the fingers and toes sloughed off. In a subsequent confinement, long after the mental agitation, a healthy unmarked infant Avas born. Hunt0 describes a case which has since become almost classic of a Avoman fatally burned, Avhen pregnant eight months, by her clothes catching fire at the kitchen grate. The day after the burns labor began and was ter- minated by the birth of a well-formed dead female child, apparently blis- tered and burned in extent and in places corresponding almost exactly to the locations of the mother's injuries. The mother died on the fourth day. Webbd reports the history of a negress who during a convulsion Avhile pregnant fell into a fire, burning the Avhole front of the abdomen, the front and inside of the thighs to the knees, the external genitals, and the left arm. Artificial delivery Avas deemed necessary, and a dead child, seemingly burned much like its mother, except less intensely, was delivered. There Avas also one large blister near the inner canthus of the eye and some large blisters about the neck and throat which the mother did not show. There Avas no history of syphilis nor of any eruptive fever in the mother, Avho died on the tenth day Avith tetanus. Grahame describes a Avoman of thirty-five, the mother of seven children, Avho Avhile pregnant Avas feeding some rabbits, Avhen one of the animals jumped at her with its eyes " glaring" upon her, causing a sudden fright. Her child was born hydrocephalic. Its mouth and face were small and rab- bit-shaped. Instead of a nose, it had a fleshy groAvth £ inch long by } inch broad, directed upward at an angle of 45°. The space between this and the mouth Avas occupied by a body resembling an adult eye. Within this Avere two small, imperfect eyes Avhich moved freely Avhile life lasted (ten minutes). The child's integument Avas covered with dark, doAvny, short hair. The woman recovered and afterward bore two normal children. a 611, No. 19, May 7, 1842. b 124, July, 1857. ° 124, 1881, lxxxi., 186. d7S3. x, 419. e 224, 1868, i., 51. 84 PRENATAL ANOMALIES. Parvin mentions an instance of the influence of maternal impression in the causation of a large, vivid, red mark or splotch on the face : " When the mother Avas in Ireland she Avas badly frightened by a fire in which some cat- tle were burned. Again, during the early months of her pregnancy she Avas frightened by seeing another woman suddenly light the fire Avith kerosene, and at that time became firmly impressed Avith the idea that her child Avould be marked." Parvin a also pictures the " turtle-man," an individual Avith de- formed extremities, Avho might be classed as an ectro- melus, perhaps as a phocomelus, or seal-like monster. According to the story, Avhen the mother was a feAV Aveeks pregnant her husband, a coarse, rough fisherman, fond of rude jokes, put a large live turtle in the cup- board. In the tAvilight the wife Avent to the cupboard and the huge turtle fell out, greatly startling her by its hideous appearance as it fell suddenly to the floor and began to move vigorously. Copeland b mentions a curious case in Avhich a Avoman was attacked by a rattlesnake when in her sixth month of pregnancy, and gave birth to a child Avhose arm ex- hibited the shape and action of a snake, and involun- tarily went through snake-like movements. The face and mouth also markedly resembled the head of a snake. Fig. 8.—The "turtle-man." The teeth Avere situated like a serpent's fangs. The mere mention of a snake filled the child (a man of tAventy-nine) with great horror and rage, " particularly in the snake season." Beale ° giAres the history of a case of a child born with its left eye blackened as by a bloAV, whose mother Avas struck in a corresponding portion of the face eight hours before confinement. There is on recordd an account of a young man of twenty-one suffering from congenital deformities attributed to the fact that his mother Avas frightened by a guinea-pig having been thrust into her face during pregnancy. He also had congenital deformity of the right auricle. At the autopsy, all the skin, tissues, muscles, and bones were found involved. OAvene speaks of a woman Avho was greatly excited ten months preATiously by a prurient curiosity to see Avhat appearance the genitals of her brother presented after he had submitted to amputation of the penis on ac- count of carcinoma. The Avhole penis had been removed. The Avoman stated that from the time she had thus satisfied herself, her mind Avas unceasingly engaged in reflecting and sympathizing on the forlorn condition of her brother. While in this mental state she gave birth to a son Avhose penis Avas entirely absent, but Avho was otherAvise Avell and likely to live. The other portions of the genitals Avere perfect and Avell developed. The appearance of a Internat. Med. Mag., Phila., June, 1892. b 218, 1839, 98. c 476, 1863, ii., 27. d 536, 1883, i., 381. e 476, 1863, 25. PATERNAL IMPRESSIONS. 85 the nephew and the uncle was identical. A most peculiar case a is stated bv Clerc as occurring in the experience of Kiiss of Strasburg. A Avoman had a negro paramour in America with whom she had had sexual intercourse several times. She was put in a convent on the Continent, Avhere she stayed two years. On leaving the convent she married a Avhite man, and nine months after she gave birth to a dark-skinned child. The supposition Avas that during her abode in the convent and the nine months subsequently she had the image of her black paramour constantly before her. Loin b speaks of a Avoman Avho Avas greatly impressed by the actions of a clown at a circus, and Avho brought into the Avorld a child that resembled the fantastic features of the cloAvn in a most striking manner. Mackay ° describes five cases in which fright produced distinct marks on the fetus. There is a case mentionedd in Avhich a pregnant woman was informed that an intimate friend had been thrown from his horse; the immediate cause of death Avas fracture of the skull, produced by the corner of a dray against Avhich the rider Avas thrown. The mother was profoundly impressed by the circumstance, Avhich was minutely described to her by an eye-witness. Her child at birth presented a red and sensitiATe area upon the scalp corresponding in location Avith the fatal injury in the rider. The child is noAV an adult Avoman, and this area upon the scalp remains red and sensitive to pressure, and is almost devoid of hair. Mastin of Mobile, Alabama, reports a curious instance of maternal impression. During the sixth month of the pregnancy of the mother her husband Avas shot, the ball passing out through the left breast. The woman Avas naturally much shocked, and remarked to Dr. Mastin : " Doctor, my baby will be ruined, for when I saAV the Avound I put my hands over my face, and got it covered with blood, and I know my baby will have a bloody face." The child came to term without a bloody face. It had, hoAvever, a well-defined spot on the left breast just beloAV the site of exit of the ball from its father's chest. The spot Avas about the size of a silver half-dollar, and had ele\Tated edges of a bright red color, and Avas quite \dsible at the distance of one hundred feet. The authors have had personal communication Avith Dr. Mastin in regard to this case, Avhich he considers the most positive e\'idence of a case of maternal impression that he has ever met. Paternal Impressions.—Strange as are the foregoing cases, those of pater- nal impression eclipse them. Several are on record, but none are of sufficient authenticity to Avarrant much discussion on the subject. Those below are given to illustrate the method of report. Stahl, quoted by Steinan, 1843, speaks of the case of a child, the father being a soldier Avho lost an eye in the Avar. The child Avas born Avith one of its eyes dried up in the orbit, in this respect presenting an appearance like that of the father. Schneider e a 239, July 7, 1873. b 645, 1879-80, xxxi. c 476, 1891, ii., 1388. d 844, 213. e 778, xxviii., 167. 86 PRENA TAL ANOMALIES. says a man whose Avife Avas expecting confinement dreamt that his oldest son stood beside his bedside Avith his genitals much mutilated and bleeding. He aAVoke in a great state of agitation, and a few days later the Avife was delivered of a child Avith exstrophy of the bladder. Hoare a recites the curious story of a man who vowed that if his next child was a daughter he would never speak to it. The child proved to be a son, and during the Avhole of the father's life nothing could induce the son to speak to his father, nor, in fact, to any other male person, but after the father's death he talked fluently to both men and Avomen. Clark b reports the birth of a child whose father had a stiff knee-joint, and the child's knee Avas stiff and bent in exactly the same position as that of its father. Telegony.—The influence of the paternal seed on the physical and mental constitution of the child is Avell knoAvn. To designate this condition, Telegony is the Avord that was coined by Weismann in his " Das Keim- plasma," and he defines it as " Infection of the Germ," and, at another time, as " Those doubtful instances in which the offspring is said to resemble, not the father, but an early mate of the mother,"—or, in other Avords, the alleged influence of a previous sire on the progeny produced by a subsequent one from the same mother. In a systematic discussion of telegony before the Royal Medical Society, Edinburgh, on March 1, 189o,° Brunton Blaikie, as a means of making the definition of telegony plainer by practical example, prefaced his remarks by citing the classic example which first drew the attention of the modern scientific Avorld to this phenomenon. The facts of this case Avere communicated in a letter from the Earl of Morton to the President of the Royal Society in 1821, and Avere as follows: In the year 1815 Lord Morton put a male quagga to a young chestnut mare of | Arabian blood, Avhich had never before been bred from. The result was a female hybrid Avhich resembled both parents. He now sold the mare to Sir Gore Ousley, Avho two years after she bore the hybrid put her to a black Arabian horse. During the two folloAving years she had tAVO foals Avhich Lord Morton thus describes : " They have the character of the Arabian breed as decidedly as can be expected Avhen -i--| of the blood are Arabian, and they are fine specimens of the breed ; but both in their color and in the hair of their manes they ha\Te a striking resemblance to the quagga. Their color is bay, marked more or less like the quagga in a darker tint. Both are distinguished by the dark line along the ridge of the back, the dark stripes across the forehand, and the dark bars across the back part of the legs." The President of the Royal Society saAV the foals and verified Lord Morton's statement. "Herbert Spencer, in the Contemporary Review for May, 1893, gives several cases communicated to him by his friend Mr. Fookes, whom Spencer says is often appointed judge of animals at agricultural sIioavs. After giving a 476, 1831-2, i., 441. b 54s, xv., 258. c 759, July, 1895. TELEGONY. 87 various examples he goes on to say : < A friend of mine near this had a valuable Dachshund bitch, Avhich most unfortunately had a litter by a stray sheep-dog. The next year the OAvner sent her on a visit to a pure Dachs- hund dog, but the produce took quite as much of the first father as the second, and the next year he sent her to another Dachshund, with the same result. Another case : A friend of mine in Devizes had a litter of puppies, unsought for, by a setter from a favorite pointer bitch, and after this she never bred any true pointers, no matter Avhat the paternity was.' " Lord Polwarth, Avhose very fine breed of Border Leicesters is famed throughout Britain, and Avhose knoAvledge on the subject of breeding is great, says that ' In sheep we always consider that if a ewe breeds to a Shrop ram, she is never safe to breed pure Leicesters from, as dun or colored legs are apt to come even Avhen the sire is a pure Leicester. This has been proved in various instances, but is not invariable.' " H©n. Henry Scott says : "Dog-breeders knoAV this theory Avell; and if a pure-bred bitch happens to breed to a dog of another breed, she is of little use for breeding pure-bred puppies afterward. Animals Avhich produce large litters and go a short time pregnant show this throwing back to previous sires far more distinctly than others—I fancy dogs and pigs most of all, and probably horses least. The influence of previous sires may be carried into the second generation or further, as I have a cat now Avhich appears to be half Persian (long hair). His dam has very long hair and every appearance of being a half Persian, whereas neither have really any Persian blood, as far as I knoAV, but the grand-dam (a very smooth-haired cat) had several litters by a half-Persian tom-cat, and all her produce since have showed the influence retained. The Persian tom-cat died many years ago, and was the only one in the district, so, although I cannot be absolutely positive, still I think this case is really as stated." Breeders of Bcdlington terriers Avish to breed dogs Avith as poAverful jaws as possible. In order to accomplish this they put the Bcdlington terrier bitch first to a bull-terrier dog, and get a mongrel litter Avhich they destroy. They now put the bitch to a Bcdlington terrier dog and get a litter of puppies Avhich are practically pure, but have much stronger jaAvs than they Avould otherwise have had, and also shoAV much of the gameness of the bull- terrier, thus proving that physiologic as well as anatomic characters may be transmitted in this Avay. After citing the foregoing examples, Blaikie directs his attention to man, and makes the folloAving interesting remarks :— " \\ e might expect from the foregoing account of telegony»amongst ani- mals that whenever a black Avoman had a child to a white man, and then married a black man, her subsequent children Avould not be entirely black. Dr. Robert Balfour of Surinam in 1851 Avrote to Haiwcy that he Avas con- tinually noticing amongst the colored population of Surinam ' that if a negress 88 PRENA TAI ANOMALIES. had a child or children by a white, and afterward fruitful intercourse Avith a negro, the latter offspring had generally a lighter color than the parents.' But, as far as I knoAV, this is the only instance of this observation on record. Herbert Spencer has shown that Avhen a pure-bred animal breeds Avith an animal of a mixed breed, the offspring resembles much more closely the pa- rent of pure blood, and this may explain Avhy the circumstance recorded by Balfour has been so seldom noted. For a negro, avIio is of very pure blood, will naturally have a stronger influence on the subsequent progeny than an Anglo-Saxon, Avho comes of a mixed stock. If this be the correct explana- tion, Ave should expect that Avhen a Avhite Avoman married first a black man, and then a Avhite, the children by the white husband would be dark colored. Unfortunately for the proof of telegony, it is very rare that a Avhite Avoman does marry a black man, and then have a Avhite as second husband ; never- theless, Ave have a fair number of recorded instances of dark-colored chil- dren being born in the above way of white parents. " Dr. Harvey mentions a case in Avhich 'a young woman, residing in Edinburgh, and born of white (Scottish) parents, but Avhose mother, some time previous to her marriage, had a natural (mulatto) child by a negro man- servant in Edinburgh, exhibits distinct traces of the negro. Dr. Simpson —afterward Sir James Simpson—whose patient the young Avoman at one time was, has had no recent opportunities of satisfying himself as to the pre- cise extent to which the negro character prevails in her features ; but he recollects being struck with the resemblance, and noticed particularly that the hair had the qualities characteristic of the negro.' Herbert Spencer got a letter from a ' distinguished correspondent' in the United States, Avho said that children by white parents had been ' repeatedly' observed to show traces of black blood Avhen the women had had previous connection with (i. e., a child by) a negro. Dr. Youmans of New York intervieAved several medi- cal professors, who said the above Avas ' generally accepted as a fact.' Prof. Austin Flint, in ' A Text-book of Human Physiology,' mentioned this fact, and Avhen asked about it said : ' He had never heard the statement ques- tioned.' " But it is not only in relation to color that we find telegony to have been noticed in the human subject. Dr. Middleton Michel gives a most in- teresting case in the American Journal of the Medical Sciences for 1868 : ' A black Avoman, mother of several negro children, none of whom were de- formed in any particular, had illicit intercourse Avith a Avhite man, by whom she became pregnant. During gestation she manifested great uneasiness of mind, lest the birth of a mulatto offspring should disclose her conduct. . . . It so happened that her negro husband possessed a sixth digit on each hand, but there was no peculiarity of any kind in the Avhite man, yet Avhen the mulatto child was born it actually presented the deformity of a supernume- rary finger.' Taruffi, the celebrated Italian teratologist, in speaking of the ANTENA TAL PA THOL OGY. 89 subject, says : * Our knoAvledge of this strange fact is by no means recent, for Fienus, in 1608, said that most of the children born in adultery have a greater resemblance to the legal than to the real father'—an observation that Avas confirmed by the philosopher Yanini and by the naturalist Ambrosini. From these observations comes the proverb : ' Filium ex adultera excusare matrem a culpa.' Osiander has noted telegony in relation to moral qualities of children by a second marriage. Harvey said that it has long been known that the children by a second husband resemble the first husband in features, mind, and disposition. He then gaA'e a case in Avhich this resemblance Avas very Avell marked. Orton, Burdach (Traite de Physiologie), and Dr. Will- iam SedgAvick have all remarked on this physical resemblance; and Dr. Metcalfe, in a dissertation delivered before this society in 1855, observed that in the cases of widoAvs remarrying the children of the second marriage frequently resemble the first husband. "An observation probably having some bearing on this subject Avas made by Count de Stuzeleci (Harvey, loc. cit.). He noticed that when an aborig- inal female had had a child by a European, she lost the poAver of conception by a male of her own race, but could produce children by a Avhite man. He belie\Ted this to be the case with many aboriginal races ; but it has been dis- proved, or at all eA'ents proved to be by no means a universal laAv, in eAery case except that of the aborigines of Australia and New Zealand. Dr. William Sedgwick thought it probable that the unfruitfulness of prostitutes might in some degree be due to the same cause as that of the Australian aborigines who have had children by Avhite men. " It would seem as though the Israelites had had some knoAvledge of telegony, for in Deuteronomy Ave find that Avhen a man died leaA'ing no issue, his Avife was commanded to marry her husband's brother, in order that he might ' raise up seed to his brother.' " We must omit the thorough inquiry into this subject that is offered by Mr. Blaikie. The explanations put forward haA^e ahvays been on one of three main lines :— (1) The imagination-theory, or, to quote Harvey : " Due to mental causes so operating either on the mind of the female and so acting on her repro- ductive poAvers, or on the mind of the male parent, and so influencing the qualities of his semen, as to modify the nutrition and development of the offspring." (2) Due to a local influence on the reproductive organs of the mother. (3) Due to a general influence through the .fetus on the mother. Antenatal Pathology.—We haA'e next to deal with the diseases, acci- dents, and operations that affect the pregnant uterus and its contents ; these are rich in anomalies and facts of curious interest, and have been recog- nized from the earliest times. In the various Avorks usually grouped together under the general designation of " Hippocratic" are to be found 90 PRENATAL ANOMALIES. the earliest opinions upon the subject of antenatal pathology Avhich the medical literature of Greece has handed doAvn to modern times. That there were medical Avriters before the time of Hippocrates cannot be doubted, and that the works ascribed to the " Father of Medicine" Avere immediately fol- lowed by those of other physicians, is likeAvise not to be questioned ; but Avhilst nearly all the Avritings prior to and after Hippocrates have been long lost to the world, most of those that Avere Avritten by the Coan physician and his followers haATe been almost miraculously preserved. As Littre puts it, " Les ecrits hippocratiques demeurent isoles au milieu des debris de l'antique litterature medicale."—(Ballantyne.) The first to be considered is the transmission of contagious disease to the fetus in utero. The first disease to attract attention A\as small- pox. Devilliers, Blot, and Depaul all speak of congenital small-pox, the child born dead and showing eA'idences of the typical small-pox pustulation, Avith a history of the mother ha\'ing been infected during pregnancy. Watson a reports tAVO cases in Avhich a child in utero had small-pox. In the first case the mother Avas infected in pregnancy ; the other Avas nursing a patient when seA'en months pregnant; she did not take the disease, although she had been infected man}' months before. Mauriceau513 delivered a Avoman of a healthy child at full term after she had recovered from a se\Tere attack of this disease during the fifth month of gestation. Mauriceau supposed the child to be immune after the delivery. Yidal reported to the French Academy of Medicine, May, 1871, the case of a Avoman who gave birth to a lh'ing child of about six and one-half months' maturation, Avhich died some hours after birth covered Avith the pustules of seven or eight days' eruption. The pustules on the fetus Avere Avell umbilicated and typical, and could have been nothing but those of small-pox ; besides, this disease Avas raging in the neighborhood at the time. The mother had never been infected before, and never Avas subsequently. Both parents Avere robust and neither of them had eA^er had syphilis. About the time of conception, the early part of December, 1870, the father had suffered from the semiconfluent type, but the mother, avIio had been vaccinated Avhen a girl, had never been stricken either during or after her husband's sickness. Quirkeb relates a peculiar instance of a child born at midnight, Avhose mother was covered Avith the eruption eight hours after delivery. The child was healthy and showed no signs of the contagion, and Avas A'accinated at once. Although it remained Avith its mother all through the sickness, it continued Avell, with the excep- tion of the ninth day, Avhen a slight fiwer due to its vaccination appeared. The mother made a good recovery, and the author remarks that had the child been born a short time later, it Avould most likely have been infected. Aver ° reports an instance of congenital variola in twins. Chantreuild a 629, 1743-50, 1043. b 224, 1886, i., 201. c 218, 1851, xliv., 397. <* 363, 1870, xliii., 173. DISEASE TRANSMITTED TO THE FETUS. 91 speaks of a Avoman pregnant Avith twins who aborted at five and a half months. One of the fetuses shoAved distinct signs of congenital variola, although the mother and other fetus were free from any symptoms of the disease. In 1853 Charcot reported the birth of a premature fetus present- ing numerous variolous pustules together Avith ulcerations of the derm and mucous membranes and stomach, although the mother had convalesced of the disease some time before. Mitchella describes a case of small-pox occur- ring three days after birth, the mother not having had the disease since childhood. Shertzer b relates an instance of confluent small-pox in the eighth month of pregnancy. The child Avas born with the disease, and both mother and babe recovered. Among many others offering evidence of variola in utero are Degner, Derham, John Hunter, Blot, Bulkley, Welch, Wright, Digk, Forbes, Marinus, and Bouteiller. Varicella, Measles, Pneumonia, and even Malaria are reported as haA7ing been transmitted to the child in utero. Hubbard ° attended a Avoman on March 17, 1878, in her seventh accouchement. The child showed the rash of varicella twenty-four hours after birth, and passed through the regu- lar course of chicken-pox of ten days' duration. The mother had no signs of the disease, but the children all about her Avere infected. Ordinarily the period of incubation is from three to four days, Avith a premonitory fever of from twenty-four to seventy-two hours' duration, Avhen the rash appears ; this case must therefore have been infected in utero. Lomerd of Ham- burg tells of the case of a woman, twenty-tAVO years, unmarried, pregnant, who had measles in the eighth month, and Avho gave birth to an infant Avith measles. The mother was attacked with pneumonia on the fifth day of her puerperium, but recovered; the child died in four Aveeks of intestinal catarrh. Gautiere found measles transmitted from the mother to the fetus in 6 out of 11 cases, there being 2 maternal deaths in the 11 cases. Netterf has observed the case of transmission of pneumonia from a mother to a fetus, and has seen two cases in Avhich the blood from the uterine vessels of patients Avith pneumonia contained the pneumococcus. Wallick g collected a number of cases of pneumonia occurring during pregnancy, sIioav- ing a fetal mortality of 80 per cent. Felkinh relates two instances of fetal malaria in Avhich the infection was probably transmitted by the male parent. In one case the father near term suffered seA'erely from malaria ; the mother had never had a chill. The violent fetal movements induced labor, and the spleen was so large as to retard it. After birth the child had seven malarial paroxysms but re- covered, the splenic tumor disappearing. The modes of infection of the fetus by syphilis, and the infection of the mother, ha\Te been Avell discussed, and need no mention here. a 124, 1830, vii., 555. b 547, iv., 756. c 224, 1878, i., 822. a 261, 1889. e 140, 1879, 321. f 300, No. 22, 1889. S 140, 1889, 439. b 313, June, 1889. 92 PRENATAL ANOMALIES. There has been much discussion on the effects on the fetus in utero of medicine administered to the pregnant mother, and the opinions as to the reliability of this medication are so varied that avc are in doubt as to a satisfactory conclusion. The effects of drugs administered and eliminated by the mammary glands and transmitted to the child at the breast are well known, and have been Avitnessed by nearly every physician, and, as in cases of strong metallic purges, etc;., need no other than the actual test. However, scientific experiments as to the efficacy of fetal therapeutics have been made from time to time Avith \Tarying results. GusseroAV of Strasbourg tested for iodin, chloroform, and salicylic acid in the blood and secretions of the fetus after maternal administration just before death. In 14 cases in Avhich iodin had been administered, he examined the fetal urine of 11 cases; in 5, iodin was present, and in the others, absent. He made some similar experiments on the loAver animals. Benicke reports having given salicylic acid just before birth in 25 cases, and in each case finding it in the urine of the child shortly after birth. At a discussion held in Ncav York some years ago as to the real effect on the fetus of gh'ing narcotics to the mother, Dr. Gaillard Thomas Avas almost alone in adA'oeating that the effect Avas quite A'isible. Fordyce Barker Avas strongly on the negative side. Henning and Ahlfeld, two German observers, ATouch for the opinion of Thomas, and Thornburn states that he has witnessed the effect of nux vomica and strychnin on the fetus shortly after birth. OATer fifty years ago, in a memoir on " Placental Phthisis," Sir James Y. Simpson adA'anced a neAv idea in the recommendation of potassium chlorate during the latter stages of pregnancy. The efficacy of this suggestion is knoAvn, and Avhether, as Simpson said, it acts by supplying extra oxygen to the blood, or Avhether the salt itself is conveyed to the fetus, has never been definitely settled. McClintock,a who has been a close observer on this subject, reports some interesting cases. In his first case he tried a mixture of iron perchlorid and potassium chlorate three times a day on a woman avIio had borne three dead children, Avith a most successful result. His second case failed, but in a third he Avas successful by the same medication with a Avoman Avho had before borne a dead child. In a fourth case of unsuccessful pregnancy for three consecuth^e births he Avas successful. His fifth case was extra- ordinary : It Avas that of a Avoman in her tenth pregnancy, Avho, Avith one exception, had ahvays borne a dead child at the seventh or eighth month. The one exception lived a feAv hours only. Under this treatment he Avas successful in carrying the Avoman safely past her time for miscarriage, and had every indication for a normal birth at the time of report. Thornburn believes that the administration of a tonic like strychnin is of benefit to a fetus which, by its feeble heart-beats and movements, is thought to be un- a 224, 1877, ii., 513. MEDICINE TO THE PREGNANT WOMAN. 93 healthy. Poraka has recently investigated the passage of substances foreign to the organism through the placenta, and offers an excellent paper on this subject, Avhich is quoted in brief in a contemporary number of Terato- logia.759 In this important paper, Porak, after giving some historical notes, describes a long series of experiments performed on the guinea-pig in order to investigate the passage of arsenic, copper, lead, mercury, phosphorus, alizarin, atropin, and eserin through the placenta. The placenta sIioavs a real affinity for some toxic substances ; in it accumulate copper and mer- cury, but not lead, and it is therefore through it that the poison reaches the fetus ; in addition to its pulmonary, intestinal, and renal functions, it fixes glycogen and acts as an accumulator of poisons, and so resembles in its action the liver; therefore the organs of the fetus possess only a potential activity. The storing up of poisons in the placenta is not so general as the accumula- tion of them in the liver of the mother. It may be asked if the placenta does not form a barrier to the passage of poisons into the circulation of the fetus ; this Avould seem to be demonstrated by mercury, Avhich Avas always found in the placenta and never in the fetal organs. In poisoning by lead and copper the accumulation of the poison in the fetal tissues is greater than in the maternal, perhaps from differences in assimilation and disassimilation or from greater diffusion. Whilst it is not an impermeable barrier to the pas- sage of poisons, the placenta offers a A'arying degree of obstruction : it alloAvs copper and lead to pass easily, arsenic with greater difficulty. The accumu- lation of toxic substances in the fetus does not folioav the same laAV as in the adult. They diffuse more Avidely in the fetus. In the adult the liver is the chief accumulator^ organ. Arsenic, which in the mother elects to accumu- late in the liver, is in the fetus stored up in the skin; copper accumulates in the fetal lh'er, central nervous system, and sometimes in the skin ; lead, Avhich is found specially in the maternal liver, but also in the skin, has been observed in the skin, liver, nervous centers, and elseAvhere in the fetus. The frequent presence of poisons in the fetal skin demonstrates its physiologic importance. It has probably not a very marked influence on its health. On the contrary, accumulation in the placenta and nerve centers explains the pathogenesis of abortion and the birth of dead fetuses (" mortinatalite "). Copper and lead did not cause abortion, but mercury did so in two out of six cases. Arsenic is a poAverful abortive agent in the guinea-pig, probably on account of placental hemorrhages. An important deduction is that Avhilst the placenta is frequently and seriously affected in syphilis, it is also the special seat for the accumulation of mercury. May this not explain its therapeutic action in this disease ? The marked accumulation of lead in the central nervous system of the fetus explains the frequency and serious char- acter of saturnine encephalopathic lesions. The presence of arsenic in the a Archives de Med. experimentale et d'Anatomie path., March, 1894, p. 192. 94 PRENATAL ANOMALIES. fetal skin alone gives an explanation of the therapeutic results of the adminis- tration of this substance in skin diseases. Intrauterine amputations are of interest to the medical man, par- ticularly those cases in Avhich the accident has happened in early pregnancy and the child is born Avith a very satisfactory and clean stump. Mont- gomery,8 in an excellent paper, advances the theory, Avhich is very plausible, that intrauterine amputations are caused by contraction of bands or mem- branes of organized lymph encircling the limb and producing amputation by the same process of disjunctive atrophy that the surgeons induce by ligature. Weinlechnerb speaks of a case in Avhich a man deAroid of all four extremi- ties Avas exhibited before the Vienna Medical Society. The amputations Ave re congenital, and on the right side there Avas a A'ery small stump of the upper arm remaining, admitting the attachment of an artificial apparatus. He Avas tAventy-seven years old, and able to Avrite, to thread a needle, pour Avater out of a bottle, etc. Cook0 speaks of a female child born of Indian parents, the fourth birth of a mother tAventy-six years old. The child weighed 5 J pounds ; the circumference of the head Avas 14 inches and that of the trunk 13 inches. The upper extremities consisted of perfect shoulder joints, but only J of each humerus was present. Both sides shoAved eA'idences of amputation, the cicatrix on the right side being 1 inch long and on the left £ inch long. The right loAver limb was merely a fleshy corpuscle f inch Avide and J inch long ; to the posterior edge Avas attached a body resembling the little toe of a neAvly-born infant. On the left side the limb Avas represented by a fleshy cor- puscle 1 inch long and i inch in circumfer- ^. „ T . ... ,„ ,, ence, resembling the great toe of an in- Fig. 9.—Intrauterine amputation (Cook). ' & & ^"L '-'-"-' "x "■" llx fant. There Avas no history of shock or injury to the mother. The child presented by the breech, and by the ab- sence of limbs caused much difficulty in diagnosis. The three stages of labor Avere one and one-half hours, forty-five minutes, and five minutes, respect- ively. The accompanying illustration (Fig. 9) shows the appearance of the limbs at the time of report. Figure 10 represents a negro boy, the A'ictim of intrauterine amputation avIio learned to utilize his toes for many purposes. The illustration shows his mode of holding his pen. There is an instance reportedd in Avhich a child at full term was born Avith an amputated arm, and at the age of seventeen the stump M'as scarcely if at all smaller than the other. Blake e speaks of a case of congenital a 309, 1832. b H8, Jan. 22, 1878. c 224, 1890, i., 1360. d222, Oct., 1837. e 218, Dec. 20, 1894. INTRAUTERINE AMPUTATIONS. 95 amputation of both the upper extremities. Gillilam a mentions a case that shoAvs the deleterious influence of even the Aveight of a fetal limb resting on a cord or band. His case Avas that of a fetus, the product of a miscarriage of traumatic origin ; the soft tissues were almost cut through and the bone denuded by the limb resting on one of the two umbilical cords, not encir- cling it, but in a sling. The cord Avas deeply imbedded in the tissues. The codings of the cord are not limited to compression about the extremi- ties alone, but may eAren decapitate the head by being firmly wrapped seATeral times about the neck. According to Ballantyne,759 there is in the treatise De Octimestri Partu, by Hip- pocrates, a reference to coiling of the umbilical cord round the neck of the fetus. This coiling Avas, indeed, regarded as one of the dangers of the eighth month, and even the mode of its pro- duction is described. It is said that if the cord be extended along one side of the uterus, and the fetus lie more to the other side, then Avhen the cul- bute is performed the funis must necessarily form a loop round the neck or chest of the infant. If it remain in this position, it is further stated, the mother Avill suffer later and the fetus Avill either perish or be born Avith difficulty. If the Hippocratic writers knew that this coiling is sometimes quite innocuous, they Fig ia_Intrauterine amputation. did not in any place state the fact. The accompanying illustrations (Fig. 11) shoAV the different ways in which the funis may be coiled, the coils sometimes being as many as 8. Bizzen b mentions an instance in Avhich from strangulation the head of a fetus was in a state of putrefaction, the funis being twice tightly bound around the neck. Cleveland,0 Cuthbert,d and Germain e report analogous instances. Matthyssens f observed the tAvisting of the funis about the arm and neck of a fetus the body of Avhich Avas markedly Avasted. There Avas complete absence of amniotic fluid during labor. Blumenthal* presented to the New York Pathological Society an.ovum Avithin Avhich the fetus A\as under- a 274, 1872, iii., 230. b 124, is,y_>, xxxiii., 565. c 778, xiii., 1. d 610, 1874-5. e 362, ix., 567. f Ann. Soc-. de med. d'Anvers, 1842, 372. e 538, 1871, vi., 278. 96 PRENA TAL A NOMA LIES. going intrauterine decapitation. Buchanan a describes a case illustrative of the etiology of spontaneous amputation of limbs in utero. Nebinger b reports a case of abortion, shoAving commencing amputation of the left thigh from being encircled by the funis. The death of the fetus was probably due to compression of the cord. OAA^en0 mentions an instance in Avhich the left arm and hand of a fetus Avere found in a state of putrescence from strangulation, the funis being tightly bound around at the upper part. Shnpsond pub- lished an article on spontaneous amputation of the forearm and rudimentary regeneration of the hand in the fetus. Among other contributors to this Fig. 11.—Coiling of the cord. subject are Avery, Boncour, BroAvn, Ware, Wrangell, Young, Nettekoven, Martin, Macau, Leopold, Hecker, Gunther, and Friedinger. AVvgodzky e finds that the greatest number of coils of the umbilical cord ever found to encircle a fetus are 7 (Baudelocque), 8 (CredS), and 9 (Midler and Gray). His own case Avas observed this year in Wilna. The patient was a primipara aged tAventy. The last period was seen on May 10, 1894. On February 19th the fetal movements suddenly ceased. On the 20th pains set in about two Aveeks before term. At noon turbid a 774, 1839, x., 41. b 124, 1867, liv., 129. c 656, 1851, 573. d Month. Jour. Med. Sc, Edin., 1848. e 261; and quoted 545, Feb. 29, 1896. INTRA UTERINE FRA CTURES. 97 liquor amnii escaped. At 2 p. m., on examination, Wygodzky defined a dead fetus in left occipito-anterior presentation, very high in the inlet. The os was nearly completely dilated, the pains strong. By 4 P. m. the head was hardly engaged in the pelvic cavity. At 7 p. m. it neared the outlet at the height of each pain, but retracted immediately afterward. After 10 p. M. the pains greAV Aveak. At midnight Wygodzky delivered the dead child by expression. Not till then Avas the cause of delay clear. The funis was Arery tense and coiled 7 times round the neck and once round the left shoulder; there Avas also a distinct knot. It measured over 65 inches in length. The fetus Avas a male, slightly macerated. It Aveighed over 5 pounds, and Avas easily delivered entire after division and umvinding of the funis. No marks remained on the neck. The placenta followed ten minutes later and, so far as naked-eye experience indicated, seemed healthy. Intrauterine fractures are occasionally seen, but are generally the re- sults of traumatism or of some extraordinary muscular efforts on the part of the mother. A bloAV on the abdomen or a fall may cause them. The most interesting cases are those in which the fractures are multiple and the causes unknoAvn. Spontaneous fetal fractures haA'e been discussed thor- oughly, and the reader is referred to any responsible text-book for the theo- ries of causation. Atkinson,a De Luna,b and Keller report intrauterine fractures of the clavicle. Filippi0 contributes an extensiA'e paper on the medicolegal aspect of a case of intrauterine fracture of the os cranium. Braun of Vienna reports a case of intrauterine fracture of the humerus and femur. Rodrigued describes a case of fracture and dislocation of the hu- merus of a fetus in utero. Gaultiere reports an instance of fracture of both femora intrauterine. Stanley, Yanderveer, and Young cite instances of in- trauterine fracture of the thigh ; in the case of Stanley the fracture occurred during the last Aveek of gestation, and there Avas rapid union of the frag- ments during lactation. Danyau, Proudfoot, and Smith f mention intrauterine fracture of the tibia; in Proudfoot's case there Avas congenital talipes talus. Dolbeaug describes an instance in Avhich multiple fractures Avere found in a fetus, some of Avhich Avere evidently postpartum, Avhile others Avere assuredly antepartum. Hirschfeldh describes a fetus showing congenital multiple frac- tures. Gross 387 speaks of a Avonderful case of Chaupier in which no less than 113 fractures Avere discovered in a child at birth. It surviATed twenty-four hours, and at the postmortem examination it was found that some were already solid, some uniting, Avhilst others Avere recent. It often happens that the intrauterine fracture is Avell united at birth. There seems to be a peculiar predisposition of the bones to fracture in the cases in which the frac- tures are multiple and the cause is not apparent. a 545, 1859-60, iii., 532. b 124, 1873, lxvi., 282. c Imparziale, Firenze, 1879, xix. '• 124. 1854, xxvii., 272. e 458, 1819, 81. f 779, xviii., 215. e 242, xxxviii., 126. h 363, xxx., 291. 7 98 PRENATAL ANOMALIES. The results to the fetus of injuries to the pregnant mother are most diversified. In some instances the marvelous escape of any serious conse- quences of one or both is almost incredible, while in others the slightest injury is fatal. Guillemont a cites the instance of a woman avIio was killed by a stroke of lightning, but Avhose fetus Avas saved ; while Fabricius Hil- danus b describes a case in Avhich there Avas perforation of the head, fracture of the skull, and a-wound of the groin, due to sudden starting and agony of terror of the mother. Here there was not the slightest history of any exter- nal A'iolence. It is a Avell-knoAvn fact that injuries to the pregnant mother sIioav visible effects on the person of the fetus. The older writers kept a careful record of the anomalous and extraordinary injuries of this character and of their effects. Brendelius tells us of hemorrhage from the mouth and nose of the fetus occasioned by the fall of the mother; Buchner ° mentions a case of fracture of the cranium from fright of the mother; Reuther describes a con- tusion of the os sacrum and abdomen in the mother from a fall, with fracture of the arm and leg of the fetus from the same cause ; Sachse d speaks of a fractured tibia in a fetus, caused by a fall of the mother ; Slevogte relates an instance of rupture of the abdomen of a fetus by a fall of the mother; the Ephemerides contains accounts of injuries to the fetus of this nature, and among others mentions a stake as having been thrust into a fetus in utero; Verducf offers seATeral examples, one a dislocation of the fetal foot from a maternal fall; Plocquet456 gives an instance of fractured femur ; Walther g describes a case of dislocation of the vertebrae from a fall; and there is also a case h of a fractured fetal vertebra from a maternal fall. There is recorded1 a fetal scalp injury, together with clotted blood in the hair, after a fall of the mother. Autenrieth describes a wound of the pregnant uterus, which had no fatal issue, and there is also another similar case on record. J The modern records are much more interesting and Avonderful on this subject than the older ones. Richardson650 speaks of a Avoman falling doAvn a few Aveeks before her delivery. Her pelvis Avas roomy and the birth Avas easy ; but the infant Avas found to have extensive wounds on the back, reach- ing from the 3d dorsal vertebra across the scapula, along the back of the humerus, to Avithin a short distance of the elbow. Part of these wounds Avere cicatrized and part still granulating, which shows that the process of reparation is as active in utero as elseAvhere. Injuries about the genitalia Avould naturally be expected to exercise some active influence on the uterine contents ; but there are many instances reported in which the escape of injury is marvelous. Gibbk speaks of a Avoman, about eight months pregnant, who fell across a chair, lacerating her a Lvons, 1590. b 334, cent, v., obs. 3. e 282, ann. x., 172. t 799, T. i., 197. i 462, T. xxi. J 106, 1712, 454. c Miscel. 1728, 1026. d 452) l. xi. g 815, obs. 50. h 524, v.( 326. k 476, 1858, i. INJURIES FROM HORNS OF CATTLE. 99 genitals and causing an escape of liquor amnii. There Avas regeneration of this fluid and delivery beyond term. The labor Avas tedious and took place tA\o and a half months after the accident, The mother and the female child did Avell. Purcell a reports death in a pregnant woman from contused Avound of the vulva. Morland b relates an instance of a Avoman in the fifth month of her second pregnancy, Avho fell on the roof of a Avoodshed by slipping from one of the steps by Avhich she ascended to the roof, in the act of hang- ing out some clothes to dry. She suffered a Avound on the internal surface of the left nympha 1J inch long and J inch deep. She had lost about three quarts of blood, and had applied ashes to the vagina to stop the bleeding. She made a recovery by the twelfth day, and the fetal sounds were plainly audible. CullingAVorth ° speaks of a woman who, during a quarrel Avith her husband, was pushed aAvay and fell between two chairs, knocking one of them OA'er, and causing a triATial Avound one inch long in the A'agina, close to the entrance. She screamed, there was a gush of blood, and she soon died. The uterus contained a fetus three or four months old, Avith the membranes intact, the maternal death being due to the A'aricosity of the pregnant pudenda, the slight injury being sufficient to produce fatal hemorrhage. Carhartd describes the case of a pregnant woman, avIio, Avhile in the stoop- ing position, milking a cow, was impaled through the \ragina by another coav. The child was born seven days later, with its skull crushed by the coav's horn. The horn had entered the vagina, carrying the clothing Avith it. There are some marArelous cases of recoA'ery and noninterference Avith pregnancy after injuries from horns of cattle. Corey e speaks of a woman of thirty-five, three months pregnant, Aveighing 135 pounds, avIio Avas horned by a coav through the abdominal parietes near the hypogastric region; she Avas lifted into the air, carried, and tossed on the ground by the infuriated animal. There Avas a Avound consisting of a ragged rent from abo\Te the os pubis, extending obliquely to the left and upAvard, through Avhich protruded the great omentum, the descending and transA-erse colon, most of the small intestines, as well as the pyloric extremity of the stomach. The great omen- tum Avas mangled and comminuted, and bore two lacerations of two inches each. The intestines and stomach were not injured, but there was consider- able extravasation of blood into the abdominal cavity. The intestines Avere cleansed and an unsuccessful attempt Avas made to replace them. The intes- tines remained outside of the body for two hours, and the great omentum was carefully spread out over the chest to preA'ent interference Avith the efforts to return the intestines. The patient remained conscious and calm throughout; finally deep anesthesia Avas produced by ether and chloroform, three and a half hours after the accident, and in twenty minutes the intes- tines Avere all replaced in the abdominal cavity. The edges Avere pared, sutured, and the Avound dressed. The Avoman Avas placed in bed, on the a 313, 1870. b218, 1858-9. c 521, 1885. <* 760, 1884. e 133, 1878. 100 PRENATAL ANOMALIES. right side, and morphin Avas administered. The sutures were removed on the ninth day, and the Avound had healed except at the point of penetration. The woman Avas discharged twenty davs after, and, incredible to relate, was delivered of a well-developed, full-term child just two hundred and two days from the time of the accident. Both the mother and child did w ell. Lucea speaks of a pregnant Avoman who Avas horned in the lower part of the abdomen by a coav, and had a subsequent protrusion of the intestines through the Avound. After some minor complications, the Avound healed fourteen weeks after the accident, and the Avoman was confined in natural labor of a healthy, vigorous child. In this case no blood Avas found on the cow's horn, and the clothing Avas not torn, so that the wound must have been made by the side of the horn striking the greatly distended abdomen. Richard,b quoted also by Tiffany,837 speaks of a woman, tAventy-two, Avho fell in a dark cellar with some empty bottles in her hand, suffering a Avound in the abdomen 2 inches above the navel on the left side 8 cm. long. Through this Avound a mass of intestines, the size of a man's head, protruded. Both the mother and the child made a good convalescence. Harris ° cites the instance of a Avoman of thirty, a multipara, six months pregnant, who A\as gored by a coav ; her intestines and omentum protruded through the rip and the uterus Avas bruised. There was rapid recovery and delivery at term. Wetmore of Illinois saw a woman who in the summer of 1860, Avhen about six months pregnant, was gored by a cow, and the large intestine and the omentum protruded through the wound. Three hours after the injury she Avas found SAvathed in rags wet Avith a compound solution of Avhiskey and camphor, Avith a decoction of tobacco. The intes- tines Avere cold to the touch and dirty, but were washed and replaced. The abdomen was seAved up Avith a darning needle and black linen thread ; the Avoman recovered and bore a healthy child at the full maturity of her gesta- tion.d CroAvdacee speaks of a female pauper, six months pregnant, Avho Avas attacked by a buffalo, and suffered a wound about 1| inch long and J inch wide just above the umbilicus. Through this small opening 19 inches of intestine protruded. The Avoman recovered, and the fetal heart-beats could be readily auscultated. Major accidents in pregnant women are often folWed by the happiest results. There seems to be no limit to Avhat the pregnant uterus can success- fully endure. Tiffany,837 Avho has collected some statistics on this subject, as Avell as on operations successfully performed during pregnancy, Avhich will be considered later, quotes1- the account of a woman of twenty-seven, eight months pregnant, who was almost buried under a clay Avail. She received terrible wounds about the head, 32 sutures being used in this location a 545, 1859. b 236, 1878. c io5> xx. d Harris, 125, xx. e 500, 1863, vii., 409. t 644, 1881, vi., 203. MAJOR ACCIDENTS IN PREGNANCY. 101 alone. Subsequently she Avas confined, easily bore a perfectly normal female child, and both did Avell. Sibois a describes the case of a Avoman Aveigh- ing 190 pounds, avIio fell on her head from the top of a Avail from 10 to 12 feet high. For several hours she exhibited symptoms of fracture of the base of the skull, and the case Avas so diagnosed ; fourteen hours after the accident she Avas perfectly conscious and suffered terrible pain about the head, neck, and shoulders. Tavo days later an ovum of about twenty days was expelled, and seven months after she Avas delivered of a healthy boy weighing 10J pounds. She had therefore lost after the accident one-half of a double conception. Yerrierb has collected the results of traumatism during pregnancy, and summarizes 61 cases. PnnvzoAvsky ° cites the instance of a patient in the eighth month of her first pregnancy who Avas Avounded by many pieces of lead pipe fired from a gun but a feAV feet distant. Neither the patient nor the child suffered materially from the accident, and gestation proceeded; the child died on the fourth day after birth without apparent cause. Milnerd records an instance of remarkable tolerance of injury in a pregnant Avoman. During her six months of pregnancy the patient Avas accidentally shot through the abdominal cavity and loAver part of the thorax. The missile penetrated the central tendon of the diaphragm and lodged in the lung. The injury Avas limited by localized pneumonia and peritonitis, and the Avound was drained through the lung by free expectoration. Recovery ensued, the patient giving birth to a healthy child sixteen weeks later. Beline mentions a stab-wound in a pregnant Avoman from Avhich a considerable portion of the epiploon pro- truded. Sloughing ensued, but the patient made a good recoA'ery, gestation not being interrupted. Fanconf describes the case of a Avoman Avho had an injury to the knee requiring drainage. She Avas attacked by erysipelas, Avhich spread over the Avhole body Avith the exception of the head and neck ; yet her pregnancy Avas uninterrupted and recoA'ery ensued. Fancon also speaks of a girl of nineteen, frightened by her lover, Avho threatened to stab her, Avho jumped from a second-story AvindoAV. For three days after the fall she had a slight bloody Aoav from the vuhTa. Although she Avas six months pregnant there Avas no interruption of the normal course of gestation. Bancroft^ speaks of a Avoman Avho, being mistaken for a burglar, Avas shot by her husband with a 44-caliber bullet. The missile entered the second and third ribs an inch from the sternum, passed through the right lung, and escaped at the inferior angle of the scapula, about three inches beloAV the spine; after leaving her body it Avent through a pine door. She suffered much hemorrhage and shock, but made a fair recovery at the end of four weeks, though pregnant Avith her first child at the seventh month. At full a 7ss. 18*7. July 1, 345. b Rev. Med.-chir. d. Mai. d. Femmes, Paris, 1888, x.. 529. S12, 1879, iv., 1113. d 533, Ixi., 243. e 236, 1878. f Quoted 844, 251. g 545, 1876. 102 PRENATAL ANOMALIES. term she Avas delivered by foot-presentation of a healthy boy. The mother at the time of report was healthy and free from cough, and Avas nursing her babe, Avhich Avas strong and bright. All the cases do not have as happy an issue as most of the foregoing ones, though in some the results are not so bad as might be expected. A German female, thirty-six, while in the sixth month of pregnancy, fell and struck her abdomen on a tub. She was delivered of a normal living child, Avith the exception that the helix of the left ear Avas pushed anteriorly, and had, in its middle, a deep incision, which also traversed the antihelix and the tragus, and continued over the cheek toward the nose, Avhere it terminated. The external auditory meatus was obliterated. Gurlt speaks of a Avoman, seven months pregnant, who fell from the top of a ladder, subsequently losing some blood and Avater from the vagina. She had also persistent pains in the belly, but there Avas no deterioration of general health. At her confinement, which was normal, a strong boy was born, Avanting the arm beloAV the middle, at Avhich point a white bone protruded. The Avound healed and the separated arm came aAvay after birth. Waimvright a relates the instance of a woman of forty, avIio when six months pregnant AA'as run over by railway cars. After a double amputation of the legs she miscarried and made a good recovery. Neugebauer b reported the history of a case of a woman ay ho, while near her term of pregnancy, committed suicide by jump- ing from a Avindow. She ruptured her uterus, and a dead child Avith a frac- ture of the parietal bone Avas found in the abdominal caA'ity. Staples ° speaks of a Swede of twenty-eight, of Minnesota, who Avas accidentally shot by a young man riding by her side in a Avagon. The ball entered the abdomen two inches above the crest of the right ilium, a little to the rear of the anterior superior spinous process, and took a doAvnward and forward course. A little shock Avas felt but no serious symptoms folioA\ed. In forty hours there Avas delivery of a dead child Avith a bullet in its abdomen. Labor Avas normal and the internal recovery complete. Yon Chelius, 265 quoting the younger Naegele, gives a remarkable instance of a young peasant of thirty-five, the mother of four children, pregnant Avith the fifth child, avIio was struck on the belly violently by a blow from a Avagon pole. She Avas throAvn doAvn, and felt a tearing pain Avhich caused her to faint. It Avas found that the Avomb had been ruptured and the child killed, for in several days it AAas delivered in a putrid mass, partly through the natural passage and partly through an abscess opening in the abdominal Avail. The Avoman made a good recovery. A curious accident of pregnancyd is that of a woman of thirty-eight, advanced eight months in her ninth pregnancy, avIio after eating a hearty meal was seized by a violent pain in the region of the stomach and soon afterAvard with convulsions, supposed to have been puer- peral. She died in a feAv hours, and at the autopsy it was found that labor a 647, 1877, 59. b 782 ; and 261, 1890, 88. c 538, 1876. d 218, Oct. 1, 1868. OPERATIONS DURING PREGNANCY. 103 had not begun, but that the pregnancy had caused a laceration of the spleen, from which had escaped four or five pints of blood. Edgea speaks of a ease of chorea in pregnancy in a Avoman of twenty-seven, not interrupting preg- nancy or retarding safe deli\Tery. This had continued for four pregnancies, but in the fourth abortion took place. Buzzard b had a case of nervous tremor in a Avoman, following a fall at her fourth month of pregnancy, avIio at term gave birth to a male child that was idiotic. Beatty ° relates a curious accident to a fetus in utero. The woman Avas in her first confinement and Avas delivered of a small but healthy and strong boy. There was a small puncture in the abdominal parietes, through which the Avhole of the intestines protruded and Avere constricted. The opening a\ as so small that he had to enlarge it with a bistoury to replace the boAvel, Avhich was dark and congested; he sutured the Avound Avith silver Avire, but the child subsequently died. Tiffany837 of Baltimore has collected excellent statistics of operations during pregnancy ; and Mann of Buffalo d has done the same Avork, limit- ing himself to operations on the pelvic organs, Avhere interference is sup- posed to have been particularly contraindicated in pregnancy. Mann, after giving his individual cases, makes the folloAving summary and conclusions :— (1) Pregnancy is not a general bar to operations, as has been supposed. (2) Union of the denuded surfaces is the rule, and the cicatricial tissue, formed during the earlier months of pregnancy, is strong enough to resist the shock of labor at term. (3) Operations on the vulva are of little danger to mother or child. (4) Operations on the vagina are liable to cause severe hemorrhage, but otherwise are not dangerous. (5) Yenereal vegetations or Avarts are best treated by removal. (6) Applications of silver nitrate or astringents may be safely made to the \'agina. For such application, phenol or iodin should not be used, pure or in strong solution. (7) Operations on the bladder or urethra are not dangerous or liable to be folloAved by abortion. (8) Operations for vesicovaginal fistulse should not be done, as they are dangerous, and are liable to be folloAved by much hemorrhage and abortion. (9) Plastic operations may be done in the earlier months of pregnancy Avith fair prospects of a safe and successful issue. (10) Small polypi may be treated by torsion or astringents. If cut, there is likely to be a subsequent abortion. (11) Large polypi removed toAvard the close of pregnancy will cause hemorrhage. (12) Carcinoma of the cervix should be removed at once. A feAv of the examples on record of operations during pregnancy of a 244, 1889, i., 516. b 476, 1868, ii., 479. c 224, 1879, i., 701. d 764, 1882. 104 PRENA TAL ANOMALIES. special interest, will be given below. Polaillon a speaks of a double ovari- otomy on a Avoman pregnant at three months, Avith the subsequent birth of a living child at term. Gordon b reports fiA'e successful ovariotomies during pregnancy, in Lebedeff's clinic. Of these cases, 1 aborted on the fifth day, 2 on the fifteenth, and the other 2 continued uninterrupted. He collected 204 cases with a mortality of only 3 per cent. ; 22 per cent, aborted, and 69.4 per cent. Avere deliA'ered at full term. Kreutzman ° reports two cases in Avhich ovarian tumors Avere successfully remoAed from pregnant subjects without the interruption of gestation. One of these Avomcn, a secundipara, had gone two Aveeks OArer time, and had a large OA'arian cyst, the pedicle of Avhich had become twisted, the fluid in the cyst being sanguineous. May d describes an OArariotomy performed during pregnaiuv at Tottenham Hospital. The Avoman, aged twenty-two, Avas pale, diminuti\Te in size, and showed an enormous abdomen (Fig. 12), Avhich measured 50 inches in circumference at the umbilicus and 27 inches from the ensiform cartilage to the pubes. At the operation, 36 pints of broMm fluid Avere dnnvn off. Delivery took place tAvelve hours after the operation, the mother re- covering, but the child Avas lost. Gala- bin e had a case of OATariotomy performed on a Avoman in the sixth month of prog- nancy Avithout interruption of pregnancy ; Potterf had a case of double ovariotomy with safe delivery at term ; and Storrv g had a similar case. Jacobsonb cites a Flg,2-i:m"L'ttvrr°-:)(M*y' °ase °f ™ginai iithot»my»»i-tiem six and a half months pregnant, with normal delivery at full term. Tiffany quotes Keelan's * description of a woman of thirty-five, in the eighth month of pregnancy, from Avhom he remo\red a stone Aveighing 12J ounces and measuring 2 by 2| inches, with subsequent recovery and continuation of pregnancy. Rvdygier J mentions a case of obstruction of the intestine during the sixtli month of gestation shoAving symptoms of strangulation for seven days, in Mdiich he performed abdominal section. Recovery of the Avoman Avithout abortion ensued. The ReAuie de Chirnrgie, 1887, contains an account of a Avoman Avho suffered internal strangulation, on Avhom celiotomy AAas performed ; she recoA'ered in twenty-five days, and did not miscarry, Avhich sIioavs that severe injury to the intestine Avith operati\7e interference does not necessarily interrupt pregnancy. Gilmore,k Avithout inducing abortion, extirpated the kidney of a negress, aged a 653, 1892. b 261, 1894. c Occidental Med. Times, Aug., 1892. d224, Dec. 2, 1893. e 224, 1880. f 125, 1888. g 476, 1882.' h 476, 1889, i., 628. i 224, Oct. 15, 1887. J 844, 250. k 125,' May, 1871. OPERATIONS DURING PREGNANCY. 105 thirty-three, for severe and constant pain. Tiffany a removed the kidney of a Avoman of twenty-seven, five months pregnant, Avithout interruption of this or subsequent pregnancies. The child was living. He says that Fancon cites instances of operation without abortion. Lovortb describes an enucleation of the eye in the second month of pregnancy. Pilcher0 cites the instance of a woman of fifty-eight, eight months in her fourth pregnancy, whose breast and axilla he removed Avithout interruption of pregnancy. Robson,d Polaillon, and Coen report similar instances. Rein speaks of the removal of an enormous echinococcus cvst of the omentum Avithout interruption of pregnancy. Robsone reports a multi- locular cyst of the ovary Avith extensive adhesions of the uterus, remoA'ed at the tenth Aveek of pregnancy and ovariotomy performed Avithout any inter- ruption of the ordinary course of labor. Russellf cites the instance of a woman Avho Avas successfully tapped at the sixth month of pregnancy. McLeang speaks of a successful amputation during pregnancy ; Napper, 778 one of the arm ; Nicod, one of the arm ; Russell,b an amputation through the shoulder joint for an injury during pregnancy, Avith delivery and recoATery ; and ATesey1 speaks of amputation for compound fracture of the arm, labor following ten hours aftenvard Avith recoA'ery. Keenj reports the successful performance of a hip-joint amputation for malignant disease of the femur during pregnancy. The patient, Avho was five months advanced in gestation, recovered without aborting. Robson reports a case of strangulated hernia in the third month of preg- nancy Avith stercoraceous A'omiting. He performed herniotomy in the femoral region, and there Avas a safe deli\Tery at full term. In the second month of pregnancy he also rotated an OA'arian tumor causing acute symptoms, and afterward performed ovariotomy Avithout interfering Avith pregnancy. Mann quotes Munde in speaking of an instance of remoA-al of elephantiasis of the vulva Avithout interrupting pregnancy, and says that there are many cases of the removal of A'enereal Avarts without any interference Avith gestation. Campbell of Georgia operated inadvertently at the second and third month in Iavo cases of AcsicoATaginal fistula in pregnant women. The first case sliOAved no interruption of pregnancy, but in the second case the Avoman nearly died and the fistula remained unhealed. Engelmann operated on a large rectovaginal fistula in the sixth month of pregnancy Avithout any in- terruption of pregnancy, Avhich is far from the general result. Cazin and Rev both produced abortion by forcible dilatation of the anus for fissure, but Gayct used both the fingers and a speculum in a case at five months and the woman Avent to term. By cystotomy Reamy removed a double hair-pin a 533, April 16, 1887. b 238, 1887. <= 648, 1879. d 224, 1889. e 224. 1879. f 535, 127, n. s. ii., 430-433. g 5*2, 1852. b476, 1872, ii., 632. ! 224, 1878. J 533, March 26, 1892. 106 PR EN A TA L A NOMA LIES. from a woman pregnant six and a half months, Avithout interruption, and according to Mann again, McClintock extracted stones from the bladder by the urethra in the fourth month of pregnancy, and Phillips did the same in the seventh month. Hendenberg and Packard a report the remoA'al of a tumor weighing 8£ pounds from a pregnant uterus Avithout interrupting ges- tation. The following extract from the University Medical Magazine of Phila- delphia illustrates the after-effects of abdominal hysteropaxy on sub- sequent pregnancies:— "Fraipont (Annates de la Societe 3Iedieo-Chirurgieale de Liege, 1894) re- ports four cases Avhere pregnancy and labor Avere practically normal, though the uterus of each patient had been fixed to the abdominal Avails. In two of the cases the hysteropexy had been performed 0Arer five years before the pregnancy occurred, and, although the bands of adhesion between the fundus and the parietes must have become ATery tough after so long a period, no special difficulty Avas encountered. In tA\o of the cases the forceps Avas used, but not on account of uterine inertia; the fetal head Avas A'oluminous, and in one of the two cases internal rotation was delayed. The placenta Avas ahvays expelled easily, and no serious postpartum hemorrhage occurred. Fraipont observed the progress of pregnancy in several of these cases. The uterus does not increase specially in its posterior part, but quite uniformly, so that, as might be expected, the fundus gradually detaches itself from the abdom- inal Avail. EAren if the adhesions were not broken down they would of ne- cessity be so stretched as to be useless for their original purpose after deliA- ery. Bands of adhesion could not share in the process of involution. As, hoAveA-er, the uterus undergoes perfect involution, it is restored to its original condition before the onset of the disease Avhich rendered hysteropexy neces- sary." The coexistence of an extensive tumor of the uterus with pregnancy does not necessarily mean that the product of conception Avill be blighted. Brochin b speaks of a case in Avhich pregnancy was complicated Avith fibroma of the uterus, the accouchement being natural at term. Byrne ° mentions a case of pregnancy complicated Avith a large uterine fibroid. Delivery Avas effected at full term, and although there Avas considerable hemorrhage the mother recovered. Ingleby d describes a case of fibrous tumor of the uterus termi- nating fatally, but not until three A\-eeks after delivery. Luske mentions a case of pregnancy Avith fibrocystic tumor of the uterus occluding the cervix. At the appearance of symptoms of eclampsia version Avas performed and delivery effected, folloAved by postpartum hemorrhage. The mother died from peritonitis and collapse, but the stillborn child Avas resuscitated. Rob- erts f reports a case of pregnancy associated Avith a large fibrocellular polypus a 590, 1890, xxv., 306. b 363, xlviii., 1178. c 3i0) 1877, 170. d 318, li., 75. e 125, 1876, ix., 94. f 476, 1867, i., 333. PROTRUSION OF THE FETAL MEMBRANES. 107 of the uterus. A living child was delivered at the seventh month, ecrase- ment Avas performed, and the mother recovered. Yon Quasta speaks of a fibromyoma removed five days after labor. (xervis b reports the removal of a large polypus of the uterus on the fifth day after confinement. Davis ° describes the spontaneous expulsion of a large polypus two days after the delivery of a fine, healthy, male child. Deasond mentions a case of anomalous tumor of the uterus during pregnancy Avhich was expelled after the birth of the child; and Daly alsoe speaks of a tumor expelled from the uterus after delivery. Cathellf speaks of a case of pregnancy complicated Avith both uterine fibroids and measles. Other Fig. 13.—Large fibroid blocking the pelvis (Spiegelberg). cases of a similar nature to the foregoing are too numerous to mention. Figure 13, taken from Spiegelberg, sIioavs a large fibroid blocking the pelvis of a pregnant Avoman. There are several peculiar accidents and anomalies not previously men- tioned Avhich deserve a place here, viz., those of the membranes surround- ing the fetus. BroAvn s speaks of protrusion of the membranes from the vulva several weeks before confinement. Da viesh relates an instance in which there Avas a copious watery discharge during pregnancy not folloAved a Kansas City Med. Index, 1888. b 778, xi., 4. c 124, 1843, vi., 519. d 593, 1859, xvi., 663. e 778, 1887, xxviii., 170. t 775, 1886, 157. g 616, 1872, xv., 246. h 537, 1834. 108 PRENATAL ANOMALIES. by labor. There is a case mentioned a in which an accident and an inoppor- tune dose of ergot at the fifth month of pregnancy were followed by rupture of the amniotic sac, and subsequently a constant flow of watery fluid con- tinued for the remaining three months of pregnancy. The fetus died at the time, and was born in an advanced state of putrefaction, by version, three months after the accident. The mother died five months after of carcinoma of the uterus. Montgomery b reports the instance of a woman who menstru- ated last on May 22, 1850, and quickened on September 26th, and continued well until the 11th of November. At this time, as she was retiring, she became conscious that there was a watery discharge from the vagina, which proved to be liquor amnii. Her health was good. The discharge continued, her size increased, and the motions of the child continued active. On the 18th of January a full-sized eight months' child was born. It had an incessant, wailing, Ioav cry, always of evil augury in neAV-born infants. The child died shortly after. The daily discharge was about 5 ounces, and had lasted sixty- eight davs, making 21 pints in all. The same accident of rupture of the membranes long before labor happened to the patient's mother. Bardt ° speaks of labor twenty-three days after the Aoav of the waters ; and Cobleighd one of seventeen days ; Bradleye relates the history of a case of rupture of the membranes six Aveeks before delivery. Rainsf cites an instance in Avhich gestation continued three months after rupture of the membranes, the labor-pains lasting thirty-six hours. Griffiths523 speaks of rupture of the amniotic sac at about the sixth month of pregnancy with no untoAvard interruption of the completion of gestation and Avith deli\^ery of a livino-child. There is another observation s of an accouchement terminating successfully tAvcnty-three days after the loss of the amniotic fluid. Camp- bell11 mentions delivery of a living child twelve days after rupture of the membranes. Chesneyi relates the history of a double collection of Avaters. Woodj reports a case in Avhich there Avas expulsion of a bag of AA'aters be- fore the rupture of the membranes. Bailly, Chestnut, Bjering, Cowger, Duncan, and others also record premature rupture of the membranes Avith- out interruption of pregnancy. Harrisk gives an instance of the membranes being expelled from the uterus a few days before delivery at the full term. Chatard, Jr.,1 mentions extrusion of the fetal membranes at the seventh month of pregnancy Avhile the patient was taking a long afternoon Avalk, their subsequent retraction, and normal labor at term. Thurston m tells of a case in Avhich Nature had ap- parently effected the separation of the placenta Avithout alarming hemorrhage, the case being one of placenta prsevia, terminating favorably by natural pro- a 366, 1844-45, v., 163. b 308, 1857. c 463, xiii., 33. d 545, 1377, xxxvii. e 22l! 1871, ii., 612. f 131, 1875. iii., 253. S 461, 1807, xiii., 33. h 218, lxxxvii., 196. i 481, 1868-69, ii., 346. J Month. Jour. Med. Sci., Lond. and Edinb., ix., 853. k778,' vii., 47. l 125, 1886. m224, 1884. ANOMALIES OF THE UMBILICAL CORD. 109 cesses. Play faira speaks of the detachment of the uterine decidua Avithout the interruption of pregnancy. Guerrant1' gives a unique example of normal birth at full term in Avhich the placenta was found in the vagina, but not a vestige of the membranes was noticed. The patient had experienced nothing unusual until within three months of expected confinement, since Avhich time there had been a daily loss of water from the uterus. She recovered and was doing her work. There Avas no possibility that this was a case of retained secundines; Anomalies of the Umbilical Cord.—Absence of the membranes has its counterpart in the deficiency of the umbilical cord, so frequently noticed in old reports. The Ephemerides, Osiander, Stark's Archives,160 Thiebault, van der YViel, Chatton, and Schurig726 all speak of it, and it has been noticed since. Danthez ° speaks of the development of a fetus in spite of the absence of an umbilical cord. Stute d reports an observation of total absence of the umbilical cord, with placental insertion near the cervix of the uterus. There is mentionede a bifid funis. The Ephemeridesf and van der AViel speak of a duplex funis. Noldes reports a cord 08 inches long; and M ernerh cites the instance of a funis ol inches long. There are modern in- stances in which the funis has been bifid or duplex, and there is also a case reported in Avhich there Avere tAvo cords in a twin pregnancy, each of them measuring five feet in length. The Lancet * gives the account of a most pe- culiar pregnancy consisting of a placenta alone, the fetus Avanting. AYhat this " placenta " Avas Avill ahvays be a matter of conjecture. Occasionally death of the fetus is caused by the formation of knots in the cord, shutting off the fetal circulation; Gery, Grieve, Mastin, Passot, Piogey, AYoets, and others report instances of this nature. NeAvmanJ reports a curious case of twins, in Avhich the cord of one child was encircled by a knot on the cord of the other. Among others, Latimerk and Motte1 report instances of the accidental tying of the boAvel Avith the funis, causing an arti- ficial anus. The diverse causes of abortion are too numerous to attempt giving them all, but some are so curious and anomalous that they deser\Te men- tion. Epidemics of abortion are spoken of by Fiekius, Fischer, and the Ephemerides. Exposure to cold is spoken of as a cause,m and the same is alluded to by the Ephemerides ;n Avhile another case is given as due to exposure Avhile nude.0 There are several cases among the older writers in which odors arc said to have produced abortion, but as analogues are not to be found in modern literature, unless the odor is very poisonous or pungent, avc can give them but little credence. The Ephemerides gives the a 610, 1879-80. b 609, 1879-80, ii., 480. c 368, 1842. d 363, xxix., 498. e Solingen,742 f 104, dec. i., ann. i., obs. 39. g 160, vii., 197. b 160, vii., 523. ' 476, 1842-43. J 318, 1858, iv., 8-10. * 545, xlvi., 242. 1 242, liv., 494. '" los, dec. i., ann. ii., 121. n 104, dec. ii., ann. i., obs. 116. ° 664, T. iv. 110 PRENATAL ANOMALIES. odor of urine as provocatiA-e of abortion; Sulzberger,* Mover,567 and Alber- tus m all mention odors ; and Yesti gives as a plausible cause b the odor of carbonic vapor. The Ephemerides ° mentions singultus as a cause of abor- tion. Mauriceau,513 Pelargus, and A^alentini793 mention coughing. Hippo- crates mentions'1 the case of a woman avIio induced abortion by calling exces- sively loud to some one. Fabricius Hildanus334 speaks of abortion folloAving a kick in the region of the coccyx. Gullmannuse speaks of an abortion which he attributes to the Avoman's constant neglect to ansAver the calls of nature, the rectum being at all times in a state of irritation from her negli- gence. HaAvleyf mentions abortion at the fourth or fifth month due to the absorption of spirits of turpentine. Solingen742 speaks of abortion produced by sneezing. Osiander135 cites an instance in Avhich a woman suddenly arose, and in doing so jolted herself so seA'erely that she produced abortion. Hip- pocrates speaks of extreme hunger as a cause of abortion. Treuner s speaks of great anger and wrath in a Avoman disturbing her to the extent of producing abortion. The causes that are observed every day, such as tight lacing, excessiAre venery, fright, and emotions, are too well known to be discussed here. There has been reported a recent case of abortion following a viper-bite, and analogues may be found in the writings of ScA'erinus and Oedman, Avho mention viper-bites as the cause; but there are so many associate conditions accompanying a snake-bite, such as fright, treatment, etc., any one of M'hich could be a cause in itself, that this is by no means a reliable explanation. In- formation from India on this subject would be quite A'aluable. The Ephemerides speak of bloodless abortion, and there have been modern instances in Avhich the hemorrhage has been hardly noticeable. Abortion in a twin pregnancy does not necessarily mean the abortion or death of both the products of conception. Chapman h speaks of the case of the expulsion of a blighted fetus at the seventh month, the living child remaining to the full term, and being safely delivered, the placenta folloAving. CrispJ says of a case of labor that the head of the child Avas obstructed' by a round body, the nature of Avhich he was for some time unable to determine. He managed to push the obstructing body up and delivered a living, full-term child ; this Avas soon followed by a blighted fetus, which was 11 inches long, AA-eighed 12 ounces, with a placenta attached weighing 6 J ounces. It is quite common for a blighted fetus to be retained and expelled at term with a living child, its twin. Bacon J speaks of twin pregnancy, Avith the death of one fetus at the fourth month and the other delivered at term. Beallk reports the conception of twins a Diss, deabortu, c. 6. b Diss, de abortu, 21. c 476, dec. ii., ann. 2, obs. 62. d416, opp. iv., 600. e 105, 1730, ii., 374. t 231, 1858-59, xiv., 469. g 160, B. iv., 527. h 550, ix., 194. i 779, xviii., 272. J Clinique, Chicago, vii., 403. * 703, xviii., 122. WORMS IN THE UTERUS. Ill with one fetus expelled and the other retained; Beauchamp cites a similar instance. Bothwell a describes a twin labor at term, in Avhich one child Avas living and the other dead at the fifth month and macerated. Beltb reports an analogous case. Jameson ° gives the history of an extraordinary case of twins in which one (dead) child Avas retained in the Avomb for forty-nine weeks, the other having been born aliA'e at the expiration of nine months. Hamilton d describes a case of twins in Avhich one fetus died from the effects of an injury between the fourth and fifth months and the second arrived at full period. Moore e cites an instance in which one of the fetuses perished about the third month, but was not expelled until the seventh, and the other was carried to full term. AVilsonf speaks of a secondary or blighted fetus of the third month Avith fatty degeneration of the membranes retained and expelled Avith its living twin at the eighth month of uterogestation. There Avas a case at Riga in 1839 of a robust girl Avho conceived in Feb- ruary, and in consequence her menses ceased. In June she aborted, but, to her dismay, soon afterward the symptoms of advanced pregnancy appeared, and in November a full-grown child, doubtless the result of the same impregna- tion as the fetus, Avas expelled at the fourth month. In 1860 Schuh reported an instance before the Yienna Faculty of Medicine in Avhich a fetus Avas dis- charged at the third month of pregnancy and the other twin retained until full term. The abortion was attended Avith much metrorrhagia, and ten Aveeks afterward the movements of the other child could be plainly felt and pregnancy continued its course uninterrupted. Bates g mentions a twin preg- nancy in Avhich an abortion took place at the second month and Avas followed by a natural birth at full term. HaAvkins h gives a case of miscarriage, followed bv a natural birth at full term ; and Newnham ' cites a similar instance in Avhich there was a miscarriage at the seventh month and a birth at full term. Worms in the Uterus.—Haines J speaks of a most curious case—that of a woman Avho had had a miscarriage three days previous ; she suffered intense pain and a fetid discharge. A number of maggots Avere seen in the vagina, and the next day a mass about the size of an orange came aAvay from the uterus, riddled Avith holes, and Avhich contained a number of dead maggots, killed bv the carbolic acid injection given soon after the miscarriage. The fact seems inexplicable, but after their expulsion the symptoms immediately ameliorated. This case recalls a somewhat similar one given by the older writers, in Avhich a fetus was eaten by a AVorm.k Analogous are those cases spoken of bv Bidell of lumbricoides found in the uterus ; by Hole,™ in which maggots Avere found in the vagina and uterus; and Simpson,0 in which the a 224, 1**9, ii., 717. b 124, 1855, xxix. c 310, 1842-43, xxii., 15. d 312, 1843. e 519, 1870, iv., 208. f Month. Jour. Med., Lond., 1855. g 77l', 1874. h 770 1881. * 776, 1823. j 476 1889 i., 16. k 104, dec. iii., ann. 7 and 8, obs. 32. 1 235^ 1856^ li!, 549. m 543, 1889-90. n 600, 1878-79, 129. 112 PRENATAL ANOMALIES. abortion was caused by worms in the womb—if the associate symptoms were trustworthy. AVe can find fabulous parallels to all of these in some of the older writings. Pare a mentions Lycosthenes' account of a Avoman in Cracovia in 1494 who bore a dead child which had attached to its back a live serpent, which had gnawed it to death. He gives an illustration (Fig. 14) showing the serpent in situ. He also quotes the case of a Avoman who conceived by a manner, and Avho, after nine months, was delivered by a midwife of a shapeless mass, followed by an animal with a long neck, blazing eyes, and clawed feet. Bal- lantyneb says that in the Avritings of Hippocrates there is in the work on " Diseases " (Ihpi voOatuv), which is not usually regarded as genuine, a some- Fig. 14.—Serpent in a fetus (after Par6). what curious statement with regard to worms in the fetus. It is affirmed that flat worms develop in the unborn infant, and the reason given is that the feces are expelled so soon after birth that there Avould not be sufficient time during extrauterine life for the formation of creatures of such a size. The same remark applies to round worms. The proof of these statements is to be found in the fact that many infants expel both these varieties of parasites with the first stool. It is difficult to know what to make of these opinions ; for, Avith the exception of certain cases in some of the seventeenth and eighteenth century writers, there are no records in medicine of the occurrence of vermes in the infant at birth. It is possible that other things, such as dried pieces of mucus, may have been erroneously regarded as worms. a 618. 733. b759, Oct., 1895. CHAPTER III. OBSTETRIC ANOMALIES. General Considerations.—In discussing obstetric anomalies we shall first consider those strange instances in Avhich stages of parturition are uncon- scious and for some curious reason the pains of labor absent. Some women are anatomically constituted in a manner favorable to child-birth, and pass through the experience in a comparatively easy manner; but to the great majority the throes of labor are anticipated with extreme dread, particularly by the victims of the present fashion of tight lacing. It seems strange that a physiologic process like parturition should be attended by so much pain and difficulty. Savages in their primitive and natural state seem to have difficulty in many cases, and even animals are not free from it. AVe read of the ancient Avild Irish Avomen breaking the pubic bones of their female children shortly after birth, and by some means preventing union subsequently, in order that these might have less trouble in child-birth—as it were, a modified and early form of symphysiotomy. In consequence of this custom the females of this race, to quote an old English authority, had a " Avaddling, lamish gesture in their going." These old Avriters said that for the same reason the Avomen in some parts of Italy broke the coccyxes of their female children. This report is A'ery likely not veracious, because this bone spontaneously repairs itself so quickly and easily. Rodet and Engelmann,325 in their most extensive and interesting papers on the modes of accouchement among the primitive peoples, substantiate the fear, pain, and difficulty Avith Avhich labor is attended, ca'cu in the lowest grades of society. In aucav of the usual occurrence of pain and difficulty Avith labor, it seems natural that exceptions to the general rule should in all ages have attracted the attention of medical men, and that literature should be replete Avith such instances. Pechlin''22 and Maasa record instances of painless births. The Ephemerides records a birth as having occurred during asphyxia, and also one during an epileptic attack. Storck also speaks of birth during unconsciousness in an epileptic attack; and Haen395 and othersb describe cases occurring during the coma attending apoplectic attacks. King0 reports the histories of tAvo married Avomen, fond mothers and anticipat- ing the event, who gave birth to children, apparently unconsciously. In a 601, 315. b 708, 1719, ii., 610. c 546, 1847, xvi., 234. 8 113 114 OBSTETRIC ANOMALIES. the first case, the appearance of the woman verified the assertion ; in the second, a transient suspension of the menstrual influence accounted for it. After some months epilepsy developed in this ease. CraAvford a speaks of a Mrs. D., Avho gave birth to twins in her first confinement at full term, and who two years after aborted at three months. In December, 1868, a year after the abortion, she Avas delivered of a healthy, living fetus of about five or six months' growth in the folloAving manner : While at stool, she discovered something of a shining, bluish appearance protruding through the external labia, but she also found that Avhen she lay doAvn the tumor disappeared. This tumor proA'ed to be the child, Avhich had been expelled from the uterus four days before, Avith the waters and membranes intact, but Avhich had not been recognized ; it had passed through the os without pain or symptoms, and had remained alive in the vagina over four days, from avhence it was delivered, presenting by the foot. The state of intoxication seems by record of seAreral cases to render birth painless and unconscious, as well as serA7ing as a means of anesthesia in the preanesthetic days. The feasibility of practising hypnotism in child-birth has been dis- cussed, and Fantonb reports 12 cases of parturition under the hypnotic influ- ence. He says that none of the subjects suffered any pain or Avere aware of the birth, and offers the suggestion that to facilitate the state of hypnosis it should be commenced before strong uterine contractions have occurred. Instances of parturition or delivery during sleep, lethargies, trances, and similar conditions are by no means uncommon. Heisterc speaks of birth during a convulsive somnolence, and Osiander d of a case during sleep. Mont- gomery relates the case of a lady, the mother of several children, who on one occasion Avas unconsciously delivered in sleep. Casee relates the instance of a French woman residing in the town of Hopedale, Avho, though near confine- ment, attributed her symptoms to over-fatigue on the previous day. AVhen summoned, the doctor found that she had severe lumbar pains, and that the os Avas dilated to the size of a half-dollar. At ten o'clock he suggested that everyone retire, and directed that if anything of import occurred he should be called. About 4 a. m. the husband of the girl, in great fright, summoned the physician, saying : " Monsieur le Medecin, il y a quelque chose entre les jambes de ma femme," and, to Dr. Case's surprise, he found the head of a child Avholly expelled during a profound sleep of the mother. In twenty minutes the secundines followed. The patient, who was only twenty years old, said that she had dreamt that something Avas the matter Avith her, and aAVoke with a fright, at Avhich instant, most probably, the head Avas expelled. She Avas afterward confined with the usual labor-pains. Palfreyf speaks of a woman, pregnant at term, Avho fell into a sleep about a 579, 1868-69, n. s., iv., 305-8. b 168, 1890. c 402, xii., 103. d 135, ii., 74. e 124, Jan., 1868. f 476, 1864, i., 36. DELIVERY DURING SLEEP, ETC. 115 eleven o'clock, and dreamed that she Avas in great pain and in labor, and that sometime after a fine child Avas craAvling over the bed. After sleepino- for about four hours she aAvoke and noticed a discharge from the \Tagina. Her husband started for a light, but before he obtained it a child Avas born by a head-presentation. In a feAv minutes the labor-pains returned and the feet of a second child presented, and the child was expelled in three pains, folloAved in ten minutes by the placenta. Here is an authentic case in Avhich labor pro- gressed to the second stage during sleep. AVeill a describes the case of a woman of tAventy-three who ga\Te birth to a robust boy on the 16th of June, 1877, and suckled him eleven months. This birth lasted one hour. She became pregnant again and was delivered under the folloAving circumstances : She had been walking on the evening of Sep- tember 5th and returned home about eleven o'clock to sleep. About 3 a. m. she awoke, feeling the necessity of passing urine. She arose and seated herself for the purpose. She at once uttered a cry and called her husband, telling him that a child Avas born and entreating him to send for a physician. AVeill saAV the Avoman in about ten minutes and she Avas in the same position, so he ordered her to be carried to bed. On examining the urinal he found a female child weighing 10 pounds. He tied the cord and cared for the child. The Avoman exhibited little hemorrhage and made a complete recovery. She had apparently slept soundly through the uterine contractions until the final strong pain, Avhich aAvoke her, and Avhich she imagined Avas a call for urina- tion. Samelson b says that in 1844 he was sent for in Zabelsdorf, some 30 miles from Berlin, to attend Hannah Rhode in a case of labor. She had passed easily through eight parturitions. At about ten o'clock in the morning, after a partially unconscious night, there Avas a sudden gush of blood and Avater from the vagina ; she screamed and lapsed into an unconscious condition. At 10.35 the face presented, soon folloAved by the body, after Avhich came a great Aoav of blood, Avelling out in several Avaves. The child was a male, middle-sized, and Avas some little time in making himself heard. Only by degrees did theAvoman's consciousness return. She felt Avearyand inclined to sleep, but soon after she aAvoke and was much surprised to know what had happened. She had seven or eight pains in all. Schultze c speaks of a Avoman who, arriving at the period for delivery, AA'cnt into an extraordinary state of somnolence, and in this condition on the third day bore a living male child. Berthier in 1859 observed a case of melancholia Avith delirium Avhich continued through pregnancy. The Avoman Avas apparently unconscious of her condition and Avas delivered without pain. Crippsd mentions a case in Avhich there Avas absence of pain in parturition. Depaule mentions a woman Avho fell in a public street and Avas delivered of a living child during a a Quoted, 224, 1881, ii., 871. b 224, 1865, ii.. Nov. c 476 1845 i. d 476, 1841-42, ii., 367. e J. d. sages-femmes, Par., 1882, 9. 116 OBSTETRIC ANOMALIES. syncope which lasted four hours. Epleya reports painless labor in a patient with paraplegia. Fahnestock b speaks of the case of a Avoman avIio Avas clcdiv- ered of a son while in a state of artificial somnambulism, Avithout pain to herself or injury to the child. Among others mentioning painless or unconscious labor are Behrens (during profound sleep), Eger, Tempel, Panis, Agnoia, Blanckmeister, AVhitehill, Gillette, Mattei, Alurray, Lemoine, and Mogliehkeit. Rapid Parturition Without Usual Symptoms.—Births unattended by symptoms that are the usual precursors of labor often lead to speedy deliveries in aAvkAvard places. According to AVilloughby,824 in Darby, February !), 1 667, a poor fool, Mary Baker, Avhile Avandering in an open, Avindy, and cold place, Avas deliA'ercd by the sole assistance of Nature, Eve's midAvife, and freed of her afterbirth. The poor idiot had leaned against a Avail, and dropped the child on the cold boards, where it lay for more than a quarter of an hour with its funis separated from the placenta. She Avas only discovered by the cries of the infant. In " Carpenter's Physiology "c is described a remarkable case of instinct in an idiotic girl in Paris, avIio had been seduced by some miscreant; the girl had gmnved the funis in tAvo, in the same manner as is practised by the lower animals. From her mental imbecility it can hardly be imagined that she had any idea of the object of this separation, and it must have been instinct that impelled her to do it. Sermon733 says the Avife of Thomas James Avas delivered of a lusty child Avhile in a Avood by herself. She put the child in an apron Avith some oak IcaA'es, marched stoutly to her husband's uncle's house a half mile distant, and after two hours' rest went on her journey one mile farther to her oavii house; despite all her exer- tions she returned the next day to thank her uncle for the two hours' accom- modation. There is relatedd the history of a case of a Avoman avIio was delivered of a child on a mountain during a hurricane, who took off her goAvn and av rapped the child up in it, together with the afterbirth, and walked two miles to her cottage, the funis being unruptured. Harvey relates a case, Avhich he learned from the President of Munster, Ireland, of a Avoman with child Avho followed her husband, a soldier in the army, in daily march. They Avere forced to a halt by reason of a river, and the woman, feeling the pains of labor approaching, retired to a thicket, and there alone brought forth tAvins. She carried them to the river, Avashed them herself, did them up in a cloth, tied them to her back, and that very day marched, barefooted, 12 miles Avith the soldiers, and was none the Avorse for her experience. The next day the Deputy of Ireland and the President of Munster, affected by the story, to repeat the Avords of Harvey, " did both vouchsafe to be godfathers of the infants." AVilloughby824 relates the account of a woman Avho, having a cramp while in bed Avith her sister, Avent to an outhouse, as if to stool, and was there delivered of a child. She quickly returned to bed, her going and her return a 597, xxxvii., 233. b 218. xxxv., 194. c ist edition, 219. d 279, 1857, RAPID PARTURITION WITHOUT USUAL SYMPTOMS. 117 not being noticed by her sleeping sister. She buried the child, " and after- Avard confessed her Avickedness, and Avas executed in the Stafford Gaol, Aiarch 3)1, 1670." A similar instance is related by the same author of a servant in Darby in 1647. Nobody suspected her, and when delivered she Avas lying in the same room Avith her mistress. She arose Avithout awakening anyone, and took the recently delivered child to a remote place, and hid it at the bottom of a feather tub, covering it Avith feathers; she returned Avithout any suspi- cion on the part of her mistress. It so happened that it Avas the habit of the Darby soldiers to peep in at night Avhere they saw a light, to ascertain if everything Avas all right, and they thus discovered her secret doings, Avhich led to her trial at the next sessions at Darby. AVagnera relates the history of a case of great medicolegal interest. An unmarried servant, who Avas pregnant, persisted in denying it, and took eA'ery pains to conceal it. She slept in a room with two other maids, and, on ex- amination, she stated that on the night in question she got up toward morn- ing, thinking to relieve her boAvels. For this purpose she secured a Avooden tub in the room, and as she Avas sitting doAvn the child passed rapidly into the empty vessel. It was only then that she became aAvare of the nature of her pains. She did not examine the child closely, but Avas certain it neither moved nor cried. The funis Avas no doubt torn, and she made an attempt to tie it. Regarding the event as a miscarriage, she took up the tub Avith its contents and carried it to a sand pit about 30 paces distant, and threAV the child in a hole in the sand that she found already made. She coATered it up Avith sand and packed it firmly so that the dogs could not get it. She re- turned to her bedroom, first calling up the man-servant at the stable. She aAvakened her fellow-servants, and feeling tired sat doAvn on a stool. Seeing the blood on the floor, they asked her if she had made Avay Avith the child. She said : " Do you take me for an old soav?" But, having their suspicions aroused, they traced the blood spots to the sand pit. Fetching a spade, they dug up the child, Avhich Avas about one foot below the surface. On the access of air, folloAving the removal of the sand and turf, the child began to cry, and was immediately taken up and carried to its mother, avIio washed it and laid it on her bed and soon gave it the breast. The child Avas healthy Avith the exception of a club-foot, and must ha\7e been under ground at least fifteen minutes and no air could have reached it. It seems likely that the child was born asphyxiated and Avas buried in this state, and only began to assume in- dependent vitality Avhen for the second time exposed to the air. This curious case Avas verified to English correspondents by Dr. AVagner, and is of unques- tionable authority ; it became the subject of a thorough criminal investiga- tion in Germany. During the funeral procession of Aiarshal AiacAiahon in Paris an enor- mous croAvd Avas assembled to see the cortege pass, and in this crowd Avas a a 554, Jan. 17, 1838. 118 OBSTETRIC ANOMALIES. woman almost at the time of delivery ; the jostling Avhich she received in her endeavors to obtain a place of vantage Avas sufficient to excite contraction, and, in an upright position, she gave birth to a fetus, which fell at her feet. The croAvd pushed back and made Avay for the ambulance officials, and mother and child were carried off, the mother apparently experiencing little embarrass- ment. Quoted by Taylor,757 Anderson speaks of a Avoman accused of child murder, avIio Avalked a distance of 28 miles on a single day with her two- days-old child on her back. There is also a case of a female servant a named Jane May, avIio Avas fre- quently charged by her mistress with pregnancy but persistently denied it. On October 26th she Avas sent to market Avith some poultry. Returning home, she asked the boy Avho drove her to stop and alloAV her to get out. She Avent into a recess in a hedge. In five minutes she Avas seen to leave the hedge and follow the cart, Avalking home, a distance of a mile and a half. The folloAving day she Avent to Avork as usual, and Avould not have been found out had not a boy, hearing feeble cries from the recess of the hedge, summoned a passer-by, but too late to save the child. At her trial she said she did not sec her babe breathe nor cry, and she thought by the sudden birth that it must have been a still-born child. Shorttb says that one day, Avhile crossing the esplanade at Villaire, between stwen and eight o'clock in the morning, he perceived three Hindoo Avomen Avith large baskets of cakes of " bratties " on their heads, coming from a village about four miles distant. Suddenly one of the Avomen stood still fof a minute, stooped, and to his surprise dropped a fully developed male child to the ground. One of her companions ran into the town, about 100 yards distant, for a knife to divide the cord. A feAV of the female passers-by formed a screen about the mother Avith their clothes, and the cord Avas divided. The after-birth came aAvay, and the Avoman Avas removed to the town. It was afterward discovered that she was the mother of tAvo children, Avas tAvcnty-eight years old, had not the slightest sign of approaching labor, and was not aware of parturition until she actually felt the child between her thighs. Smith of Madras, in 1862, says he Avas hastily summoned to see an English lady Avho had borne a child Avithout the slightest Avarning. He found the child, Avhich had been born ten minutes, lying close to the mother's body, Avith the funis uncut. The native female maid, at the lady's orders, had left the child untouched, lifting the bed-clothes to give it air. The lady said that she arose at 5.30 feeling well, and during the forenoon had Avalked doAvn a long flight of steps across a walk to a small summer-house Avithin the enclosure of her grounds. Feeling a little tired, she had lain down on her bed, and soon experienced a slight discomfort, and Avas under the impression that something solid and Avarm Avas lying in contact Avith her person. She directed the ser- vant to look beloAV the bed-clothes, and then a female child was discovered. a 548, 1867, i., 500. b 773, 1863. UNUSUAL PLACES OF BIRTH. 119 Her other labors had extended over six hours, and Avere preceded by all the signs distinctive of childbirth, Avhich fact attaches additional interest to the ease. The ultimate fate of the child is not mentioned. Smith quotes AVilson, Avho said he Avas called to see a Avoman Avho Avas deli\Tered Avithout pain Avhile Avalking about the house. He found the child on the floor Avith its umbilical cord torn across. Langston a mentions the case of a Avoman, twenty-three, Avho, between 4 and 5 a. m., felt griping pains in the abdomen. KnoAving her condition, she suspected labor, and determined to go to a friend's house Avhere she could be confined in safety. She had a distance of about 600 yards to go, and Avhen she was about half Avay she Avas delivered in an upright position of a child, Avhich fell on the pavement and ruptured its funis in the fall. Shortly after, the placenta Avas expelled, and she proceeded on her journey, carrying the child in her arms. At 5.50 the physician saw the woman in bed, looking Avell and free from pain, but complaining of being cold. The child, Avhich Avas her first, Avas healthy, Avell nourished, and normal, Avith the exception of a slight ecchymosis of the parietal bone on the left side. The funis Avas lacerated transA'ersely four inches from the umbilicus. Both mother and child progressed favorably. Doubtless the intense cold had so contracted the blood-vessels as to prevent fatal hemorrhage to mother and child. This case has a legal bear- ing in the supposition that the child had been killed in the fall. There is reportedb the case of a woman in AVales, Avho, Avhile Avalking Avith her husband, Avas suddenly seized Avith pains, and Avould have been delivered by the Avayside but for the timely help of Madame Patti, the celebrated diva, who Avas driving by, and Avho took the Avoman in her carriage to her palatial residence close by. It Avas to be christened in a feAV days with an appropriate name in remembrance of the occasion. Coleman0 met an instance in a mar- ried Avoman, who Avithout the slightest Avarning Avas delivered of a child Avhile standing near a AvindoAV in her bedroom. The child fell to the floor and ruptured the cord about one inch from the umbilicus, but Avith speedy attention the happiest results were attained. TAvitchelld has an example in the case of a young Avoman of seventeen, Avho was suddenly delivered of a child Avhile ironing some clothes. The cord in this case was also ruptured, but the child sustained no injury. Taylor 757 quotes the description of a child who died from an injury to the head caused by dropping from the mother at an unexpected time, while she was in the erect position ; he also speaks of a parallel case on record. Unusual Places of Birth.—Besides those mentioned, the other awkward positions in Avhich a child may be born are so numerous and diversified that mention of only a feAV can be made here. Coltone tells of a painless labor in an Irish girl of twenty-three, Avho felt a desire to urinate, and while seated on a 476 1S64 i 637. b 548, 1887, ii., 157. c 476, 1864, ii., 377. d 476,'1864! 476. e 520, 1879, i., 68. 120 OBSTETRIC ANOMALIES. the chamber dropped a child. She never felt a labor-pain, and twelve days after- ward rode 20 miles over a rough road to go to her baby's funeral. Leonhard a describes the case of a mother of thirty-seven, avIio had borne six children alive, who Avas pregnant for the tenth time, and who had miscalculated her pregnancy. During pregnancy she had an attack of small-pox and suffered all through preg- nancy Avith constipation. She had taken a laxative, and Avhen returning to bed from stool was surprised to find herself attached to the stool by a band. The child in the vessel began to cry and Avas separated from the Avoman, AArho returned to bed and suddenly died one-half hour later. The mother Avas entirely unconscious of the deli\'ory. AVestphal b mentions a delivery in a water-closet. Brown c speaks of a woman of twenty-six avIio had a call of nature Avhile in bed, and Avhile sitting up she gave birth to a fine, full-grown child, Avhich, falling on the floor, ruptured the funis. She took her child, lay doAvn with it for some time, and feeling easier, hailed a cab, drove to a hospital with the child in her arms, and Avanted to walk upstairs. She was put to bed and delivered of the placenta, there being but little hemorrhage from the cord; both she and her child made speedy recoveries. Thebaultd reports an instance of delivery in the erect position, Avith rupture of the funis at the placenta. There Avas recently a rumor, probably a neAvspapcr fabrication, that a Avoman while at stool in a railway car gaA7e birth to a child which was found aliAre on the track afterward. There is a curious instance on record in which a child Avas born in a hip- bath and narroAvly escaped droAvning.e The mother Avas a European Avoman aged forty, who had borne two children, the last nine years before. She Avas supposed to have dropsy of the abdomen, and among other treatments was the use of a speculum and caustic applications for inflammation of the Avomb. The escape of Avatery fluid for two days was considered evidence of the rup- ture of an oA-arian cyst. At the end of two days, severe pains set in, and a warm hip-bath and an opiate were ordered. AVhile in the bath she bore a fully-matured, living, male child, to the great surprise of herself and her friends. The child might have been drowned had not assistance been close at hand. Birth by the Rectum.—In some cases in which there is some obstacle to the delivery of a child by the natural passages, the efforts of nature to expel the product of conception lead to an anomalous exit. There are some details of births by the rectum mentioned in the last century by Reta and others. Paynef cites the instance of a woman of thirty-three, in labor thirty- six hours, in whom there Avas a congenital absence of the vaginal orifice. The finger, gliding along the perineum, arrived at a distended anus, just inside of which Avas felt a fetal head. He anesthetized the patient and delivered the a 554, No. 24, 1837. b 807, xxi., 329. c 224, April 3, 1863. d809, 1875, ii., 230. e 548, 1862, ii., 396. f 491, 1886, 542. BIRTH THROUGH PERINEAL PERFORATION. 121 child Avith forceps, and Avithout perineal rupture. There Avas little hemor- rhage, and the placenta was removed Avith slight difficulty. Five months later, Payne found an unaltered condition of the perineum and vicinity ; there Avas absence of the vaginal orifice, and, on introducing the finger along the anterior Avail of the rectum, a fistula Avas found, communicating with the vagina; aboA'e this point the arrangement and the situation of the parts Avere normal. The Avoman had giA^en birth to three still-born children, and always menstru- ated easily. Coitus always seemed satisfactory, and no suspicion existed in the patient's mind, and had never been suggested to her, of her abnormality. Harrisona saw a fetus delivered by the anus after rupture of the uterus; the membranes came away by the same route. In this case the neck of the uterus Avas cartilaginous and firmly adherent to the adjacent parts. In seven days after the accouchement the Avoman had completely regained her health. Vallisneri796 reports the instance of a woman who possessed two uteruses, one communicating with the vagina, the other Avith the rectum. She had permitted rectal copulation and had become impregnated in this manner. Louis, the celebrated French surgeon, created a furore by a pamphlet entitled " De partium externarum generationi inservientium in mulieribus naturali vitiosa et morbosa dispositione, etc.," for which he Avas punished by the Sor- bonne, but absolved by the Pope. He described a young lady Avho had no vaginal opening, but avIio regularly menstruated by the rectum. She allowed her lover to have connection Avith her in the only possible way, by the rectum, Avhich, hoAvever, sufficed for impregnation, and at term she bore by the rec- tum a well-formed child. Hunterb speaks of a case of pregnancy in a Avoman Avith a double vagina, who Avas delivered at the seventh month by the rectum. Mekelnc and AndreAVSd give instances of parturition through the anus. Morisanie describes a case of extrauterine pregnancy Avith tubal rupture and discharge into the culdesac, in which there was delivery by the rectum. After an attack of severe abdominal pain, folloAved by hemorrhage, the woman ex- perienced an urgent desire to empty the rectum. The fetal movements ceased, and a recurrence of these symptoms led the patient to go to stool, at Avhich she passed blood and a seromucoid fluid. She attempted manually to remove the offending substances from the rectum, and in consequence grasped the leg of a fetus. She Avas removed to a hospital, Avhere a fetus nine inches long Avas removed from the rectum. The rectal opening gradually cicatrized, the sac became obliterated, and the Avoman left the hospital well. Birth Through Perineal Perforation.—Occasionally there is perineal perforation during labor, Avith birth of the child through the opening. Brownf mentions a case of rupture of the perineum Avith birth of a child between the vaginal opening and the anus. Cassidy * reports a case of child-birth through the perineum. A successful operation Avas performed fifteen days after the a Reportorio Med.-Chirurg. di Torino, 1825. b Trans. N. Y. Obs. Soc, 1879, i., 348. c 372, 1833, 184. d 526, 1839. e 838, 1889. ' 476, 1860, i., 496. g 545, ix., 192. 122 OBSTETRIC ANOMALIES. accident. Dupuytrena speaks of the passage of an infant through a central opening of the perineum. Capuron, Gravis, and Lebrun all report accouche- ment through a perineal perforation, without alteration in the sphincter ani or the fourchct. In his "Diseases of Women" Simpson speaks of a fistula left by the passage of an infant through the perineum. Wilson, Toloshinoff, Stolz, Argles, Demarquay, Harley, Hcrnu, Martyn, Lamb, Morere, Pollock, and others record the birth of children through perineal perforations. Birth Through the Abdominal Wall.—Hollerius421 gives a very pecu- liar instance in Avhich the abdominal Avails gave Avay from the pressure exerted by the fetus, and the uterus ruptured, allowing the child to be extracted by the hand from the umbilicus; the mother made a speedy recovery. In such cases delivery is usually by means of operative interference (Avhich will be spoken of later), but rarely, as here, spontaneously. Farquharson b and 111c both mention rupture of the abdominal parietes during labor. There have been cases reported in which the recto-vaginal septum has been ruptured, as Avell as the perineum and the sphincter ani, giving all the appear- ance of a birth by the anus. There is an accountd of a female Avho had a tumor projecting betAvccn the Aragina and rectum, Avhich was incised through the intestine, and proved to be a dead child. SaAriard713 reported Avhat he considered a rather unique case, in Avhich the uterus Avas ruptured by external violence, the fetus being thrown fonvard into the abdomen and afterAvard extracted from an umbilical abscess. Birth of the Fetus Enclosed in the Membranes.—Harvey404 says that an infant can rest in its membranes several hours after birth Avithout loss of life. Schurig72G eventrated a pregnant bitch and her puppies lived in their membranes half an hour. AVrisberg cites three observations of infants born closed in their membranes ; one liA'ed seven minutes ; the other two nine minutes; all breathed Avhen the membranes Avere cut and air admitted. AVilloughby824 recorded the history of a case Avhich attracted much comment at the time. It Avas the birth of twins enclosed in their secundines. The sac Avas opened and, together Avith the afterbirth, Avas laid o\Ter some hot coals ; there Avas, however, a happy issue, the children recovering and living. Since AVil- loughby's time several cases of similar interest have been noticed, one in a womane of forty, who had been married sixteen years, and Avho had had several pregnancies in her early married life and a recent abortion. Her last preg- nancy lasted about tAventy-eight or twenty-nine weeks, and terminated, after a short labor, by the expulsion of the ovum entire. The membranes had not been ruptured, and still enclosed the fetus and the liquor amnii. On break- ing them, the fetus Avas seen floating on the Avaters, alive, and, though A^ery diminutive, Avas perfectly formed. It continued to live, and a day afterward took the breast and began to cry feebly. At six Aveeks it weighed 2 pounds 2 ounces, and at ten months, 12 pounds, but was still very weak and ill-nour- a 368, 1832, iii., 684. b 524, 1789. c 600, 1878-9, xli., 43. d 470, 1722. e 492, 1828. "DRY BIRTHS. 123 ished. Evans a has an instance of a fetus expelled enveloped in its membranes entire and unruptured. The membranes Avere opaque and preternaturally thickened, and were opened with a pair of scissors ; strenuous efforts Avere made to save the child, but to no purpose. The mother, after a short con- valescence, made a good recovery. Forman b reports an instance of unruptured membranes at birth, the delivery folloAving a single pain, in a Avoman of twenty-tAvo, pregnant for a second time. Woodson0 speaks of a case of twins, one of which was born enveloped in its secundines. A"an Bibber d Avas called in great haste to see a patient in labor. He reached the house in about fifteen minutes, and was told by the midAvife, a woman of experience, that she had summoned him because of the expulsion from the Avomb of something the like of which she had never seen before. She thought it must have been some variety of false conception, and had Avrapped it up in some flannel. It proved to be a fetus enclosed in its sac, Avith the placenta, all having been expelled together and intact. He told the nurse to rupture the membranes, and the child, Avhich had been in the unrup- tured sac for over twenty minutes, began to cry. The infant lived for over a month, but eventually died of bronchitis. Cowgere reports labor at the end of the seventh month Avithout rupture of the fetal sac. Macknusf and Rootesg speak of expulsion of the entire ovum at the full period of gestation. Roe mentions a case of parturition with unruptured membrane. Slusser h describes the delivery of a full-grown fetus Avithout rupture of the membrane. " Dry Births."—The reA'crse of the foregoing are those cases in which, by reason of the deficiency of the Avaters, the birth is dry. Numerous causes can be stated for such occurrences, and the reader is referred elscAvhere for them, the subject being an old one. The Ephemerides speaks of it, and Rudolph 695 discusses its occurrence exhaustively and tells of the difficulties of such a labor. Burrall * mentions a case of labor Avithout apparent liquor amnii, delivery being effected by the forceps. Strong J records an unusual obstetric case in Avhich there Avas prolongation of the pregnancy, Avith a large child, and entire absence of liquor amnii. The case Avas also complicated with interstitial and subserous fibroids and a contracted pelvis, combined Avith a posterior position of the occiput and nonrotation of the head. Lentek mentions a case of labor Avithout liquor amnii ; and ToAvnsend! records de- livery Avithout any sanguineous discharge. Cosentino m mentions a case of the absence of liquor amnii associated Avith a fetal monstrosity. Delivery After Death of the Mother.—Curious indeed are those a 252, 1852-3, i., 146. b 538, 1896, Feb. 1, 160. <= 124, 1860, 569. d 510, 1879, iv., 303. e 53S, xxv., 84. f 476, 1846, i., 186. g 476, 1845. ii., 474. h West. Lancet, Cincin., xii., 501. » 124, cxl., 446. J 218, ex., 30. k 124, clxi., 125. » 124, 1854, 342. m Arch, di (Met. e Ginec, p. 41, Feb.-March, 1894. 124 OBSTETRIC ANOMALIES. anomalous cases in Avhich the delivery is effected spontaneously after the death of the mother, or when, by manipulation, the child is saved after the maternal decease. Wegelina giA'cs the account of a birth in Avhich A'ersion was per- formed after death and the child successfully delivered. Bartholinus, Wolff, Schenck, Horstius, Hagendorn, Fabricius Hildanus, Valerius, Rolfinck, Oor- narius, Boener, and other older Avriters cite cases of this kind. Pinardb gives a most Avonderful case. The patient Avas a Avoman of thirty-eight who had experienced five previous normal labors. On October 27th she fancied she had labor pains and Avent to the Lariboisiere Maternite, Avhere, after a careful examination, three fetal poles were elicited, and she Avas told, to her surprise, of the probability of triplets. At 6 p. m., November 13th, the pains of labor commenced. Three hours later she Avas haA'ing great dyspnea with each pain. This soon assumed a fatal aspect and the mkhvife attempted to resuscitate the patient by artificial respiration, but failed in her efforts, and then she turned her attention to the fetuses, and, one by one, she extracted them in the short space of five minutes; the last one was born twelve minutes after the mother's death. They all lived (the first two being females), and they weighed from 4^ to 6 J pounds. Considerable attention has been directed to the ad\Tisability of accelerated and forced labor in the dying, in order that the child may be saA'ed. Belluzzi has presented several papers on this subject. Csurgay of Budapest mentions saving the child by forced labor in the death agonies of the mother. Devil- liersc considers this question from both the obstetric and medicolegal points of A'iew. Hyneaux mentions forcible accouchement practised on both the dead and the dying. RogoAvicz advocates artificial delivery by the natural channel in place of Cesarian section in cases of pending or recent death, and Thevenotd discussed this question at length at the International Medico-Legal Congress in 1878. Duere presented the question of postmortem delivery in this country. Kellyf reports the history of a Avoman of forty Avho died in her eighth pregnancy, and Avho was delivered of a female child by version and artificial means. Artificial respiration Avas successfully practised on the child, although fifteen minutes had elapsed from the death of the mother to its extraction. DriATer s relates the history of a Avoman of thirty-five, who died in the eighth month of gestation, and who Avas delivered postmortem by the vagina, man- ual means only being used. The operator Avas about to perform Cesarean section when he heard the noise of the membranes rupturing. Thorntonh reports the extraction of a living child by version after the death of the mother. Aveling1 has compiled extensive statistics on all varieties of post- mortem deliveries, collecting 44 cases of spontaneous expulsion of the fetus after death of the mother. a 160, B. i., 4 St., n. 7. d 140, 1878. g 579, 1860, 494. bl40, Jan., 1889. e 125, xii., 1 and 374. b 272, 1858. c789, 1862, 581. f 125, viii., 558. 1 778, 1873, xiv., 240. DELIVERY AFTER DEATH OF THE MOTHER. Aveling states that in 1820 the Council of Cologne sanctioned the placing of a gag in the mouth of a dead pregnant woman, thereby hoping to prevent suffocation of the infant, and there are numerous such laAvs on record, although most of them pertain to the performance of Cesarean section immediately after death. Reiss records the death of a woman Avho was hastily buried while her husband was away, and on his return he ordered exhumation of her body, and on opening the coffin a child's cry Avas heard. The infant had evidently been born postmortem. It lived long afterward under the name of " Fils de la terre." AVilloughby824 mentions the curious instance in which rum- bling was heard from the coffin of a Avoman during her hasty burial. One of her neighbors returned to the grave, applied her ear to the ground, and was sure she heard a sighing noise. A soldier with her affirmed her tale, and together they went to a clergyman and a justice, begging that the grave be opened. When the coffin was opened it was found that a child had been born, Avhich had descended to her knees. In Derbyshire, to this day, may be seen on the parish register : "April ye 20, 1650, was buried Emme, the Avife of Thomas Toplace, Avho was found delivered of a child after she had lain two hours in the grave." Johannes Alatthaeus relates the case of a buried Avoman, and that some time aftenvard a noise was heard in the tomb. The coffin Avas immediately opened, and a living female child rolled to the feet of the corpse. Hagen- dorn mentions the birth of a living child some hours after the death of the mother. Dethardingius mentions a healthy child born one-half hour after the mother's death. In the Gentleman's Magazine a there is a record of an in- stance, in 1759, in Avhich a midAvife, after the death of a Avoman whom she had failed to deliver, imagined that she saAV a movement under the shroud, and found a child between its mother's legs. It died soon after. Valerius Maximus says that Avhile the body of the mother of Gorgia Epirotas Avas being carried to the grave, a loud noise Avas heard to come from the coffin, and on examination a live child Avas found betAveen the thighs,—whence arose the proArerb : "Gorgiam prius ad funus elatum, quam natum fuisse." Other cases of postmortem delivery are less successful, the delivery being delayed too late for the child to be Auable. The first of Avding's cases was that of a pregnant woman Avho Avas hanged by a Spanish Inquisitor in 1551. While still hanging, four hours later, tAVO children Avere said to have dropped from her Avomb. The second case Avas of a Avoman of Aladrid, who after death was shut in a sepulcher. Some months after, when the tomb Avas opened, a dead infant was found by the side of the corpse. Rolfinkius tells of a Avoman avIio died during parturition, and her body being placed in a cellar, five davs later a dead boy and girl were found on the bier. Bartholinus is accredited with the following : Three midwives failing to deliver a Avoman, a xxix., 390. 126 OBSTETRIC ANOMALIES. she died, and forty-eight hours after death her abdomen swelled to such an extent as to burst her grave-clothes, and a male child, dead, was seen issuing from the vagina. Bonet216 tells of a Avoman, avIio died in Brussels in 163)3, who, undelivered, expired in convulsions on Thursday. On Friday abdomi- nal movements in the corpse Avere seen, and on Sunday a dead child Avas found hanging between the thighs. According to Aveling, Herman of Berne reports the instance of a young lady Avhose body Avas far advanced in putrefaction, from Avhich A\as expelled an unbroken ovum containing tAvins. Even the placenta shoAved signs of decomposition. Naumann relates the birth of a child on the second day after the death of the mother. Richtcr of AVeissenfels, in 1861, reported the case of a woman avIio died in convulsions, and sixty hours after death an eight months' fetus came aAvay. Stapedius writes to a friend of a fetus being found dead betAveen the thighs of a Avoman Avho expired suddenly of an acute disease. Schenk mentions that of a woman, dying at 5 P. m., a child having two front teeth was born at 3 A. M. A'eslingius tells of a Avoman dying of epilepsy on June 6, 1630, from Avhose body, two days later, issued a child. AVolfius relates the case of a Avoman dying in labor in 1677. Abdominal moA^ements being seen six hours after death, Cesarean section was suggested, but its performance was delayed, and eighteen hours after a child was spontaneously born. Hoyer of Mulhausen tells of a child with its mouth open and tongue protruding, which was born while the mother was on the way to the grave. Bedford of Sydney, accord- ing to Aveling, relates the story of a case in which malpractice was suspected on a Avoman of thirty-seven, who died Avhile pregnant with her seventh child. The body Avas exhumed, and a transverse rupture of the womb six inches long above the cervix Avas found, and the body of a dead male child lay between the thighs. In 1862, Lanigan tells of a Avoman who was laid out for funeral obsequies, and on removal of the covers for burial a child was found in bed with her. Swayne is credited with the description of the death of a Avoman whom a midAvife failed to deliver. Desiring an inquest, the coroner had the body exhumed, when, on opening the coffin, a well-developed male infant Avas found parallel to and lying on the lower limbs, the cord and placenta being entirely unattached from the mother. Some time after her decease HarA'ey found between the thighs of a dead Avoman a dead infant which had been expelled postmortem. MaA'era relates the history of a case of a Avoman of forty-five who felt the movement of her child for the fourth time in the middle of November. In the folloAving March she had hemoptysis, and serious symptoms of inflammation in the right lung folloAving, led to her apparent death on the 31st of the month. For two days previous to her death she had failed to perceive the fetal movements. She Avas kept on her back in a room, covered up and undisturbed, for thirty- six hours, the members of the family occasionally visiting her to sprinkle holy a 801, 1854. ANTEPARTUM CRYING OF THE CHILD. 127 Avater on her face. There was no remembrance of cadaA'eric distortion of the features or any odor. AVhen the undertakers Avere drawing the shroud on they noticed a half-round, bright-red, smooth-looking body between the geni- tals which they mistook for a prolapsed uterus. Early on April 2d, a feAV hours before interment, the men thought to examine the SAvelling they had seen the day before. A second look showed it to be a dead female child, uoav lying between the thighs and connected with the mother by the umbilical cord. The interment Avas stopped, and Mayer was called to examine the body, but Avith negative results, though the signs of death were not plainly visible for a woman dead fifty-eight hours. By its development the body of the fetus con- firmed the mother's account of a pregnancy of twenty-one weeks. Mayer satisfies himself at least that the mother was in a trance at the time of delivery and died soon afterward. Moritz a gives the instance of a woman dying in pregnancy, undeliA^ered, who happened to be disinterred several days after burial. The body Avas in an advanced state of decomposition, and a fetus was found in the coffin. It was supposed that the pressure of gas in the mother's body had forced the fetus from the uterus. Ostmannb speaks of a Avoman married five months, who Avas suddenly seized with rigors, headache, and vomiting. For a Aveek she continued to do her daily work, and in addition Avas ill-treated by her husband. She died suddenly Avithout having any abdominal pain or any symptoms indicative of abortion. The body was examined twenty-four hours after death and was seen to be dark, discolored, and the abdomen distended. There Avas no sanguineous discharge from the genitals, but at the time of rais- ing the body to place it in the coffin, a fetus, with the umbilical cord, escaped from the vagina. There seemed to have been a rapid putrefaction in this case, generating enough pressure of gas to expel the fetus as Avell as the uterus from the body. This at least is the view taken by Hoffman and others in the solution of these strange cases. Antepartum Crying of the Child.—There are on record fabulous cases of children crying in the uterus during pregnancy, and all sorts of unbe- lieA'able stories Iuia'c been constructed from these reported occurrences. Quite possible, however, and Avorthy of belief are the cases in Avhich the child has been heard to cry during the progress of parturition—that is, during delivery. Jonston c speaks of infants crying in the Avomb, and attempts a scientific explanation of the fact. He also quotes the following lines in reference to this subject:— " Mirandum fetus materna clausus in alvo Dicitur insuetos ore dedisse sonos. Causa subest; doluit se angusta sede teueri, Kt cupiit magnae cernere moliis opus. Aut quia quaerendi studio vis fessa parentum Aucupii aptas innuit esse maims. a Quoted by 124, cvi., 117. b 807, Band 28, 228. ° 447, 464. 128 OBSTETRIC ANOMALIES. The Ephemerides a gives examples of the child hiccoughing in the uterus. Oases of crying before delivery, some in the vagina, some just before the com- plete expulsion of the head from the os uteri, are very numerous in the older Avriters ; and it is quite possible that on auscultation of the pregnant abdomen fetal sounds may have been exaggerated into cries. Bartholinus,b Borellus, c Boyle, Buchner, Paullini, Mczger, Riolanus, Lentillus, Marcellus Donatus, d and Wolffe all speak of children crying before delivery ; and Mazinusf relates the instance of a puppy whose feeble cries could be heard before expulsion from the bitch. Osiander fully discusses the subject of infants crying during parturition. McLean s describes a case in which he positiArely states that a child cried lustily in utero during application of the forceps. He compared the sound as though from a voice in the cellar. This child Avas in the uterus, not in the vagina, and continued the crying during the Avhole of the fiA'c minutes occupied by delivery. Cesarean Section.—Although the legendary history of Cesarean section is quite copious, it is very seldom that we find authentic records in the Avritings of the older medical observers. The works of Hippocrates, Aretseus, Galen, Celsus, and Aetius contain nothing relatiA'e to records of successful Cesarean sections. HoAvever, Pliny says that Scipio Africanus AA'as the first and Manlius the second of the Romans Avho OAved their lives to the operation of Cesarean section ; in his seventh book he says that Julius Csesar was born in this Avay, the fact giving origin to his name. Others deny this and say that his name came from the thick head of hair which he possessed, it is a fre- quent subject in old Roman sculpture, and there are many delineations of the birth of Bacchus by Cesarean section from the corpse of Semele. Greek mythology tells us of the birth of Bacchus in the folloAving manner : After Zeus burnt the house of Semele, daughter of Cadmus, he sent Hermes in great haste with directions to take from the burnt body of the mother the fruit of seven months. This child, as Ave knoAV, Avas Bacchus. ^Esculapius, accord- ing to the legend of the Romans, had been excised from the belly of his dead mother, Corinis, who Avas already on the funeral pile, by his benefactor, Apollo ; and from this legend all products of Cesarean sections Avere regarded as sacred to Apollo, and were thought to have been endowed Avith sagacity and bravery. Old records tell us that one of the kings of Navarre Avas delivered in this way, and we also have records of the birth of the celebrated Doge, Andreas Doria, by this method. Jane Seymour was supposed to have been delivered of EdAvard VI. by Cesarean section, the father, after the consultation of the physicians Avas announced to him, replying : " Save the child by all means for I shall be able to get mothers enough." Robert II. of Scotland Avas sup- a 104, dec. ii., ann. v., obs. 194, and obs. 15. b 190, cent, i., hist. 18. c Cent, iii., obs. 72. d 306, L. vi., cap. ii., 620. e Lect. memor., T. ii., 647, 666, 983. f 514, T. iii., 8. g 125, xxii., 166. CESAREAN SECTION. 129 posed to have been delivered in this way after the death of his mother, Alar- gery Bruce, avIio was killed by being thrown from a horse. Shakespere's immortal citation of Macduff, " Avho Avas from his mother's Avomb untimely ripped," must have been such a case, possibly crudely done, perchance by cattle- horn. Pope Gregory XI A", was said to have been taken from his mother's belly after her death. The Philosophical Transactions,629 in the last century, contain accounts of Cesarean section performed by an ignorant butcher and also by a midwife ; and there are many records of the celebrated case per- formed by Jacob Niifer, a cattle gelder, at the beginning of the sixteenth century. By the advent of antisepsis and the impro\Tements of Porro and others, Cesarean section has come to be a quite frequent eA'ent, and a record of the successful cases Avould hardly be considered a matter of extraordinary interest, and would be out of the province of this Avork, but a citation of anomalous cases will be given. BaldAvina reports a case of Cesarean section on a typical rachitic dwarf of twenty-four, Avho weighed 100 pounds and Avas only 471 inches tall. It was the ninth American case, according to the calculation of Harris, only the third successful one, and the first successful one in Ohio. The Avoman had a uniformly contracted peh'is Avhose anteroposterior diameter Avas about 1J inches. The hygienic surroundings for the operation Avere not of the best, as the woman liA'ed in a cellar. Tait's method of per- forming the operation Avas determined upon and successfully performed. Convalescence Avas prompt, and in three Aveeks the case Avas dismissed. The child Avas a female of 7^ pounds Avhich inherited the deformities of its mother. It thrived for nine and a half months, Avhen it died of angina Ludovici. Figure 15 represents the mother and child. Harris124 gives an account of an operation upon a rachitic dAvarf who Avas impregnated by a large man, a baby weighing 14 pounds arid measuring 20 inches being delivered by the knife. St. Braunb gives the account of a Porro-Cesarean operation in the case of a rachitic dwarf 3 feet 10 inches tall, in which both the mother and child recovered. Mundec speaks of twins being delivered by Cesarean section. Franklin* gives the instance of a Avoman delivered at full term of a living child by this means, in Avhom was also found a dead fetus. It lay behind the stump of the amputated cervix, in the culdesac of Douglas. The patient died of hemorrhage. Crostone reports a case of Cesarean section on a primipara of twenty-four at full term, with the delivery of a double female monster weighing 12| pounds. This monster consisted of laa'O females of about the same size, united from the sternal notch to the navel, having one cord and one placenta. It was stillborn. The diagnosis was made before operation by vaginal examination. In a communication to Croston, Harris remarked that this was the first suc- a r,33, Aug. 9, 1890, 138. b 657, 1888 : quoted by 124, 1890. c 21H' 1876, ci., 747. d224, 1894. e 218, Dec. 21, 1893. 9 130 OBSTETRIC . I NOMA LIES cessful Cesarean section for double monstrous conception in America, and added that in 1881 Collins and Leidy performed the same operation without success. instances of repeated Cesarean section Avere quite numerous, and the pride of the operators lioteAvorthy, before the uterus Avas removed at the first opera- tion, as is noAv generally done. Bacque a reports tA\o sections in the same woman, and Bertrandi speaks of a case in which the operation was success- fully executed many times in the same woman. Rosenberg b reports three cases repeated successfully by Leopold of Dresden. Skutsch reports a case in Fig. 15.—Cesarean operation on a dwarf (Baldwin). which it was tAvice performed on a Avoman Avith a rachitic pelvis, and Avho the second time Avas pregnant Avith twins ; the children and mother recovered. Zweifelc cites an instance in which tA\o Cesarean sections were performed on a patient, both of the children delivered being in vigorous health. Stolz d relates a similar case. Beck e gives an account of a Cesarean operation twice on the same woman; in the first the child perished, but in the second it survived. Merinarf cites an instance of a Avoman thrice opened. Parravini e gives a a 463, xi., 572. b 125, 1891. c 261, 18*9, No. 13. d 368, 1885, iii., 182 e 593^ 1849-50, vi., 355. f 264, 1856, xi., 172. g 360, 1860, 273. CESAREAN SECTION BY THE PATIENT HERSELF. 131 similar instance. Charlton8 gives an account of the performance carried out successfully four times in the same woman ; Chisholm b mentions a case in Avhich it Avas twice performed. Michaelis of Kiel0 gh'esan instance in which he performed the same operation on a Avoman four times, Avith successful issues to both mother and children, despite the presence of peritonitis the last time. He had operated in 1826, 1830, 1832, and 1836. Coed and Gueniote botli mention cases in which Cesarean section had been twice performed Avith success- ful terminations as regards both mothers and children. Rosenbergf tabulates a number of similar cases from medical literature. Cases of Cesarean section by the patient herself are most curious, but may be readily believed if there is any truth in the reports of the opera- tion being done in savage tribes. Felkin g gives an account of a successful case performed in his presence, Avith preservation of the Katcs of both mother and child, by a native African in Kahura, Uganda Country (Fig. 16). The Fig. 16.—Cesarean operation in Uganda. Fig. 17.—Suture of abdominal walls after Cesarean section in Africa. Fig. 18.—Knife used in performing Cesarean section in Africa. young girl was operated on in the crudest manner, the hemorrhage being checked by a hot iron. The sutures Avere made by means of seven thin, hot iron spikes, resembling acupressure-needles, closing the peritoneum and skin (Fig. 17). The Avound healed in eleven days, and the mother made a complete re- covery. Thomas CoAvleyh describes the case of a negro Avoman who, being unable to bear the pains of labor any longer, took a sharp knife and made a deep incision in her belly—deep enough to wound the buttocks of her child, and extracted the child, placenta and all. A negro horse-doctor Avas called, who seAved the Avound up in a manner similar to the way dead bodies are closed at the present time. a 31 a, 1837, xlvii., 417. b 318, 1808, iv., 178. c 628, Heft vii., viii., 1836. d NeAV York Polyclinic, Aug. 15, 1894. e 789, July 5, 1894. f 125, xxiv., No. 10, 1891. 8 318, April, 1884. b Lond. Med. Jour., 1785, vi., 366. 132 OBSTETRIC ANOMALIES. Barker a gives the instance of a Avoman Avho, on being abused by her hus- band after a previous tedious labor, resolved to free herself of the child, and slvlv made an incision fiA'e inches Ions: on the left side of the abdomen Avith a weaver's knife. When Barker arriATed the patient was literally drenched with blood and to all appearance dead. He extracted a dead child from the abdomen and bandaged the mother, avIio lived only forty hours. In his discourses on Tropical Diseases Moseley speaks of a young negress in Jamaica Avho opened her uterus and extracted therefrom a child Avhich lived six days ; the Avoman recovered. Barker relates another caseb in Rensselaer County, N. Y., in Avhich the incision was made Avith the razor, the woman likcAvisc recovering. There is an interesting accountc of a poor Avoman at Prischtina, near the Servian frontier, Avho, suffering greatly from the pains of labor, resolved to open her abdomen and uterus. She summoned a neighbor to seAV up the incision after she had extracted the child, and at the time of report, several months later, both the mother and child Avere doing Avell. Madigan d cites the case of a Avoman of thirty-four, in her seA'enth confine- ment, who, Avhile temporarily insane, laid open her abdomen Avith a razor, in- cised the uterus, and brought out a male child. The abdominal Avound was five inches long, and extended from one inch above the umbilicus straight doAvn- ward. There was little or no bleeding and the uterus Avas firmly contracted. She did not see a physician for three hours. The child Avas found dead and, with the placenta, was lying by her side. The neighbors were so frightened by the awful sight that they ran away, or possibly the child might have been saved by ligature of the funis. Xot until the arrival of the clergyman was anything done, and death ultimately ensued. A most wonderful case of endurance of pain and heroism.was one occurring in Italy,e Avhich attracted much European comment at the time. A young woman, illegitimately pregnant, at full term, on March 28th, at dawn, opened her own abdomen on the left side with a common knife such as is generally used in kitchens. The Avound measured five inches, and Avas directed obliquely outward and doAvmvard. She opened the uterus in the same direction, and endeavored to extract the fetus. To expedite the extraction, she drew out an arm and amputated it, and finding the extraction still difficult, she cut off the head and completely emptied the womb, including the placenta. She bound a tight bandage around her body and hid the fetus in a straw mattress. She then dressed herself and attended to her domestic duties. She afterward mounted a cart and Avent into the city of Viterbo, Avhere she showed her sis- ter a cloth bathed in blood as menstrual proof that she was not pregnant. On returning home, haA'ing walked five hours, she Avas seized Avith an attack of vomiting and fainted. The parents called Drs. Scrpieri and Baliva, Avho relate the case. Thirteen hours had elapsed from the infliction of the wound, a 597, 1830-1, i., 381. b 59^ ii.; 40. c \Vien. med. Wocbenschrift, 1880, No. 13. d 476, 1884, i., 146. e 359, May 2, 1886. DELIVERY OF FETUS BY CATTLE-HORN INJURIES. 133 through Avhich the bulk of the intestines had been protruding for the past six hours. The abdomen Avas irrigated, the toilet made, and after the eighteenth day the process of healing Avas well progressed, and the woman made a recovery after her plucky efforts to hide her shame. Cases like the foregoing excite no more interest than those on record in which an abdominal section has been accidental, as, for instance, by cattle- horns, and the fetus born through the wound. Zuboldie a speaks of a case in Avhich a fetus Avas born from the wound made by a bull's horn in the mother's abdomen. Deneux294 describes a case in which the wound made by the horn Avas not sufficiently large to permit the child's escape, but it was sub- sequently brought through the opening. Pigne b speaks of a woman of thirty- eight, who in the eighth month of her sixth pregnancy was gored by a bull, the horn effecting a transverse wound 27 inches long, running from one an- terior spine to the other. The Avoman was found cold and insensible and Fig. 19.—Accouchement by a bull (after an engraving dated 1647). with an imperceptible pulse. The small intestines were lying between the thighs and covered Avith coagulated blood. In the process of cleansing, a male child Avas expelled spontaneously through a rent in the uterus. The Avoman was treated Avith the usual precautions and Avas conscious at midday. In a month she Avas up. She lived twenty years without any inconvenience except that due to a slight hernia on the left side. The child died at the end of a fortnight. In a verv exhaustive article Harris of Philadelphia c has collected nearly all the remaining cases on record, and brief extracts from some of them will be given beloAv. In Zaandam, Holland, 1647, a farmer's wife was tossed by a furious bull. Her abdomen was ripped open, and the child and membranes escaped. The child suffered no injuries except a bruised upper lip and lived nine months. The mother died Avithin forty hours of her injuries. Figure a 097 ii. n. 43. b 162, July, 1836. c 125, 1887, xx., 673. 134 OBSTETRIC A NOMA LIES. 19, taken from an engraATing dated 1647, represents an accouchement by a mad bull, possibly the same case. In Dillenberg, Germany, in 177!), a multipara was gored by an ox at her sixth month of pregnancy ; the horn entered the right epigastric region, three inches from the linea alba, and perforated the uterus. The right arm of the fetus protruded ; the Avound Avas enlarged and the fetus and placenta deliA'ered. Thatcher a speaks of a woman Avho Avas gored by a coav in King's Park, and both mother and child Avere safely deliv- ered and survived. In the Parish of Zecoytia, Spain, in 1785, Marie Gratien Avas gored by an ox in the superior portion of her epigastrium, making a Avound eight inches long which wounded the uterus in the same direction. Dr. Antonio di Zubeldia and Don Martin Monaco Avere called to take charge of the case. While they Avere preparing to effect delivery by the A'agina, the Avoman, in an attack of singultus, ruptured the line of laceration and expelled the fetus, dead. On the twenty-first day the patient Avas doing well. The Avound closed at the end of the sixteenth Aveek. The woman subsequently enjoyed excellent health and, although she had a small ventral hernia, bore and nursed tAvo children. Marsh b cites the instance of a woman of forty-two, the mother of eight chil- dren, avIio Avhen eight months pregnant was horned by a cow. Her clothes Avere not torn, but she felt that the child had slipped out, and she caught it in her dress. She Avas seen by some neighbors twelve yards from the place of accident, and Avas assisted to her house. The bowels protruded and the child was separated from the funis. A physician saw the woman three-quar- ters of an hour aftenvard and found her pulseless and thoroughly exhausted. There was considerable but not excessive loss of blood, and several feet of intestine protruded through the Avound. The Avomb was partially imported through the Avound, and the placenta Avas still attached to the inverted por- tion. The Avound in the uterus was Y-shaped. The mother died in one and a half hours from the reception of her injuries, but the child was uninjured. Scottc mentions the instance of a Avoman thirty-four years old who Avas gored by an infuriated ox wrhile in the ninth month of her eighth pregnancy. The horn entered at the anterior superior spinous process of the ilium, involv- ing the parietes and the uterus. The child Avas extruded through the Avound about half an hour after the occurrence of the accident. The cord Avas cut and the child survived and thrived, though the mother soon died. Stalpart d tells the almost incredible story of a soldier's wife who went to obtain water from a stream and was cut in two by a cannonball while stooping over. A passing soldier observed something to move in the water, which, on investi- gation, he found to be a living child in its membranes. It was christened by order of one Cordua and lived for some time after. Postmortem Cesarean Section.—The possibility of delivering a child a 319, July, 1850, 88. b 538, 1867. c 51s, 1885, iii., 341. d Dissert, de Foet. Nutrit, 45. POSTMORTEM CESAREAN SECTION. 135 by Cesarean section after the death of the mother has been known for a long time to the students of medicine. In the olden times there Avere kvws making compulsory the opening of the dead bodies of pregnant Avomen shortly after death. Numa Pompilius established the first laAV, Avhich Avas called " lex regia," and in later times there Avere many such ordinances. A full description of these laws is on record.302 Life Avas believed possible after a gestation of six months or over, and, as stated, some famous men Avere sup- posed to have been born in this manner. Francois de Civile, Avho on great occasions signed himself " trois fois enterr6 et trois fois par le grace de Dieu, ressucite," saw the light of the Avorld by a happy Cesarean operation on his exhumed mother. Fabricius Hildanus and Bourton report similar instances. Bourton cites among others the case of an infant who Avas found living twelve hours after the death of his mother. Dufour a and Mauriceau513 are two older French medical writers avIio discuss this subject. Flajani3U speaks of a case in Avhich a child Avas delivered at the death of its mother, and some of the older Italian Avriters discuss the advisability of the operation in the moribund state before death actually ensues.' Heister411 Avrites of the delivery of the child after the death of the mother by opening the abdomen and uterus. Harris b relates several interesting examples. In Peru in 1794 a Sambi woman Avas killed by lightning, and the next day the abdomen Avas opened by official command and a living child Avas extracted. The Princess von Swartzen- berg, who Avas burned to death at a ball in Paris in 1810, Avas said to have had a living child removed from her body the next day. Like all similar instances, this Avas proved to be false, as her body was burned beyond the possibility of recognition, and, besides, she was only four months pregnant. Harris b men- tions another case of a young woman Avho threwv herself from the Pont Xeuf into the Seine. Her body Avas recovered, and a surgeon Avho Avas present seized a knife from a butcher standing by and extracted a living child in the presence of the curious spectators. Campbell248 discusses this subject most » thoroughly, though he advances no neAV opinions upon it. Duer tabulates the successful results of a number of cases of Cesarean section after death as folloAvs :— Children extracted between 1 and 5 minutes after death of the mother, 21 " 10 and 15 " " " " " 13 " 15 and 30 " " " " " 2 1 hour " " " " 2 2 hours " " " " 2 Garezky of St, Petersburg c collected reports of 379 cases of Cesarean section after death Avith the folloAving results : 308 Avere extracted dead ; 37 showed signs of life; 34 Avere born alive. Of the 34, only 5 lived for any length of time. He concludes that if extracted Avithin five or six minutes after death, they may be born alive; if from six to ten minutes, they may a 462, T. xix., 263. b 125, ISsO, 141. c Quoted by 545, Aug. 23, 1879. 136 OBSTETRIC ANOMALIES. still be born alive, though asphyxiated; if from ten to twenty-six minutes, they will be highly asphyxiated. In a great number of these cases the infant Avas asphyxiated or dead in one minute. Of course, if the death is sudden, as by apoplexy, accident, or suicide, the child's chances are better. These statistics seem conscientious and reliable, and Ave are safe in taking them as indicative of the usual result, which discountenances the old reports of death as taking place some time before extraction. Peuch a is credited Avith statistics shoAving that in 453 operations 101 chil- dren gave signs of life, but only 45 surviATed. During the Commune of Paris, Tarnier, one night at the Maternite, Avas called to an inmate Avho, Avhile lying in bed near the end of pregnancy, had been killed by a ball Avhich fractured the base of the skull and entered the brain. He removed the child by Cesarean section and it lived for se\Teral days. In another case1 a pregnant Avoman fell from a Avindow for a distance of more than 30 feet, instant death resulting; thirty minutes at least after the death of the mother an infant Avas removed, Avhich, after some difficulty, Avas resuscitated and lived for thirteen years. Tarnier states that delivery may take place three-quarters of an hour or even an hour after the death of the mother, and he also quotes an extraordinary case by Hubert of a successful Cesarean operation two hours after the mother's death; the Avoman, Avho Avas eight months pregnant, was instantly killed Avhile crossing a railroad track. h Hoffman c records the case of a successful Cesarean section done ten min- utes after death. The patient Avas a woman of thirty-six, in her eighth month of pregnancy, Avho Avas suddenly seized Avith eclampsia, Avhich terminated fatally in ten hours. Ten minutes after her last respiration the Cesarean sec- tion Avas performed and a living male child delivered. This infant was nour- ished Avith the aid of a spoon, but it died in twenty-five hours in consequence of its premature birth and enfeebled A'itality. Green d speaks of a Avoman, nine months pregnant, who Avas run over by a heavily laden stage-coach in the streets of Soutlrwark. She died in about twenty minutes, and in about twenty minutes more a living child was ex- tracted from her by Cesarean section. There Avas a similar case in the Hopital St. Louis, in Paris, in 1829 ; but in this case the child Avas born alive five minutes after death. Squiree tells of a case in which the mother died of dilatation of the aorta, and in from tAventy to thirty minutes the child Avas saA^ed. In comment on this case Aveling is quoted as saying that he believed it possible to save a child one hour after the death of the mother. No less an authority than Playfair speaks of a case in which a child Avas born half an hour after the death of the mother. Beckman f relates the history of a Avoman Avho died suddenly in convulsions. The incision Avas made about five minutes after death, and a male child about four pounds in Aveight Avas a 844, 644. b 844. 645. c 261, 1895, No. 50, 1319. d 550, xii., 46-51. e 476, 1877, ii., 89. f 199, 1869. RUPTURE OF THE UTERUS DURING PREGNANCY. 137 extracted. The child exhibited feeble heart-contractions and Avas despaired of. Happily, after numerous and persistent means of resuscitation, applied for about two and a half hours, regular respirations Avere established and the child eventually recovered. Walter a reports a successful instance of removal of the child after the death of the mother from apoplexy. Cleveland b giA'es an account of a Avoman of forty-seven Avhich is of special interest. The mother had become impregnated five months after the cessa- tion of menstruation, and a uterine sound had been used in ignorance of the impregnation at this late period. The mother died, and one hour later a living child was extracted by Cesarean section. There are two other recent cases recorded of extraction after an hour had expired from the death. One is cited by Veronden c in Avhich the extraction was tAvo hours after death, a living child resulting, and the other by Blatnerd in which one hour had elapsed after death, when the child was taken out alive. Cases of rupture of the uterus during pregnancy from the pressure of the contents and delivery of the fetus by some unnatural passage are found in profusion through medical literature, and seem to have been of special interest to the older observers. Benivenius e saAV a case in Avhich the uterus ruptured and the intestines protruded from the vulva. An instance similar to the one recorded by Benivenius is also found in the last century in Germany.742 Bouillonf and Desbois, two French physicians of the last century, both record examples of the uterus rupturing in the last stages of pregnancy and the mother recovering. Schreiber^ gives an instance of rupture of the uterus occasioned by the presence of a 13-pound fetus, and there is recorded h the account of a rupture caused by a 20-pound fetus that made its way into the abdomen. We find old accounts of cases of rupture of the uterus Avith birth by the umbilicus and the recovery of the Avoman.1 Vcsprej describes a case in Avhich the uterus was ruptured by the feet of the fetus. Farquharson k has an account of a singular case in midAvifery in Avhich the abdomen ruptured from the pressure of the fetus ; and quite recently Geo- ghegan * illustrates the possibilities of uterine pressure in pregnancy by a post- mortem examination after a fatal parturition, in Avhich the stomach was found pushed through the diaphragm and lying under the left claA'icle. HeyAvood Smith™ narrates the particulars of a case of premature labor at seven months in Avhich rupture of the uterus occurred and, notAvithstanding the fact that the case Avas complicated by placenta praevia, the patient recovered. Rupture of the uterus and recovery does not necessarily prevent subsequent successful pregnancy and delivery by the natural channels. Whinery n relates a 573, 1855, v., 179. b 125, 1878, xi., 626-632. c 780, 1876, iv., 7. dl2."), 1875, viii., 160. e L. iv., obs. B., 13. f Histoire de la Soc. Royale de Med., Paris, 1776, 310. S 160, iii., 235 hSamml. Medic. Wahruehmungen, 1 B., 363. i 108, dec. i., viii., 90. J 462, T. xiii., 84. k 524, 1789. 1 465, 1881, 52. m 476, 1875, ii., 911. n 124, Oct., 1866. 138 OBSTETRIC ANOMALIES. an instance of a ruptured uterus in a healthy Irish Avoman of thirty-seven from whom a dead child Avas extracted by abdominal section and who Avas safely delivered of a healthy female child about one year aftenvard. Analo- gous to this case is that of Lawrence,11 Avho details the instance of a woman Avho had been delivered five times of dead children ; she had a very narroAV pelvis and labor Avas ahvays induced at the eighth month to assure delivery. In her sixth pregnancy she had miscalculated her time, and, in consequence, her uterus ruptured in an unexpected parturition, but she recovered and had several subsequent pregnancies. Occasionally there is a spontaneous rupture of the vagina during the process of parturition, the uterus remaining intact. AViltshire reports such a case in aAvoman avIio had a most prominent sacrum; the laceration Avas trans- verse and quite extensive, but the Avoman made a good recovery. Schauta pictures an exostosis on the promontory of the sacrum (Fig. 20). Blenkin- sop b cites an instance in Avhich the labor was neither protracted nor abnormally severe, yet the rupture of the vagina took place with the escape of the child into the abdomen of the mother, and was from thence extracted by Cesarean sec- tion. A peculiarity of this case Avas the easy expulsion from the uterus, no instrumental or other manual interfer- ence being attempted and the uterus remaining perfectly intact. In some cases there is extensive sloughing of the genitals after parturition with recovery far beyond expectation. Gooch mentions a case in which the whole vagina sloughed, yet to his surprise the patient recov- ered. Aetius and Benivenius speak of recovery in such cases after loss of the whole uterus. Cazenave of Bordeaux0 relates a most marvelous case in Avhich a primipara suffered in labor from an impacted head. She was twenty-five, of very diminutive stature, and was in labor a long time. After labor, sloughing of the parts commenced and progressed to such an extent that in one month there were no traces of the labia, nymphae, vagina, perineum, or anus. There Avas simply a large opening extending from the meatus urinarius to the coccyx. The rectovaginal septum, the lower portion of the rectum, and the neck of the bladder were obliterated. The Avoman sur- vived, although she ahvays experienced great difficulty in urination and in entirely emptying the rectum. A similar instance is reportedd in a Avoman of thirty Avho Avas thirty-six hours in labor. The fundus of the uterus Fig. 20.—Knob-like exostosis on the promontory (Schauta). a 224, 1885, 601. c 330, No. 84, Feb. 7, 1839. b 656, No. xi., Dec. 2, 1841. d 124, Aug., 1838. ACCIDENTAL EXTRACTION OF PELVIC ORGANS. 139 descended into the vagina and the whole uterine apparatus Avas remoA'ed. The loAver part of the rectum depended betAveen the labia; in the presence of the physician the nurse drew this out and it separated at the sphincter ani. On examining the parts a single opening Avas seen, as in the preceding case, from the pubes to the coccyx. Some time afterward the end of the intestine descended seA'eral inches and hung loosely on the concaA'e surface of the rec- tum. A sponge was introduced to support the rectum and prcA-ent access of air. The destruction of the parts was so complete and the opening so large as to bring into view the whole inner surface of the pehis, in spite of which, after prolonged suppuration, the wound cicatrized from behind forward and health returned, except as regards the inconvenience of feces and urine. Milk-secretion appeared late and lasted tAVO months Avithout influencing the other functions. There are cases in which, through the ignorance of the midAvife or the physician, prolapsed pelvic organs are mistaken for afterbirth and ex- tracted. There have been instances in which the whole uterus and its ap- pendages, not being recognized, have been dragged out. Waltersa cites the instance of a Avoman of twenty-two, who was in her third confinement. The midwife in attendance, finding the afterbirth did not come aAvay, pulled at the funis, Avhich broke at its attachment. She then introduced her hand and tore away what proved to be the Avhole of the uterus, with the right ovary and fallopian tube, a portion of the round ligament, and the left tube and ovarian ligament attached to it, A large quantity of omentum protruded from the vulva and upper part of the vagina, and an enormous rent was left, Walters saw the woman twenty-one hours afterward, and ligated and severed the pro- truding omentum. On the tAventy-eighth day, after a marvelous recovery, she was able to drive to the Royal Berkshire Hospital, a distance of fiAre miles. At the time of report, two years and six months after the mutilation, she Avas in perfect health. Walters looked into the statistics of such cases and found 36 accidental removals of the uterus in the puerperium with 14 recoveries. All but three of these Avere Avithout a doubt attended by previous inversion of the uterus. A medical man Avas tried for manslaughter in 1878b because he made a similar mistake. He had delivered a Avoman by means of the forceps, and, after delivery, brought away Avhat he thought a tumor. This "tumor" con- sisted of the uterus, Avith the placenta attached to the fundus, the funis, a por- tion of the lateral ligament, containing one ovary and about three inches of vagina. The uterus Avas not inverted. A horrible case, with similar results, happened in France, and was reported by Tardieu.0 A brutal peasant, whose wife Avas pregnant, dragged out a fetus of seven months, together with the uterus and the whole intestinal canal, from within 50 cm. of the pylorus to within 8 cm. of the ileocecal valve. The Avoman was seen three-quarters of a 476, 1884, ii., 779. b 548, 1878, ii., 728. c 141, xxxix., 157, 172. 140 OBSTETRIC ANOMALIES. an hour after the intestines had been found in the yard (avIiciv the brute had throAvn them), still alive and reproaching her murderer. Hoffman a cites an instance in which a midwife, in her anxiety to extract the afterbirth, made traction on the cord, brought out the uterus, ovaries, and tubes, and tore the vulva and perineum as far as the anus. Woodson b tells the story of a negress Avho Avas four months pregnant, and who, on being seized Avith severe uterine pains in a bath, succeeded in seizing the fetus and dragging it out, but inverting the uterus in the operation. There is a case recordedc of a girl of eighteen, near her labor, avIio, being driven from her house by her father, took refuge in a neighboring house, and soon felt the pains of child-birth. The accoucheur Avas summoned, pro- nounced them false pains, and Avent aAvay. On his return he found the girl dying, with her uterus completely inverted and hanging between her legs. This unfor- tunate maiden had been delivered Avhile standing upright, with her elbows on the back of a chair. The child suddenly escaped, bringing Avith it the uterus, but as the funis ruptured the child fell to the floor. Wagner pictures partial prolapse of the Avomb in labor (Fig. 21). It Avould too much extend this chap- ter to include the many accidents inci- dent to labor, and only a few of especial interest Avill be given. Cases like rupture of an aneurysm during labor, extensive hemorrhage, the entrance of air into the uterine veins and sinuses, and common lacerations will be omitted, together with complicated births like those of double monsters, etc., but there are several other cases that deserve mention. Eldridged gives an instance of separation of the symphysis pubis during labor,—a natural symphysiotomy. A separation of f inch could be discerned at the symphysis, and in addition the sacroiliac synchondrosis Avas also quite movable. The Avoman had not been able to Avalk in the latter part of her pregnancy. The child weighed 10| pounds and had a large head in a remarkably advanced stage of ossification, Avith the fontanelles nearly closed. Delivery Avas effected, though during the passage of the head the pubes separated to such an extent that Eldridge placed tAvo fingers between them. The mother recovered, and had perfect union and normal locomotion. Fig. 21.—Partial prolapse of the womb in labor (AVagner). a 807, 1865. c American System of Obstetrics, Hirst. b 124, 1860. d269, 1884, xlix., 495. S YMPHYSIO TOMY. 141 Sandersa reports a case of the separation of the pubic bones in labor. Studley b mentions a case of fracture of the pelvis during instrumental deliv- ery. Humphreys c cites a most curious instance. The patient, it appears, had a large exostosis on the body of the pubes Avhich, during parturition, Avas forced through the walls of the uterus and bladder, resulting in death. Kilian reports four cases of death from perforation of the uterus in this manner. Schauta pictures such an exostosis (Fig. 22). Chandlerd relates an instance in which there was laceration of the liver during parturition; and Hubbarde records a case of rupture of the spleen after labor. Symphysiotomy is an operation consisting of division of the pubic symphy- sis in order to facilitate delivery in narroAv pelves. This operation has under- gone a most remarkable revival during the past two years. It originated in a suggestion by Pineau in his work on surgery in 1598/ and in 1665 was first performed by La Courvee upon a dead body in order to save the child, and aftenvard by Plenk, in 1766,s for the same purpose. In 1777 Sigault first proposed the operation on the living, and Ferrara Avas the one to carry out, practically, the proposition,—although Sigault is generally considered to be the first symphysiotomist, and the pro- cedure is very generally known as the " Sigaultean operation." From Fer- rara's time to 1858, when the oper- n/ ation had practically died OUt, it had Fig. 22.—Exostosis on the symphysis (Schauta). been performed 85 times, Avith a re- corded mortality of 33 per cent. In 1866 the Italians, under the leadership of Morisani of Naples, revived the operation, and in twenty years had per- formed it 70 times Avith a mortality of 24 per cent. OAving to rigid anti- septic technic, the last 38 of these operations (1886 to 1891) shoAved a mortality of only 5 J per cent., Avhile the infant-mortality Avas only lOf percent. The modern history of this operation is quite interesting, and is very completely revieAved by Hirst and Dorland.b In November, 1893, Hirst reported 212 operations since 1887, Avith a maternal mortality of 12.73 per cent, and a fetal mortality of 28 per cent. In his later statistics Morisani gives 00 cases Avith 2 maternal deaths and 1 infantile death, Avhile ZAveifel1 reports 14 cases from the Leipzig clinic with no maternal death and 2 fetal deaths, 1 from asphyxia and 1 from pneumonia, two days after birth. All the modern statistics are correspond- ingly encouraging. a Trans. Amer. Instit. Homeopathy. b 125, 1879, xii., 269. c 531, 1857-8, iii., 322-326. d 218, xxxiii., 398. e 597, xxx., 75. f 533, Jan. 12, 1895. 8 843, 401. h 843, 401. i 261, No. 22, 1893. 142 OBSTETRIC ANOMALIES. Irwin reports a case in Avhich the firm attachment of the fetal head to the uterine parietes rendered delivery Avithout artificial aid impossible, and it Avas necessary to perform craniotomy. The right temporal region of the child adhered to the internal surface of the neck of the uterus, being connected by membranes. The Avoman Avas forty-four years old, and the child Avas her fourth. Delay in the Birth of the Second Twin.—In twin pregnancies there is sometimes a delay of many days in the birth of a second child, iwen to such an extent as to give suspicion of superfetation. Pignot speaks of one twin tAvo months before the other. De Bosch speaks of a delay of seven- teen days; and there Avere 2 cases on record in France in the last century, a one of Avhich Avas delayed ten days, and the other shoAved an interval of seven Aveeks between the delivery of the tAvins. There is an old case on record b in Avhich there was an interval of six Aveeks between deliveries ; Jansen 160 gives an account of three births in ten months ; Pinartc mentions a case Avith an interval of ten days ; Thilenius, one of thirteen days ; and Ephemerides, one of one Aveck. Wildbergd describes a case in which one twin Avas born two months after the other, and there Avas no secretion of milk until after the second birth. A full description of Wildberg's case is given in another journale in brief, as follows : A Avoman, eighteen months married, Avas in labor in the eighth month of pregnancy. She gave birth to a child, which, though not fully matured, lived. There Avas no milk-secretion in her breasts, and she could distinctly feel the moA'ements of another child; her abdomen increased in size. After Iavo months she had another labor, and a fully developed and strong child Avas born, much heavier than the first. On the third day after, the breasts became enlarged, and she experienced considerable fever. It Avas noticeable in this case that a placenta Avas discharged a quarter of an hour after the first birth. Irvinef relates an instance of thirty-two days' delay; and Pfaug one of seven days'. Carson h cites the instance of a noblewoman of forty, the mother of four children, avIio Avas taken ill about two Aveeks before confinement Avas expected, and Avas easily delivered of a male child, which seemed Avell formed, Avith perfect nails, but Aveakly. After the birth the mother neA'er became healthy or natural in appearance. She was supposed to be dying of dropsy, but after forty-four days the mystery was cleared by the birth of a fine, Avell-groAvn, and healthy daughter. Both mother and child did well. Addisoni describes the case of a Avoman Avho Avas delivered of a healthy male child, and everything Avas well until the evening of the fourth day, Avhen intense labor-pains set in, and Avell-formed twins about the size of a pigeon's egg were born. In this strange case, possibly an example of superfetation, a 418, 1751, 107 ; and 418, 1752, 112. b 160, iv. B., 771. c 462, T. xl., 448. d 611, April 5, 1845. e 136, 1844, 3 Heft. f 546, Dec. 28, 1844. g 611, April 20, 1844. h 224, 1880, i., 242. i 476, 1886, i., 477. DELAY IN THE BIRTH OF THE SECOND TWIN. 143 the patient made a good recovery and the first child lived. A similar case is reported by Lumbya in Avhich a Avoman Avas delivered on January 18th by a midwife, of a full-groAvn and healthy female child. On the third dav she came down-stairs and resumed her ordinary duties, Avhich she con- tinued until February 4th (seventeen days after). At this time she Avas de- livered of tAvins, a boy and a girl, healthy and avell-developed. The placenta was of the consistency of jelly and had to be scooped aAvay with the hand. The mother and children did avcII. This Avoman Avas the mother of ten children besides the product of this conception, and at the latter occurrence had entire absence of pains and a very easy parturition. Pincott b had a ease with an interval of seven Aveeks betAveen the births ; A ale c 1 of tAvo months ; Bush d 1 of seventeen days ; and Burke e 1 Avith an interATal of two months. Douglas f cites an instance of tAvins being born four days apart. Bessems of AntAverp, in 1866, mentions a Avoman Avith a bicor- nate uterus who bore two twins at fifty-four days' interval. * 224, 1878, i., 227. b 224, 1886. c 476, 1842. d 535, 1825, 121. e 582, 1855, 241. f 538, xxvii.. 196. CHAPTER IV. PROLIFICITY. General Historic Observations.—Prolificity is a much discussed sub- ject, for besides its medical and general interest it is of importance in social as Avell as in political economy. Superfluous population was a question that came to consciousness early ; Aristotle spoke of legislation to prevent the in- crease of population and the physical and mental deterioration of the race,— he believed in a population fixed as regards numbers,—and later Lycurgus transformed these precepts into a terrible law. Strabonius reports that the inhabitants of Cathea brought their infants at the age of two months before a magistrate for inspection. The strong and promising were preserved and the Aveak destroyed. The founders of the Roman Empire followed a similar usage. With great indignation Seneca, Ovid, and Juvenal reproved this barbarity of the Romans. With the domination of Christianity this custom gradually diminished, and Constantine stopped it altogether, ordering succor to the people too poor to rear their own children. The old Celts were so jealous of their vigor that they placed their babes on a shield in the river, and regarded those that the Avaves respected as legitimate and Avorthy to become members of their clans. In many of the Oriental countries, where the population is often very excessive and poverty great, the girl babies of the loAver classes Avere destroyed. At one time the crocodiles, held sacred in the Nile, Avere given the surplus infants. By destroying the females the breed- ing necessarily diminished, and the number of the weaker and dependent classes became less. In other countries persons having children beyond their ability to support were privileged to sell them to citizens, Avho contracted to raise them on condition that they became their slaves. General Law, and the Influence of War.—In the increase of the Avorld's population, although circumstances may for the time alter it, a general average of prolificity has, in the long run, been maintained. In the history of every nation artificial circumstances, such as fashion, war, poverty, etc. at some period have temporarily loAvered the average of prolificity ; but a further search finds another period, under opposite circumstances, Avhich Avill more than compensate for it. The effect of a long-continued Avar or Avars on generation and prolificity has never been given proper consideration. In such times marriages become much less frequent; the husbands are separated 144 INFLUENCE OF RURAL AND URBAN LIFE. 145 from their wives for long periods ; many women are left widoAVs ; the females become in excess of the males ; the excitement of the times overtops the desire for sexual intercourse, or, if there is the same desire, the unprolific prostitute furnishes the satisfaction ; and such facts as these, coupled with many similar ones, soon produce an astonishing effect upon the comparative birth-rate and death-rate of the country. The resources of a country, so far as concerns population, become less as the period of peace-disturbance is prolonged. Mayo-Smith a quotes von Mayr in the following example of the influence of the Avar of 1870-71 on the birth-rate in Bavaria,—the figures for births are throAvn back nine months, so as to show the time of conception: Before the Avar under normal conception the number of births was about 16,000 per month. During the war it sank to about 2000 per month. Immediately on the cessation of hostilities it arose to its former number, while the actual return of the troops brought an increase of 2000 per month. The maximum Avas reached in March, 1872, when it was 18,450. The war of 1866 seems to have passed over Germany without any great influence, the birth-rate in 1865 being 39.2; in 1866, 39.4; in 1867, 38.3; in 1868, 38.4. On the other hand, while the birth-rate in 1870 was 40.1, in 1S71 it was only 35.9; in 1872 it recovered to 41.1, and remained above 41 doAvn to 1878. Von Mayr believes the war had a depressing influence upon the rate apart from the mere absence of the men, as shown in the fact that immediately upon the cessation of hostilities it recovered in Bavaria, although it was several months before the return of the troops. Mayo-Smith, in remarking on the influence of war on the marriage-rate, says that in 1866 the Prussian rate fell from 18.2 to 15.6, while the Austrian rate fell from 15.5 to 13.0. In the war of 1870-71 the Prussian rate fell from 17.9 in 1869 to 14.9 in 1870 and 15.9 in 1871 ; but in the two years after peace Avas made it rose to 20.6 and 20.2, the highest rates ever recorded. In France the rate fell from 16.5 to 12.1 and 14.4, and then rose to 19.5 and 17.7, the highest rates ever recorded in France. Influence of Rural and Urban Life.—Rural districts are always very prolific, and when we hearthe AAails of writers on " Social Economy," bemoan- ing the small birth-rates of their large cities, we need have no fear for urban extinction, as emigration from the country by many ambitious sons and daughters, to aA'ail themselves of the superior advantages that the city offers, Avill not only keep up but to a certain point increase the population, until the reaction of overcroAvding, folloAving the self-regulating laAv of compensation, starts a return emigration. The effect of climate and race on prolificity, though much spoken of, is not so great a factor as supposed. The inhabitants of Great Britain are surpassed by none in the point of prolificity; yet their location is quite northern. The SAvedes have ahvays been noted for their fecundity. Olaf a Statistics and Sociology, New York, 1895. 10 146 PROLIFICITY. Rudbecka says that from 8 to 12 was the usual family number, and some ran as high as 25 or 30. According to Lord Karnes, in Iceland before the plague (about 1710) families of from 15 to 20 avc re quite common. The old settlers in cold North America Avere ahvays blessed with large families, and Quebec is still noted for its prolificity. There is little difference in this respect among nations, woman being limited about the same everyAvhere, and the general aA'erage of the range of the productive function remaining nearly identical in all nations. Of course, exception must be made as to the extremes of north or south. Ancient and Modern Prolificity.—Nor is there much difference betAveen ancient and modern times. We read in the Avritings of Aristotle, Pliny, and Albucasis of the wonderful fertility of the Avomen of Egypt, Arabia, and other Avarm countries, from 3 to 6 children often being born at once and living to maturity; but from the Avonder and surprise shown in the narration of these facts, they were doubtless exceptions, of Avhich parallels may be found in the present day. The ancient Greek and Roman families were no larger than those of to-day, and were smaller in the zenith of Roman affluence, and continued small until the period of decadence. Legal Encouragement of Prolificity.—In Quebec Province, Canada, according to a Montreal authority,b 100 acres of land are allotted to the father Avho has a dozen children by legitimate marriage. The same journal states that, stimulated by the premium offered, families of 20 or more are not rare, the results of patriotic efforts. In 1895, 1742 "chefs de famille" made their claim according to the conditions of the law, and one, Paul Bellanger, of the River du Loup, claimed 300 acres as his premium, based on the fact that he Avas the father of 36 children. Another claimant, Monsieur Thioret de Sainte Genevieve, had been presented by his wife, a woman not yet thirty years old, Avith 17 children. She had triplets twice in the space of five years and twins thrice in the mean time. It is a matter of conjecture what the effect would be of such a premium in countries with a lowering birth-rate, and a French medical journal, quoting the foregoing, regretfully wishes for some countrymen at home like their brothers in Quebec. Old Explanations of Prolificity.—The old explanation of the causation of the remarkable exceptions to the rules of prolificity was similar to that adA-anced by Empedocles, Avho says that the greater the quantity of semen, the greater the number of children at birth. Pare,618 later, uses a similar reason to explain the causation of monstrosities, grouping them into two classes, those due to deficiency of semen, such as the acephalous type, and those due to ex- cess, such as the double monsters. Hippocrates, in his work on the " Nature of the Infant," tells us that twins are the result of a single coitus, and we are also informed that each infant has a chorion; so that both kinds of plural gestation (monochorionic and dichorionic) were known to the ancients. In this a Atlantica, Upsal, 1684. b 788, June, 1895. OLD RECORDS OF GREAT PROLIFICITY. 147 treatise it is further stated that the tAvins may be male or female, or both males or both females ; the male is formed when the semen is thick and strong. The greatest number of children at a single birth that it is possible tor a Avoman to have has never been definitely determined. Aristotle giA'es it as his opinion that one Avoman can bring forth no more than 5 children at a single birth, and discredits reports of multiplicity aboATe this number; Avliile 1 liny, avIio is not held to be so trustAvorthy, positively states that there Avere authentic records of as many as 12 at a birth. Throughout the ages in which superstitious distortion of facts and unquestioning credulity Avas unchecked, all sorts of incredible accounts of prolificity are found. Martin Cromerus, a Polish historian, quoted by Pare, Avho has done some good work in statistical research on this subject, saysa that Margaret, of a noble and ancient family near Cracovia, the Avife of Count Virboslaus, brought forth 36 living children on January 20, 1296. The celebrated case of Countess Margaret, daughter of Florent IV., Earl of Holland, and spouse of Count Hermann of Henneberg, was supposed to have occurred just before this, on Good Friday, 1278. She was at this time forty-tAvo years of age, and at one birth brought forth 365 infants, 182 males, 182 females, and 1 hermaphrodite. They were all baptized in two large brazen dishes by the Bishop of Treras, the males being called John, the females Elizabeth. During the last century the basins were still on exhibi- tion in the village church of Losdun, and most of the visitors to Hague went out to see them, as they were reckoned one of the curiosities of Holland. The affliction was ascribed to the curse of a poor Avoman who, holding twins in her arms, approached the Countess for aid. She was not only denied alms, but Avas insulted by being told that her twins were by different fathers, Avhereupon the poor Avoman prayed God to send the Countess as many children as there were days in the year. There is room for much speculation as to what this case really Avas. There is a possibility that it was simply a case of hydatidi- form or multiple molar pregnancy, elaborated by an exhaustive imagination and superstitious aAve. As late as 1799 there was a woman of a toAvn of Andalusia Avho was reported to have been delivered of 16 male infants, 7 of which Avere alive tAvo months later. Mayo-Smith remarks that the proportion of multiple births is not more than 1 per cent, of the total number of parturitions. The latest statistics, by Westergaard, give the folloAving averages to number of cases of 100 births in which there Avere 2 or more at a birth :— Sweden. . . , . 1.45 . . . 1.24 . . 1.38 . . 1.34 . . . 1.30 . . 1.26 . . 1.22 Norway, . . . . . 1.32 . . 1.20 Italy, . . . - . . 1.21 Austria, . . . . . 1.17 Switzerland, . . 1.16 . . 0.99 . . . 0.97 . . 0.85 a 618, 1014. 148 PROLIFICITY. In Prussia, from 1826 to IS SO, there Avere 85 cases of quadruplets and 3 cases of 5 at a birth. The most extensive statistics in regard to multiple births are those of A eit, who reviews 13,000,000 births in Prussia. According to his deductions, twins occur once in 88 births ; triplets, once in 7910 ; and quadruplets, once in 371,126. Recent statistics supplied by the Boards of Health of Ncav York and Philadelphia place the frequency of tAvin births in these cities at 1 in every 120 births, Avhile in Bohemia twins occur once in about 60 births, a proportion just tAvice as great.a Of 150,000 tAvin pregnancies studied by Veit, in one-third both children were boys; in slightly less than one-third both were girls; in the remaining third both sexes were represented. Authentic records of 5 and 6 at a birth are extremely rare and infinitesimal in proportion. The reputed births in excess of 6 must be looked on with suspicion, and, in fact, in the great majority of reports are apochryphal. The examples of multiple births of a single pregnancy Avill be taken up under their respective numbers, several examples of each being given, together with the authorities. Many twin and triplet brothers have figured prominently in history, and, in fact, they seem especially favored. The instance of the Horatii and the Curatii, and their famous battle, on which hung the fate of Rome and Alba, is familiar to every one, their strength and wisdom being legendary Avith the Romans. Twins and triplets, being quite common, will not be considered here, although there are 2 cases of interest of the latter that deserve citation. Sperling839 reports 2 instances of triplets ; in the first there was 1 placenta and chorion, 2 amnions, and the sex was the same ; in the second case, in Avhich the sexes were different, there were 3 placentas, 3 chorions, and 3 amnions. What significance this may have is only a matter of conjecture. Petty b describes a case of triplets in which one child was born alive, the other 2 having lost their vitality three months before. Mirabeauc has recently found that triple births are most common (1 to 6500) in multiparous women betAveen thirty and thirty-four years of age. Heredity seems to be a factor, and duplex uteruses predispose to multiple births. Ross d reports an instance of double uterus with triple pregnancy. Quadruplets are supposed to occur once in about every 400,000 births. There are 72 instances recorded in the Index Catalogue of the Surgeon General's Library, U. S. A., up to the time of compilation, not including the subsequent cases in the Index Medicus. At the Hotel-Dieu, in Paris, in 108,000 births, covering a period of sixty years, mostly in the last century, there Avas only one case of quadruplets. The folloAving extract of an account of the birth of quadruplets is given by Dr. De Leon of Ingersoll, Texas :— " I Avas called to see Mrs. E. T. Page, January 10, 1890, about 4 o'clock a 844, 142. b 490, 1845. c TJeber Drillingsgeburten, Miinchen, 1894. d Medecin. Paris, 1879, v., No. 43, 2. QUADRUPLETS. 149 A. m. ; found her in labor and at full time, although she assured me that her ' time ' Avas six Aveeks ahead. At 8 o'clock a. m. I deliA'ered her of a girl baby; I found there Avere triplets, and so informed her. At 11 A. m. I delivered her of the second girl, after haA'ing rectified presentation, Avhich Avas singular, face, hands, and feet all presented ; I placed in proper position and practised ' version.' This child Avas ' still-born,' and after considerable effort by artificial respiration it breathed and came around ' all right.' The third girl Avas born at 11.40 A.m. This was the smallest one of the four. In attempting to take away the placenta, to my astonishment I found the feet of another child. At 1 p. m. this one Avas born ; the head of this child got firmly impacted at the lower strait, and it AAas Avith a great deal of difficulty and much patient effort that it Avas finally disengaged ; it Avas blocked by a mass of placenta and cords. The first child had its OAvn placenta; the second and third had their placenta; the fourth had also a placenta. They weighed at birth in the aggregate 19 J pounds Avithout cloth- ing ; the first Aveighed 6 pounds ; the second 5 pounds ; the third 4^ pounds ; the fourth 4 pounds. Mrs. Page is a blonde, about thirty-six years old, and has given birth to 14 children, twins three times before this, one pair by her first husband. She has been married to Page three years, and has had 8 children in that time. I have waited on her each time. Page is an Englishman, small, Avith dark hair, age about twenty-six, and Aveighs about 115 pounds. They are in St. Joseph, Mo., now, having contracted with Mr. Uffner of NeAV York to travel and exhibit themselves in Denver, St. Joseph, Omaha, and Nebraska City, then on to Boston, Mass., where they will spend the summer." There is a report from Canadaa of the birth of 4 liAring children at one time. The mother, a Avoman of thirty-eight, of small stature, weighing 100 pounds, had 4 living children of the ages of tAvelve, ten, eight, and seven years, respectively. She had aborted at the second month, and at full term Avas delivered of 2 males, Aveighing, respectively, 4 pounds 9| ounces and 4 pounds 3 ounces ; and of 2 females, Aveighing 4 pounds 3 ounces and 3 pounds 13f ounces, respectively. There Avas but one placenta, and no more exhaustion or hemorrhage than at a single birth. The father Aveighed 169 pounds, Avas forty-one years old, and Avas 5 feet 5 inches tall, healthy and robust. The Journal of St. Petersburg, a neAvspaper of the highest standard, stated that at the end of July, 1871, a JeAvish Avoman residing in Courland gave birth to 4 girls, and again, in May, 1872, bore 2 boys and a girl; the mother and the 7 children, born within a period of ten months, Avere doing Avell at the time of the report. In the village of Lvokina, on May 26, 1854, b the Avife of a peasant bore 4 children at a birth, all surviv- ing. Bousquetc speaks of a primiparous mother, aged tAventy-four, giving birth to 4 living infants, 3 by the breech and 1 by the vertex, apparentlv all a 250, Oct., 1883. b 476, 1857, ii., 259. c 140, 1894, ii., 55. 150 PROLIFICITY. in one bag of membranes. They Avere nourished by the help of 3 Avet-nurses. Bedford a speaks of 4 children at a birth, averaging 5 pounds each, and all nursing the mother. Quintuplets are quite rare, and the Index Catalogue of the Surgeon General's Library, U. S. A., gives only 19 cases, reports of a Icav of Avhich Avill be given here, together Avith others not giAren in the Catalogue, and from less scientific though reliable sources. In the year 1731282 there Avas one case of quintuplets in Upper Saxony and another near Prague, Bohemia. In both of these cases the children Avere all christened and had all lived to maturity. Garthshoreb speaks of a healthy Avoman, Margaret Waddington, giving birth to 5 girls, 2 of Avhich lived; the 2 that lived Aveighed at birth 8 pounds 12 ounces and 9 pounds, respectively. Me discusses the idea that Avoman Avas meant to bear more than one child at a birth, using as his argument the existence of the double nipple and mamma, to Avhich might be added the not infrequent occurrence of polymazia. In March, 1736,c in a dairy cellar in the Strand, London, a poor Avoman gave birth to 3 bovs and 2 girls. In the same journal Avas reported the birth at Wells, Somersetshire, in 1739, of 4 boys and a girl, all of Avhom were christened and Avere healthy. Pare d in 1549 gives several instances of 5 children at a birth, and Pliny reports that in the peninsula of Greece there was a woman who gave birth to quintuplets on four different occasions. Petritus, a Greek physician,e speaks of the birth of quintuplets at the seventh month. Tavo males and one female Avere born dead, being attached to the same placenta; the others Avere united to a common placenta and lived three days. Chambonf mentions an instance of 5 at a birth. Not far from Berne, Switzerland, the Avife of John Gelinger, a preacher in the Lordship of Berne, brought forth twins, and Avithin a year after she brought forth quintuplets, 3 sons and 2 daughters.8 There is a similar instance reported in 1827 b of a Avoman of twenty-se\Ten avIio, having been delivered of twins two years before, Avas brought to bed Avith 5 children, 3 boys and 2 girls. Their length Avas from 15\ to 16 J inches. Although regularly formed, they did not seem to have reached maturity. The mother Avas much exhausted, but recovered. The children appeared old-looking, had tremulous Aoices, and slept continually ; during sleep their temperatures seemed ATery Ioav. Kennedy1 shoAved before the Dublin Pathological Society 5 fetuses Avith the involucra, the product of an abortion at the third month. At Naples in 1839 Giuseppa Califani gave birth to 5 children; and about the same time Paddock reported the birth in Franklin County, Pa., of quintuplets. The Lancet J relates an account of the birth of quintuplets, 2 boys and 3 girls, by the Avife of a peasant on ISIarch 1, 1854. Moffittk records the a 538, 1867. b 629, 1787, 344. c 374, Oct. 5, 1736. d 618, L. xxv., chap, iii., 54. e 302, iv., 183. f 302, xix., 389. 8 618.1014. h371, T. ii., 1827. i 476, 1837, 743. J 476, 1857, ii., 259. k 545, 1881. QUINTUPLETS. 151 birth at Monticello, 111., of quintuplets. The Avoman was thirty-five years of age ; examination shoAved a breech presentation ; the second child was born by a foot-presentation, as Avas the third, but the last Avas bv a head- presentation. The combined weight Avas something over 19 pounds, and of the 5, 3 Avere still-born, and the other 2 died soon after birth. The Elgin Courant (Scotland), 1858, speaks of a Avoman named Elspet Gordon, at Rothes, giving birth to 3 males and 2 females. Although they were six months' births, the boys all lived until the folloAving morning. The girls Avere still-born. One of the boys had tAvo front teeth when born. Dr. DaAvson of Rothes is the obstetrician mentioned in this case. The folloAving recent instance is given Avith full details to illustrate the difficulties attending the births of quintuplets. Stoker a has reported the case of a healthy Avoman, thirty-five years old, 5 feet 1 inch high, and of slight build, Avhom he delivered of 5 fetuses in the seventh month of pregnancy, none of the children surviving. The patient's mother had on two occasions given birth to twins. The Avoman herself had been married for six years and had borne 4 children at full term, having no difficulty in labor. When she came under observation she computed that she had been pregnant for six months, and had had her attention attracted to the unusually large size of her abdomen. She complained of fixed pain in the left side of the abdomen, on which side she thought she was larger. Pains set in with regularity and the labor lasted eight and three-quarter hours. After the rupture of the membranes the first child presented by the shoulder. Version Avas readily performed ; the child Avas dead (recently). Examination after the birth of the first child disclosed the existence of more than one remaining fetus. The membranes protruded and became tense Avith each contraction. The presentation was a transverse one. In this case also there Avas little difficulty in effecting internal version. The child lived a couple of hours. The third fetus Avas also enclosed in a separate sac, Avhich had to be ruptured. The child presented by the breech and was delivered naturally, and liAred for an hour. In the fourth case the membranes had likewise to be ruptured, and alarming hemorrhage ensued. ATersion Avas at once practised, but the chin became locked Avith that of the remaining fetus. There Avas some difficulty and considerable delay in freeing the children, though the extent of locking AAas not at any time formidable. The child AA'as dead (recently). The fifth fetus presented by the head and Avas delivered naturally. It liA'ed for half an hour. The placenta Avas deliA'ered about fiA'e minutes after the birth of the last child, and consisted of t\A'o portions united by a narroAV isthmus. One, the smaller, had two cords attached centrally and close together; the other, and larger, had tAvo cords attached in a similar Avay and one Avhere it AA'as joined to the isthmus. The organ appeared to be perfectly healthy. The cord of the fourth child Avas so short that it had to be ligated in the vagina. The a 476, 1895, ii., 1164. 152 PROLIFICITY. children Avere all females and of about the same size, making a total Avcight of 8 pounds. The mother rallied quickly and got on avcII. Trustworthy records of sextuplets are, of course, extremely scarce. There are feAV catalogued at Washington, and but tAvo authentic cases are on record in the United States. On December 30, 1831,3G8 a Avoman in Dropin Avas delivered of 6 daughters, all living, and only a little smaller than usual in size. The mother A\as not quite tAventy years old, but Avas of strong constitution. The 6 lived long enough to be baptized, but died the evening of their births. There Avas a case a of sextuplets in Italy in 1844. In Maine, June 27, 1847, a Avoman Avas delivered of 6 children, 2 sur- viving and, together Avith the mother, doing well.b In 1885 there Avas reported the birth of sextuplets in Lorca, Spain, of Avhich only one survived. c At Dallas, Texas, in 1888,d Mrs. George Hirsh of Navarro County gave birth to 6 children, the mother and the children all doing well. There Avere 4 boys and 2 girls, and they Avere all perfect, avcII formed, but rather small. Valsallie gives an instance Avhich is quoted by the Medical NeAvsf Avithout giving the authority. Valsalli's account, Avhich differs slightly from the account in the Medical News, is briefly as follows : AVhile straining at stool on the one hundred and fifteenth day of pregnancy the membranes ruptured and a foot prolapsed, no pain having been felt before the accident. A fetus was delivered by the midwife. Valsalli Avas summoned and found the woman with an enormously distended abdomen, Avithin AA'hich Avere felt numerous fetal parts ; but no fetal heart-sounds or movements were noticed. The cervix Avas only slightly dilated, and, as no pains were felt, it was agreed to Avait. On the next day the membranes Avere ruptured and 4 more fetuses Avere deliA- ered. Traction on the umbilical cord started hemorrhage, to check which the physician placed his hand in the uterine cavity. In this most arduous posi- tion he remained four hours until assistance from Lugano came. Then, in the presence of the three A'isiting physicians, a sixth amniotic sac was deliv- ered Avith its fetus. The Avoman had a normal convalescence, and in the fol- lowing year gaA'e birth to healthy, liAdng twins. The Ncavs says the chil- dren all moved vigorously at birth ; there were 4 males and 2 females, and for the 6 there was only one placenta. The mother, according to the same authority, Avas thirty-six years of age, and Avas in her second pregnancy. Multiple Births over Six.—When Ave pass sextuplets the records of multiple births are of the greatest rarity and in modern records there are almost none. There are several cases mentioned by the older writers AA'hose statements are generally Avorthy of credence, which, hoAveA'er incredible, are of sufficient interest at least to find a place in this chapter. Albucasis affirms that he knew of the birth of seven children at one time ; and d'Alechampius reports that Bonaventura, the slave of one SaATelli, a gentleman of Siena, gave a 152, 1S44, 343. b 218, 1847. c 373, 1885. d 450, Nov. 17, 1888. e 360, 1888. f 533, March 23, 1895. MULTIPLE BIRTHS OVER SIX. 153 birth to 7 children, 4 of whom Avere baptized. At the Parish of San Ildefonso, Valladolid, Julianna, wife of Benito Quesada, gave birth to 3 children in one day, and during the folloAving night to 4 more.a Sigebert, in his Chronicles, says that the mother of the King of Lombardy had borne 7 children at a birth. Borellus b says that in 1650 the lady of the then present Lord Darre gave birth to eight perfect children at one parturition and that it Avas the unusual event of the country. Mrs. Timothy Bradlee of Trumbull County, Ohio, in 1872 is reported to have given birth to 8 children at one time.c They Avere healthy and living, but quite small. The mother Avas married six years previously and then Aveighed 273 pounds. She had given birth to 2 pairs of twins, and, with these 3 boys and 5 girls, she had borne 12 children in six years. She herself Avas a triplet and her father and her mother Avere of twin births and one of her grandmothers Avas the mother of 5 pairs of twins. This case was most celebrated and Avas much quoted, seA'eral British journals extracting it. Watering of Maregnacd speaks of the simultaneous birth of 8 children at one time. When seAeral months preg- nant the woman Avas seized Avith colicky pains and thought them a call of nature. She Avent into a A'ineyard to ansAver it, and there, to her great astonishment, gave birth to 8 fetuses. Watering found them enclosed in a sac, and thought they probably had died from mutual pressure during groAvth. The mother made a good reCOA'Ciy. Fig 23.-Pregnancy with 11 fetuses (after Par6). Iii 1755 Seignette of Dijon e reports the simultaneous birth of nine children. Franciscus Picus Mirandulse, quoted by Pare, says that one Dorothea, an Italian, bore 20 children at 2 confinements, the first time bearing 9 and the second time eleven. He giATes a picture of this marArel of prolificity, in Avhich her belly is represented as hanging doAvn to her knees, and supported by a girdle from the neck (Fig. 23). In the Annals, History, and Guide to Leeds and York, according to Walford,813 there is mention of Ann Birch, avIio in 1781 AA'as delivered a 373, Nov. 22, 1S8."> : quoted by 476, 1885, ii., 1125 ; and several other authorities. b Observ., cent, ii., Paris, 1656. c 218, Sept. 26, 1872. d349, June, 1880. e 280, 1755, i., 300. 154 PROLIFICITY. of 10 children. One daughter, the sole survivor of the 10, married a market gardener named Piatt, Avho Avas avcII knoAvn in Leeds. Jonston447 quotes Baytraff as saying that he kneAV of a case in Avhich 9 children Avere born simultaneously; and also says that the Countess of Altdorf gave birth to twelve at one birth. Albucasis mentions a case of fifteen Avell-formed children at a birth. According to Le Brun,a Gillcs de Trazegincs, avIio accompanied Saint Louis to Palestine, and Avho Avas made Constable of France, Avas one of thirteen infants at a simultaneous accouchement. The Marquise, his mother, Avas impregnated by her husband before his departure, and during his absence had 13 living children. She Avas suspected by the native people and thought to be an adulteress, and some of the children were supposed to be the result of superfetation. They condemned them all to be droAvned, but the Marquis appeared upon the scene about this time and, moA'ed by compassion, acknoAvledged all 13. They grew up and thriA'ed, and took the name of Trazegincs, meaning, in the old language, 13 droAvned, although many commentaries say that "gines" Avas supposed to mean in the twelfth century " ncs," or, in full, the interpretation Avould be "13 born." Cases in Avhich there is a repetition of multiple births are quite numer- ous, and sometimes so often repeated as to produce a family the size of Avhich is almost incredible. Aristotle is credited with sayingb that he kneAV the history of a Avoman who had quintuplets four times. Pliny's case of quin- tuplets four times repeated has been mentioned ; and Pare,618 who may be believed Avhen he quotes from his own experience, says that the wife of the last Lord de Maldemeure, Avho lived in the Parish of Seaux, was a marvel of prolificity. Within a year after her marriage she gaA^e birth to tAvins; in the next year to triplets ; in the third year to quadruplets ; in the fourth year to quintuplets, and in the fifth year bore sextuplets ; in this last labor she died. The then present Lord de Maldemeure, he says, Avas one of the final sextuplets. This case attracted great notice at the time, as the family was quite noble and very well knoAvn. Seaux, their home, was near Chambellay. Picus Mirandulse gathered from the ancient Egyptian inscriptions that the women of Egypt brought forth sometimes 8 children at a birth, and that one Avoman bore 30 children in 4 confinements. He also cites, from the history of a certain Bishop of Necomus, that a Avoman named Antonia, in the Territory of Mutina, Italy, noAV called Modena, had brought forth 40 sons before she Avas forty years of age, and that she had had 3 and 4 at a birth. At the auction of the San Donato collection of pictures a portrait of Dianora Frescobaldi, by one of the Bronzinos in the sixteenth century, sold for about §3000. At the bottom of this portrait AAas an inscription stating that she was the mother of 52 children. This remarkable Avoman never had less than 3 at a birth, and tradition giA'es her as many as 6. Merrimanc quotes a case of a woman, a shopkeeper named Blunet, Avho a 302, iv., 183. b 302, xix., 389. c 374, Sept., 1783, iii., 753. REPETITION OF MULTIPLE BIRTHS. 155 had 21 children in 7 successive births. They Avere all born alive, and 12 still survived and Avere healthy. As though to settle the question as to Avhom should be given the credit in this case, the father or the mother, the father experimented upon a female servant, Avho, notAvithstanding her youth and delicateness, gave birth to 3 male children that lived three weeks. According to despatches from Lafayette, Indiana, investigation folioAving the murder, on December 22, 1895, of Hester Curtis, an aged Avoman of that city, developed the rather remarkable fact that she had been the mother of 25 children, including 7 pairs of tAvins. According to a French authority the wife of a medical man at Fuente- major, in Spain, forty-three years of age, a was delivered of triplets 13 times. Puech read a paper before the French Academy in which he re- ports 1262 tAvin births in Nimes from 1790 to 1875, and states that of the Avhole number in 48 cases the twins Avere duplicated, and in 2 cases thrice repeated, and in one case 4 times repeated. Warrenb gives an instance of a lady, Mrs. M-----, thirty-two years of age, married at fourteen, who, after the death of her first child, bore twins, one living a month and the other six Aveeks. Later she again bore tAvins, both of whom died. She then miscarried with triplets, and afterAvard gave birth to 12 living children, as folloAvs : July 24, 1858, 1 child; June 30, 1859, 2 children; March 24, 1860, 2 children; March 1, 1861, 3 children; February 13, 1862, 4 children ; making a total of 21 children in eighteen years, Avith remarkable prolificity in the later pregnancies. She Avas never confined to her bed more than three days, and the children Avere all healthy. A Avoman in Schlossberg, Germany, gave birth to twins ; after a year, to triplets, and again, in another year, to 3 fairly strong boys.c In the State Papers, Domestic Series, Charles I., according to Walford,813 appears an extract from a letter from George Garrard to Viscount CoiiAvay, Avhich is as folloAvs : " Sir John Melton, Avho entertained you at York, hath buried his Avife, Curran's daughter. Within twelve months she brought him 4 sons and a daughter, 2 sons last summer, and at this birth 2 more and a daughter, all alive." SAvand mentions a Avoman Avho gave birth to 6 to " . children in seventeen months in 2 triple pregnancies. The first terminated prematurely, 2 children dying at once, the other in five Aveeks. The sec- ond Avas uneventful, the 3 children living at the time of the report. Rockwell e gives the report of a case of a Avoman of twenty-eight, herself a tAvin, who gave birth to twins in January, 1879. They died after a few weeks, and in March, 1880, she again bore twins, one living three and the other nine weeks. On March 12, 1881, she gave birth to triplets. The first child, a male, Aveighed 7 pounds ; the second, a female, 6£ pounds ; the a 365 Oct, 1, 1863. b 218, 1862, 331. c 224, 1*7*. ii., 767. fl 512, March, 1893. e 612» Columbus, 1881. 156 PROLIFICITY. third, a male, 5J pounds. The third child lived twenty days, the other two died of cholera infantum at the sixth month, attributable to the bottle-feed- ing. Banerjeea gives the history of a case of a woman of thirty being de- livered of her fourth pair of tAvins. Her mother was dead, but she had 3 sisters liATing, of one of Avhich she Avas a twin, and the other 2 avc re tAvins. One of her sisters had 2 twin terms, 1 child surviving; like her own children, all Avere females. A second sister had a tAvin term, both males, 1 surviving. The other sister aborted female tAvins after a fall in the eighth month of pregnancy. The name of the patient AAas Mussamat Somni, and she Avas the AArife of a respectable Indian carpenter. There are recorded the most Avonderful accounts of prolificity, in Avhich, by repeated multiple births, a Avoman is said to have borne children almost beyond belief. A Naples correspondent to a Paris Journalb giAres the folloAving: "About 2 or 3 stations beyond Pompeii, in the City of Nocera, lives Maddalena Granata, aged forty-seven, Avho Avas married at twenty-eight, and has giAren birth to 52 living and dead children, 49 being males. Dr. de Sanctis, of Nocera, states that she has had triplets 15 times." Peasant KiriloAv c Avas presented to the Empress of Russia in 1853, at the age of seA^enty years. He had been tAvice married, and his first Avife had presented him Avith 57 children, the fruits of 21 pregnancies. She had quad- ruplets four times, triplets seven times, and twins thrice. By his second Avife he had 15 children, twins six times, and triplets once. This man, accordingly, Avas the father of 72 children, and, to magnify the Avonder, all the children were alive at the time of presentation. Herman, in some Russian statistics, d relates the instance of Fedor Vassilet, a peasant of the Moscow Jurisdiction, avIio in 1872, at the age of seventy-five years, Avas the father of 87 children. He had been tAvice married ; his first Avife bore him 69 children in 27 accouche- ments, haA'ing tAvins sixteen times, triplets seven times, and quadruplets four times, but never a single birth. His second wife bore him 18 children in 8 accouchcments. In 1872, 83 of the 87 children were living. The author says this case is beyond all question, as the Imperial Academy of St. Petersburg, as well as the French Academy, have substantial proof of it. The family are still living in Russia, and are the object of governmental favors. The following fact is interesting from the point of exaggeration, if for nothing else : " The NeAV York Medical Journal is accredited Avith publishing the folloAving extract from the history of a journey to Saragossa, Barcelona, and Valencia, in the year 1585, by Philip II. of Spain. The book was written by Henrique Cock, who accompanied Philip as his private secretary. On page 248 the folloAving statements are to be found : At the age of eleven years, Margarita Goncalez, Avhose father was a Biscayian, and whose mother Avas French, Avas married to her first husband, AA'ho Avas forty years a 540, June 1, 1894. b Quoted by 536, 1886, i., 57. c 476, 1857, ii., 259. d 476, 187*, i., 289. EXTREME PROLIFICITY BY SINGLE BIRTHS. 157 old. By him she had 78 boys and 7 girls. He died thirteen years after the marriage, and, after having remained a widoAV two years, the Avoman married again. By her second husband, Thomas Gchoa, she had 66 boys and 7 girls. These children Avere all born in Valencia, betAveen the fifteenth and thirty- fifth year of the mother's age, and at the time Avhen the account Avas Avritten she Avas thirty-five years old and pregnant again. Of the children, 47 by the first husband and 52 by the second Avere baptized ; the other births Avere still or premature. There Avere 33 confinements in all." Extreme Prolificity by Single Births.—The number of children a woman may bring forth is therefore not to be accurately stated; there seems to be almost no limit to it, and eATen Avhen Ave exclude those cases in Avhich remarkable multiplicity at each birth augments the number, there are still some almost incredible cases on record. The statistics of the St. Pancras Royal Dispensary, 1853, estimated the number of children one woman may bear as from 25 to 69. Eisenmenger relates the history of a case of a Avoman in the last century bearing 51 children, and there is another casea in Avhich a Avoman bore 44 children, all boys. Atkinson b speaks of a lady married at sixteen, dying Avhen she Avas sixty-four, avIio had borne 39 children, all at single births, by one husband, Avhom she surviA'ed. The children, 32 daughters and 7 sons, all attained their majority. There was a case of a Avoman in America0 Avho in twenty-six years gave birth to 22 children, all at single births. Thoresby in his "History of Leeds," 1715, mentions three remarkable cases—one the wife of Dr. Phineas Hudson, Chancellor of York, as having died in her thirty-ninth year of her twenty-fourth child ; another of Mrs. Joseph Cooper, as dying of her twenty-sixth child, and, lastly, of Mrs. William Greenhill, of a village in Hertford, England, avIio gaA'e birth to 39 children during her life. Brand, a Avriter of great repute, in his " History of NeAvcastle," quoted by Walford,813 mentions as a Avell attested fact the Avife of a Scotch weaver Avho bore 62 children by one husband, all of Avhom liA^ed to be baptized. A curious epitaph is to be seen at Comvay, Carnarvonshire :— "Here lieth the body of Nicholas Hookes, of Conway, gentleman, who was one-and-fortieth child of his father, William Hookes, Esq., by Alice, his wife, and the father of 27 children. He died 20th of March, 1637." On November 21, 1768, Mrs. Shury, the Avife of a cooper, in Vine Street, Westminster, Avas deliATered of 2 boys, making 26 by the same hus- band. She had preA7iously been confined Avith twins during the year. It Avould be the task of a mathematician to figure the possibilities of paternity in a man of extra long life Avho had married several prolific Avomen during his prolonged period of virility. A man by the name of Pearsons of Lexton, Nottingham, at the time of the report had been married 4 times. By his first 3 wives he had 39 children and by his last 14, making a a 559, 1806, 1 B., 127. b 224, 1883, ii., 557. c 218, Sept. 26, 1872. 158 PROLIFICITY. total of 53. He was 6 feet tall and lived to his ninety-sixth year. We have already mentioned the tAvo Russian cases in Avhich the paternity Avas 72 and 87 children respectively, and in "Notes and Queries," June 21, 1S56, there is an account of David Wilson of Madison, Ind., Avho had died a feAV years previously at the age of one hundred and seven. He had been 5 times mar- ried and Avas the father of 47 children, 35 of Avhom were living at the time of his death. On a tomb in Ely, Cambridgeshire, there is an inscription saying that Richard Worster, buried there, died on May 11, 1856, the tomb being in memory of his 22 sons and 5 daughters. Artaxerxes Avas supposed to have had 106 children; Conrad, Duke of Moscow, 80 ; and in the polygamous countries the number seems incredible. Herotinus Avas said a to haA'e had 600 ; and Jonston also quotes instances of 225 and even of 650 in the Eastern countries. Recently there haA'e been published accounts of the alleged experiments of Luigi Erba, an Italian gentleman of Perugia, Avhose results haAre been an- nounced. About forty years of age and being quite wealthy, this bizarre philanthropist \Tisited Ararious quarters of the world, securing Avomen of differ- ent races; having secured a number sufficient for his purposes, he retired Avith them to Polynesia, where he is accredited Avith maintaining a unique establishment Avith his household of females. In 1896, just seven years after the experiment commenced, the reports say he is the father of 370 children. The folloAving is a report from Raleigh, N. O, on July 28, 1893, to the Ncav York Evening Post:— " The fecundity of the negro race has been the subject of much comment and discussion. A case has come to light in this State that is one of the most remarkable on record. Moses Williams, a negro farmer, lives in the eastern section of this State. He is sixty-five years old (as nearly as he can make out), but does not appear to be OArer fifty. He has been married twice, and by the tAvo Avives has had born to him 45 children. By the first Avife he had 23 children, 20 of Avhom were girls and 3 Avere boys. By the second Avife he had 22 children—20 girls and 2 boys. He also has about 50 grand- children. The case is Avell authenticated." We also quote the following, accredited to the " Annals of Hygiene : "— " Were it not part of the records of the Berks County courts, we could hardly credit the history of John Heffner, who was accidentally killed some years ago at the age of sixty-nine. He was married first in 1840. In eight years his wife bore him 17 children. The first and second years of their marriage she gave birth to tAvins. For four successive years afterAvard she gave birth to triplets. In the seventh year she gave birth to one child and died soon afterAvard. Heffner engaged a young AAroman to look after his large brood of babies, and three months later she became the second Mrs. Heffner. She a 447, 466. POSSIBLE DESCENDANTS. 159 presented her husband Avith 2 children in the first two years of her Avedded life. Five years later she had added 10 more to the family, having twins 5 times. Then for three years she added but 1 a year. At the time of the death of the second Avife 12 of the 32 children had died. The 20 that Avere left.,did not appear to be any obstacle to a young Avidow Avith one child con- senting to become the third wife of the jolly little man, for he Avas knoAvn as one of the happiest and most genial of men, although it kept him toiling like a slave to keep a score of mouths in bread. The third Mrs. Heffner became the mother of 9 children in ten years, and the contentment and happiness of the couple Avere proverbial. One day, in the fall of 1885, the father of the 41 children Avas crossing a railroad track and Avas run doAvn by a locomotive and instantly killed. His widoAv and 24 of the 42 children are still living." Many Marriages.—In this connection it seems appropriate to mention a feAV examples of multimarriages on record, to give an idea of the possibilities of the extent of paternity. St. Jerome mentions a AvidoAv avIio married her tAventy- second husband, Avho in his time had taken to himself 20 lo\Ting spouses. A gentleman living in Bordeaux184 in 1772 had been married 16 times. DeLongueville, a Frenchman, lived to be one hundred and ten years old, and had been joined in matrimony to 10 wives, his last Avife bearing him a son in his one hundred and first year. Possible Descendants.—When we indulge ourselves as to the possible number of living descendants one person may have, we soon get extraordinary figures. The Madrid Estafette a states that a gentleman, Seiior Lucas Ne- queiras Saez, who emigrated to America seAenty years previously, recently returned to Spain in his OAvn steamer, and brought Avith him his whole family, consisting of 197 persons. He had been thrice married, and by his first Avife had 11 children at 7 births; by his second wife, 19 at 13 births, and by his third Avife, 7 at 6 births. The youngest of the 37 Avas thirteen years old and the eldest seventy. This latter one had a son aged forty-seven and 16 children besides. He had 34 granddaughters, 45 grandsons, 45 great granddaughters, 39 great grandsons, all liA'ing. Seiior Saez himself was ninety-three years old and in excellent health. At Litchfield, Conn., there is said to be the following inscription:487— "Here lies the body of Mrs. Mary, wife of Dr. John Bull, Esq. She died November 4, 1778, aetat. ninety, having had 13 children, 101 grandchil- dren, 274 great grandchildren, and 22 great-great grandchildren, a total of 410; surviving, 336." In Esher Church there is an inscription, scarcely legible, Avhich records the death of the mother of Mrs. Mary Morton on April 18, 1634, and saying that she Avas the Avonder of her sex and age, for she lived to see nearly 400 issued from her loins. a 224, 1883, ii., 207. 160 PROLIFICITY. The folloAving is a communication to " Notes and Queries," March 21, 1891 : " Mrs. Mary HonevAvood Avas daughter and one of the coheiresses of Robert AVatcrs, Esq., of Lenham, in Kent. She Avas born in 1527 ; married in February, 1543, at sixteen years of age, to her only husband, Robert HoneyAYOod, Esq., of Charing, in Kent. She died in the ninety-third year of her age, in May, 1620. She had 16 children of her oavu body, 7 sons and 9 daughters, of Avhom one had no issue, 3 died young—the young- est Avas slain at NeAvport battle, June 20, 1600. Her grandchildren, in the second generation, Avere 114 ; in the third, 228, and in the fourth, 9 ; so that she could almost say the same as the distich doth of one of the Dalburg family of Basil: 'Rise up, daughter, and go to thy daughter, for thy daugh- ter's daughter hath a daughter.' " In Markshal Church, in Essex, on Airs. HoneyAvood's tomb is the follow- ing inscription : ' Here lieth the body of Mary Maters, the daughter and co- heir of Robert Waters, of Lenham, in Kent, Avife of Robert Honey wood, of Charing, in Kent, her only husband, Avho had at her decease, huvfully de- scended from her, 367 children, 16 of her OAvn body, 114 grandchildren, 228 in the third generation, and 9 in the fourth. She lived a most pious life and died at Markshal, in the ninety-third year of her age and the forty-fourth of her widowhood, May 11, 1620.' (From 'Curiosities for the Ingenious,' 1825.) S. S. R." Animal prolificity, though not finding a place in this Avork, presents some wonderful anomalies.3 a In illustration we may note the following : In the Illustrated London News, May 11, 1895, is a portrait of "Lady Millard," a fine St. Bernard bitch, the property of Mr. Thorp of Northwold, with her litter of 21 puppies, born on February 9, 1895, their sire being a magnificent dog—"Young York." There is quoted an incredible account1 of a cow, the property of J. N. Sawyer of Ohio, which gave birth to 56 calves, one of which was fully matured and lived, the others being about the size of kittens ; these died, together with the mother. There was a cow in France, in 1871, delivered of 5 calves. * 609, 1879, i., 525. CHAPTER V. MAJOR TERATA. Monstrosities have attracted notice from the earliest time, and many of the ancient philosophers made references to them. In mythology Ave read of Centaurs, impossible beings Avho had the body and extremities of a beast; the Cyclops, possessed of one enormous eye ; or their parallels in Egyptian myths, the men with pectoral eyes,—the creatures " Avhose heads do beneath their shoulders grow;" and the Fauns, those sylvan deities whose loAver extremities bore resemblance to those of a goat. Monsters possessed of two or more heads or double bodies are found in the legends and fairy tales of every nation. Hippocrates, his precursors, Empedocles and Demo- critus, and Pliny, Aristotle, and Galen, have all described monsters, although in extravagant and ridiculous language. Ballantyne remarks that the occasional occurrence of double monsters was a fact knoAvn to the Hippocratic school, and is indicated by a passage in De morbis muliebribus, in Avhich it is said that labor is gravely interfered with when the infant is dead or apoplectic or double. There is also a reference to monochorionic tAvins (Avhich are by modern teratologists regarded as mon- strosities) in the treatise De Superfaiatione, in Avhich it is stated that " a Avoman, pregnant Avith tAvins, gives birth to them both at the same time, just as she has conceived them ; the two infants are in a single chorion." Ancient Explanations of Monstrosities.—From the time of Galen to the sixteenth century many incredible reports of monsters are seen in medical literature, but Avithout a semblance of scientific truth. There has been little improvement in the mode of explanation of monstrous births until the present century, Avhile in the Middle Ages the superstitions Avere more ludicrous and observers more ignorant than before the time of Galen. In his able article on the teratologic records of Chaldea, Ballantynea makes the following trite statements : " Credulity and superstition have never been the peculiar pos- session of the loAver types of ciATilization only, and the special beliefs that haA'e gathered round the occurrence of teratologic phenomena haAre been common to the cultured Greek and Roman of the past, the ignorant peasant of modern times, and the savage tribes of all ages. Classical Avritings, the literature of the Middle Ages, and the popular beliefs of the present day all contain vieAvs a 759. 1891, 130. 11 161 162 MAJOR TERATA. concerning teratologic subjects Avhich so closely resemble those of the Chal- dean magi as to be indistinguishable from them. Indeed, such works as those of Obsequens, Lycosthenes, Licetus, and Ambroise Pare only repeat, but Avith less accuracy of description and Avith greater freedom of imagina- tion, the beliefs of ancient Babylon. Even at the present time the most impossible cases of so-called ' maternal impressions' are Avidely scattered through medical literature; and it is not A'ery long since I received a letter from a distinguished member of the profession asking me Avhether, in my opinion, I thought it possible for a Avoman to give birth to a dog. Of course, I do not at all mean to infer that teratology has not made immense advances within recent times, nor do I suggest that on such subjects the knoAvledge of the magi can be compared with that of the aAerage medical student of the present; but Avhat I wish to emphasize is that, in the literature of ancient Babylonia, there are indications of an acquaintance with structural defects and malformations of the human body which will compare favorably Avith even the writings of the sixteenth century of the Christian era." Many reasons Avere given for the exist- ence of monsters, and in the Middle Ages these Avere as faulty as the descriptions themselves. They Avere interpreted as divi- nations, and Avere cited as forebodings and examples of Avrath, or eA'en as glorifica- tions of the Almighty. The semi-human creatures were invented or imagined, and cited as the results of bestiality and allied forms of sexual perversion prevalent in those times. We find minute descriptions and portraits of these impossible results of wicked practices in many of the older medical books. According to Parea there Avas born in 1493, as the result of illicit intercourse between a Avoman and a dog, a creature resembling in its upper extremities its mother, while its lower extremities Avere the exact counterpart of its canine father (Fig. 24). This particular case was believed by Bateman and others to be a precursor to the murders and Avickedness that followed in the time of Pope Alexander I. Yolateranus, Cardani, and many others cite instances of this kind. Lycosthenes says that in the year 1110, in the bourg of Liege, there Avas found a creature Avith the head, visage, hands, and feet of a man, and the rest of the body like that of a pig. Pare quotes this case and gives an illustration. Rhodiginusb mentions a shepherd of Cybare by the name of Cratain, who had connection with a female goat and a 618, 1031. b 679, L. xxv., chap. 32. Fig. 24.—Dog-boy (after Par6). ANCIENT EXPLANATIONS OF MONSTROSITIES. 163 impregnated her, so that she brought forth a beast with a head resembling that of the father, but Avith the lower extremities of a goat. He says that the likeness to the father Avas so marked that the head-goat of the herd recog- nized it, and accordingly sleAV the goatherd Avho had sinned so unnaturally. In the year 1547, at CracoA'ia,191 a very strange monster AAas born, which lived three days. It had a head shaped like that of a man; a nose long and hooked like an elephant's trunk; the hands and feet looking like the web-foot of a goose; and a tail Avith a hook on it. It Avas supposed to be a male, and Avas looked upon as a result of sodomy. Rueffa says that the pro- creation of human beings and beasts is brought about — (1) By the natural appetite ; (2) By the provocation of nature by delight; (3) By the attractive virtue of the matrix, which in beasts and women is alike. Plutarch, in his " Lesser Parallels," says that Aristonymus Ephesius, son of Demonstratus, being tired of Avomen, had carnal knowledge with an ass, which in the process of time brought forth a very beautiful child, avIio became the maid Onoscelin. He also speaks of the origin of the maiden Hippona, or as he calls her, Hippo, as being from the connection of a man with a mare. Aristotle mentions this in his paradoxes, and we know that the patron of horses Avas Hippona. In Helvetiam was reported the exist- ence of a colt (whose mother had been covered by a bull) that was half horse and half bull. One of the kings of France was supposed to have been presented Avith a colt with the hinder part of a hart, and which could out- run any horse in the kingdom. Its mother had been covered by a hart. Writing in 1557, Lycosthenes reports the mythical birth of a serpent by a woman. It is quite possible that some known and classified type of monstrosity Avas indicated here in A'ague terms. In 1726 Mary Toft, of Godalming, in Surrey, England, achieved considerable notoriety throughout Surrey, and even over all England, by her extensively circulated statements that she bore rabbits. Even at so late a day as this the credulity of the people Avas so great that many persons believed in her. The woman Avas closely AA'atched, and being detected in her maneuA'ers confessed her fraud. To show the extent of discussion this case called forth, there are no less than nine pamphlets and books in the Surgeon-General's library at Wash- ington devoted exclusively to this case of pretended rabbit-breeding. Hamilton in 1848, and Hardb in 1884, both report the births in this country of fetal monstrosities Avith heads which showed marked resemblance to those of dogs. Doubtless many of the older cases of the supposed results of bestiality, if seen to-day, could be readily classified among some of our known forms of monsters. Modern investigation has shown us the sterile results of the connections betAveen man and beast or betAveen beasts of a "The Expert Midwife," London, 1637. b 269, xlviii., 246. 164 MAJOR TERATA. different species, and avc can only Avonder at the simple credulity and the imaginative minds of our ancestors. At one period certain phenomena of nature, such as an eclipse or comet, Avere thought to exercise their influence on monstrous births. Rueff mentions that in Sicily there happened a great eclipse of the sun, and that Avomen immediately began to bring forth deformed and double-headed children. Before ending these preliminary remarks, there might be mentioned the marine monsters, such as mermaids, sea-serpents, and the like, Avhich from time to time have been reported ; even at the present day there are people who devoutly believe that they have seen horrible and impossible demons in the sea. Parea describes and pictures a monster, at Rome, on Novem- ber 3, 1520, with the upper portion of a child apparently about five or six years old, and the loAver part and ears of a fish- like animal. He also pictures a sea- devil in the same chapter, together Avith other gruesome examples of the poAver of imagination. Early Teratology.—Besides such cases as the foregoing, Ave find the medi- eval Avriters report likely instances of terata, as, for instance, Rhodiginus, 679 Avho speaks of a monster in Italy Avith two heads and two bodies; Lycosthenes saAV a double monster, both components of Avhich slept at the same time ; he also says this creature took its food and drink simultaneously in its two mouths. Even Saint Augustine says that he knew of a child born in the Orient Avho, from the belly up, Avas in all parts double. The first evidences of a step toAvard classification and definite reasoning in regard to the causation of monstrosities Avere evinced by Ambroise Pare in the sixteenth century, and though his ideas are crude and some of his phenomena impossible, yet many of his facts and arguments are worthy of consideration. Pare attributed the cause of anomalies of excess to an excessive quantity of semen, and anomalies of default to deficiency of the same fluid. He has collected many instances of double terata from reliable sources, but has intersjiersed his collection Avith accounts of some hideous and impossible creatures, such as are illustrated in the accompanying figure (Fig. 25), Avhich sIioavs a creature that Avas born shortly after a battle of a 618, 1053. Fig. 25.—Bird-boy (after Par6j. SCIENTIFIC TERA TOL OGY. 165 Louis XII., in 1512 ; it had the wings, crest, and loAver extremity of a bird and a human head and trunk ; besides, it Avas an hermaphrodite, and had an extra eye in the knee. Another illustration represents a monstrous head found in an egg, said to have been sent for examination to King Charles at Metz in 1569. It represented the face and visage of a man, with small living serpents taking the place of beard and hair. So credulous Avere people at this time that even a man so well informed as Pare believed in the pos- sibility of these last two, or at least represented them as facts. At this time were also reported double hermaphroditic terata, seemingly without latter- day analogues. Rhodiginus a speaks of a two-headed monster born in Ferrari, Italy, in 1540, well formed, and with tAvo sets of genitals, one male and the Fig. 26.—Bicephalic and hermaphroditic monster (after Par6). Fig. 27.—Double hermaphroditic monster (after Pare). other female (Fig. 26). Pare b gives a picture (Fig. 27) of twins, born near Heidelberg in 1486, which had double bodies joined back to back; one of the twins had the aspect of a female and the other of a male, though both had tAvo sets of genitals. Scientific Teratology.—About the first half of the eighteenth century what might be called the positive period of teratology begins. Following the advent of this era come Men-, Duverney, Winslow, Lemery, and Littre. In their works true and concise descriptions are given and violent attacks are made against the ancient beliefs and prejudices. From the beginning of the second half of the last century to the present time may be termed the scien- tific epoch of teratology. We can almost Avith a certainty start this era with a 679, L. xxiv., chap. 30. b 618, 1016. 166 MAJOR TERATA. the names of Haller, Morgagni, Geoffroy-Saint-Hilaire, and Meckel, Avho adduced the explanations asked for by Harvey and Wolff. From the appearance of the treatise by Geoffroy-Saint-Hilaire, teratology has made enormous strides, and is to-day Avell on the road to becoming a science. Hand in hand Avith embryology it has been the subject of much investiga- tion in this century, and to enumerate the workers of the present day who have helped to bring about scientific progress would be a task of many pages. Even in the artificial production of monsters much has been done, and a glance at the Avork of Dareste a Avell repays the trouble. Essays on terato- genesis, Avith reference to batrachians, have been offered by Lombardini ; and by Lereboullet and Knock Avith reference to fishes. Foil and AVarynskib have reported their success in obtaining visceral inversion, and even this branch of the subject promises to become scientific. Terata are seen in the lower animals and always excite interest. Pare0 gives the history of a sheep with three heads, born in 1577; the central head Avas larger than the other tAvo, as shoAvn in the accompanying illustration (Fig. 28). Many of the Museums of Natural History contain evidences of animal terata. At Hallee is a two-headed mouse; the Conant Museum in Maine contains the skele- ton of an adult sheep Avith two heads ; there Avas an account of a two-headed pigeon published in France in 1734 ;d Fig. 28.-Three-headed sheep (after Pare). Leidy found a two-headed snake in a field near Philadelphia; Geoffroy- Saint-Hilaire and Conant both found similar creatures, and there is one in the Museum at Harvard; Wyman saAV a living double-headed snake in the Jardin des Plantes in Paris in 1853, and many parallel instances are on record. Classification.—We shall attempt no scientific discussion of the causa- tion or embryologic demTation of the monster, contenting oursehTes Avith simple history and description, adding any associate facts of interest that may be suggested. For further information, the reader is referred to the authors cited or to any of the standard treatises on teratology. Many classifications of terata have been offered, and each possesses some advantage. The modern reader is referred to the modification of the group- ing of Geoffroy-Saint-Hilaire giATen by Hirst and Piersol417, or those of Blanc 212 and Guinard390. For convenience, Ave have adopted the following classification, which will include only those monsters that have lived after a Recherches sur la production artificielle des monstruosites, etc., Paris, 1894, 8°. b Recueil zoologique suisse, 1883. c 618, 1034. d Memoires de l'Acad. des Sciences. TRIPLE MONSTERS. 167 Class 1. Class 2_. Class 3. Class 4. Class 5. Class 6. Class 7. Class 8. Class 9. Class 10. Class 11. Class 12. birth, and who have attracted general notice or attained some fame in their time, as attested by accounts in contemporary literature. -Union of several fetuses. -Union of two distinct fetuses by a connecting band. -Union of two distinct fetuses by an osseous junction of the cranial bones. -Union of two distinct fetuses in which one or more parts are eliminated by the junction. -Fusion of two fetuses by a bony union of the ischii. -Fusion of two fetuses below the umbilicus into a common lower extremity. -Bicephalic monsters. -Parasitic monsters. -Monsters with a single body and double lower extremities. -Diphallic terata. -Fetus in fetu, and dermoid cysts. -Hermaphrodites. Class I.—Triple Monsters.—Haller and Meckel were of the opinion that no cases of triple monsters worthy of credence are on record, and since their time this has been the popular opinion. Surely none have ever lived. Licetus486 describes a human monster Avith two feet and seven heads and as many arms. Bartho- linus a speaks of a three-headed monster who after birth gave vent to horrible cries and expired. Borellus841 speaks of a three- headed dog, a veritable Cerberus. Blasius214 published an essay on triple monsters in 1677. Bordenave b is quoted as mention- ing a human monster formed of three fetuses, but his description proves clearly that it AAas only the union of two. Probably the best example of this anomaly that Ave haA'e AA'as described by Galvagni at Cattania in 1834. This monster had tAvo necks, on one of Avhich a\ as a single head normal in dimensions. On the other neck Avere tAvo heads, as seen in the accompanying illustration (Fig. 29). Geoffroy-Saint-Hilaire mentions several cases, and Martin de Pedro publishes a description of a case in Madrid in 1870. There are also on record some cases of triple monster by inclusion which Avill be spoken of later. Instances in the lower animals have been seen, the three-headed sheep of Par6, already spoken of, being one. Class II.—Double Monsters.—A curious mode of junction, probably the most interesting, as it admits of longer life in these monstrosities, is that of a simple cartilaginous band extending between tAvo absolutely distinct and a 190, cent, vi., obs. 49, 278. b 302, xxxiv., 158. Fig. 29. -Three-headed monster (Galvagni). 168 MAJOR TERATA. different individuals. The band is generally in the sternal region. In 1752374 there Avas described a remarkable monstrosity Avhich consisted of conjoined tAvins, a perfect and an imperfect child, connected at their ensiform cartilages by a band 4 inches in circumference. The Hindoo sisters, de- scribed by Dr. AndreAv Berry,* lived to be seven years old ; they stood face to face, Avith their chests 6J inches and their pubes 8 a inches apart. Mitchell b describes the full-groAvn female tAvins, born at NeAvport, Ivy., called the New- port twins. The woman Avho gave birth to them became impregnated, it is said, immediately after seeing the famous Siamese tAvins, and the products of this pregnancy took the conformation of those celebrated exhibitionists. Perhaps the best known of all double monsters Avere the Siamese twins. They Avere exhibited all over the globe and had the additional benefit and advertisement of a much- mooted discussion as to the advis- ability of their se\-erance, in which opinions of the leading medical men of all nations Avere advanced. The literature on these famous brothers is simply stupendous. The amount of material in the Surgeon-General's library at Washington Avould sur- prise an inA^estigator. A curious volume in this library is a book con- taining clippings, advertisements, and divers portraits of the twins. It will be impossible to speak at all fully on this subject, but a short history and running review of their lives will be Fig. 30.-Siamese twins at eighteen years of age. given : Eng and Chang AVere born in Siam about May, 1811. Their father Avas of Chinese extraction and had gone to Siam and there married a Avoman Avhose father Avas also a Chinaman. Hence, for the most part, they Avere of Chinese blood, Avhich probably accounted for their dark color and Chinese features. Their mother was about thirty-fiA-e years old at the time of their birth and had borne 4 female children prior to Chang and Eng. She afterward had twins several times, having eventually 14 children in all. She gave no history of special significance of the pregnancy, although she averred that the head of one and the feet of the other Avere born at the same time. The twins Avere both feeble at birth, and Eng continued delicate, Avhile Chang thrived. It Avas only aa ith difficulty that their lives were saved, a 776, 1821. b 818, 1832. SIAMESE TWINS. 169 as ChoAvpahvi, the reigning king, had a superstition that such freaks of nature alAvavs presaged e\'il to the country. They Avere really discoATered by Robert Hunter, a British merchant at Bangkok, Avho in 1824 saAV them boating and stripped to the Avaist. He prevailed on the parents and King CIioav- pahyi to alloAv them to go aAvay for exhibition. They Avere first taken out of the country by a certain Captain Coffin. The first scientific descrip- tion of them AA'as gi\Ten by Professor J. C. Warren, Avho examined them in Boston, at the Harvard University, in 1829. At that time Eng Avas 5 feet 2 inches and Chang 5 feet 1^ inches in height. They presented all Fig. 31.—Siamese twins in old age. the characteristics of Chinamen and wore long black queues coiled thrice around their heads, as shoAvn by the accompanying illustration (Fig. 30). A fter an eight-Aveeks' tour over the Eastern States they went to London, arriv- ing at that port November 20, 1829. Their tour in France Avas forbidden on the same grounds as the objection to the exhibition of Ritta-Christina, namely, the possibility of causing the production .of monsters by maternal impressions in pregnant Avomen. After their European tour they returned to the United States and settled doAvn as farmers in North Carolina, adopt- ing the name of Bunker. When forty-four years of age they married two sis- 170 MAJOR TERATA. ters, English Avomen, tAventy-six and tAventy-eight years of age, respectively. Domestic infelicity soon compelled them to keep the Avivcs at different houses, and they alternated Aveeks in visiting each Avife. Chang had six children and Eng five, all healthy and strong. In 1869 they made another trip to Europe, ostensibly to consult the most celebrated surgeons of Great Britain and France on the advisability of being separated. It Avas stated that a feeling of antagonistic hatred after a quarrel prompted them to seek " surgical sepa- ration," but the real cause Avas most likely to replenish their depicted exchequer by reneAved exhibition and advertisement. A most pathetic characteristic of these illustrious brothers Avas the affec- tion and forbearance they showed for each other until shortly before their death. They bore each other's trials and petty maladies with the greatest sympathy, and in this manner rendered their lives far more agreeable than a casual observer Avould suppose possible. They both became Christians and members or attendants of the Baptist Church. Figure 31 is a representation of the Siamese twins in old age. On each side of them is a son. The original photograph is in the Mutter Museum, College of Phy- sicians, Philadelphia. The feasibility of the operation of separating them AAras discussed by many of the leading men of America, and Thompson, Fergus- son, Syme, Sir J. Y. Simpson, Xelaton, and many others in Eu- rope, with various reports and opinions after examination. These opinions can be seen in full in nearly any large medical library. At this time they had diseased and atheromatous arteries, and Chang, Avho was quite intem- perate, had marked spinal curvature, and shortly afterward became hemi- plegic. They Avere both partially blind in their two anterior eyes, possibly from looking outAvard and obliquely. ^ The point of junction Avas about the sterno-xiphoid angle, a cartilaginous band extending from sternum to sternum. In 1869 Simpson measured this band and made the distance on the superior aspect from sternum to sternum 4£ inches, though it is most likely that during the early period of exhibition it Avas not over 3 inches. The illustration shoAVS very Avell the position of the joining band (Fig. 32). Fig. 32.—Diagram from a cast showing the position of the ligament and of the primary anterior incisions. Dur- ing life the twins never assumed the face-to-face position in which they are here represented, and which is without doubt that of their fetal life. "ORISSA SISTERS." 171 The twins died on January 17, 1874, and a committee of surgeons from the College of Physicians of Philadelphia, consisting of Doctors AndreAvs, Allen, and Pancoast, Avent to North Carolina to perform an autopsy on the body, and, if possible, to secure it. They made a long and most interesting report on the results of their trip to the College. The arteries, as Avas anticipated, were found to have undergone calcareous degeneration. There Avas an hepatic connection through the band, and also some interlacing diaphragmatic fibers therein. There was slight \rascular intercommunica- tion of the livers and independence of the two peritoneal cavities and the intestines (Fig. 33). The band itself Avas chiefly a coalescence of the xyphoid cartilages, surrounded by areolar tissue and skin (Fig. 34). The " Orissa sisters," or Radica-Doddica, shown in Europe in 1893, were similar to the Siamese twins in conformation. They Avere born in Fig. 34.—Diagrammatic representation of the band. A, upper or hepatic pouch of Chang; E, E (dotted line), union of the ensiform cartilages ; D, connecting liver band, or the "tract of portal con- tinuity ;" B, the peritoneal pouch of Eng; C, the lower peritoneal pouch of Chang; F, F, lower bor- der of the band. Orissa, India, September, 1889, and were the result of the sixth pregnancy, the other five being normal. They Avere healthy girls, four years of age, and apparentlv perfect in every respect, except that, from the ensiform cartilage to the umbilicus, they Avere united by a band 4 inches long and 2 inches Avide (Fig. 35). The children when facing each other could draw their chests three or four inches apart, and the band Avas so flexible that they could sit on either side of the body. Up to the date mentioned it was not knoAvn Avhether the connecting band contained viscera. A portrait of these twins Avas shown at the World's Fair in Chicago. In the village of Arasoor, district of BhaA'any, there Avas reported a mon- strosity in the form of two female children, one 34 inches and the other 33f inches high, connected by the sternum. They were said to have had small-pox and to have recovered. They seemed to have had individual ner- vous systems, as Avhen one Avas pinched the other did not feel it, and Avhile one slept the other Avas aAvake. There must have been some vascular connection, as medicine given to one affected both. Fig. 33.—Diagrammatic representation of the livers, portraying the relations of the vessels, etc. The arrows show the direction in which an injection passed from Chang to Eng. 172 MAJOR TERATA. Fig. 36 shoAvs a mode of cartilaginous junction by Avhich each component of a double monster may be virtually independent. Operations on Conjoined Twins.—Swinglera speaks of two girls joined at the xiphoid cartilage and the umbilicus, the band of union being l\ inches thick, and running beloAv the middle of it Avas the umbilical cord, common to both. They first ligated the cord, Avhich fell off in nine days, and then sepa- rated the tAvins Avith the bistoury. They each made early recovery and lived. In the Ephemerides of 1690 Konig gives a description of tA\o Swiss sisters born in 1689 and united belly to belly, who were separated by means Fig. 35.—Radica-Doddica, the " Orissa Sisters." Fig. 36.—Skeleton showing a mode of junction of independent double monsters. of a ligature and the operation afterAvard completed by an instrument. The constricting band Avas formed by a coalition of the xiphoid cartilages and the umbilical vessels, surrounded by areolar tissue and covered Avith skin. Le Beau b says that under the Roman reign, A. D. 945, tAvo male children were brought from Armenia to Constantinople for exhibition. They were Avell formed in every respect and united by their abdomens. After they had been for some time an object of great curiosity, they Avere removed by governmen- tal order, being considered a presage of evil. They returned, hoAvever, at a Quoted 302, vol. xxxiv. b Histoire du Bas-Empire, 1776. CRANIOPA GI 173 the commencement of the reign of Constantine VII., Avhen one of them took sick and died. The surgeons undertook to preserve the other by separating him from the corpse of his brother, but he died on the third day after the operation. In 1866 Boehma gives an account of Guzenhausen's case of twins Avho Avere united sternum to sternum. An operation for separation Avas per- formed Avithout accident, but one of the children, already very feeble, died three days after; the other survived. The last attempt at an oper- ation like this was in 1881, when Biaudet and Buginon attempted to separate conjoined sisters (Marie-Adele) born in SAvitzerland on June 26th. Unhappily, they Avere A'ery feeble and life was despaired of Avhen the opera- tion was performed, on October 29th. Adele died six hours afterward, and Marie died of peritonitis on the next day. Class III.—Those monsters joined by a fusion of some of the cranial bones are some- times called craniopagi. A very ancient obser- vation of this kind is cited by Geoffroy-Saint- Hilaire. These two girls Avere born in 1495, and lived to be ten years old. They were normal in every respect, except that they were joined at the forehead, causing them to stand face to face and belly to belly (Fig. 37). When one walked for- ward, the other was compelled to walk backAvard ; their noses almost touched, and their eyes Avere directed laterally. At the death of one an attempt to separate the other from the cadaver Avas made, but it Avas unsuccessful, the second soon dying; the operation necessitated opening the cranium and parting the meninges. Bateman 191 said that in 1501 there was living an instance of double female twins, joined at the forehead. This case was said to have been caused in the following manner: Tavo Avomen, one of Avhom Avas pregnant Avith the tAvins at the time, Avere engaged in an earnest conversation, AA'hen a third, coming up behind them, knocked their heads together Avith a sharp bloAV. Bateman describes the death of one of the tAvins and its excision from the other, avIio died subsequently, evidently of septic infection. There is a possibility that this is merely a duplication of the account of the preceding case with a slight anachronism as to the time of death. At a foundling hospital in St. Petersburg b there Avere born two living girls, in good health, joined by the heads. They Avere so united that the nose of one, if prolonged, Avould strike the ear of the other; they had perfectly independent existences, but their vascular systems had evident connection. a 161, 1866, 152. b 573, July, 1855. Fig. 37.—Craniopagus (after Par6). 174 MAJOR TERATA. Through extra mobility of their necks they could really lie in a straight line, one sleeping on the side and the other on the back. There is a reporta of two girls joined at their vertices, Avho survived their birth. With the excep- tion of this junction they Avere Avell formed and independent in existence. There AAas no communication of the cranial cavities, but simply fusion of the cranial bones covered by superficial fascia and skin (Fig. 38). Daubenton has seen a case of union at the occiput,b but further details are not quoted. Class IV.—The next class to be considered is that in Avhich the indi- viduals are separate and Avell formed, except that the point of fusion is a common part, eliminating their individual components in this location. The pygopagous twins belong in this section. According to Bateman,191 twins Avere born in 1493 at Rome joined back to back, and survived their birth. The same authority speaks of a female child Avho Avas born Avith " 2 bellies, 4 arms, 4 legs, 2 heads, and 2 sets of privates, and AAas exhibited throughout Italy for gain's sake." The " Biddenden Maids " were born in Bidden- den, Kent, in 1100.c Their names Avere Mary and Eliza Chulkhurst, and their parents Avere fairly Avell-to-do people. They were supposed to have been united at the hips and the shoulders, and lived until 1134. At the death of one it was proposed to separate them, but the remaining sister refused, saying, "As we came together, Ave will also go together," and, after about six hours of this Mezentian existence, they died. They bequeathed to the church-wardens of the parish and their successors land to the extent of 20 acres, at the present time bringing a rental of about $155.00 annually, with the instructions that the money was to be spent in the distribution of cakes (bearing the impression of their images, to be given aAvay on each Easter Sunday to all strangers in Biddenden) and also 270 quartern loaves, with cheese in proportion, to all the poor in said parish. Ballantyne has accompanied his description of these sisters by illustrations, one of Avhich shoAvs the cake (Fig. 39). Heatond gives a very good description of these maids; and a Avriter in "Notes and Queries" of March 27, 1875, gives the folloAving information relative to the bequest:— " On Easter Monday, at Biddenden, near Staplehurst, Kent, there is a distribution, according to ancient custom, of ' Biddenden Maids' cakes,' Avith bread and cheese, the cost of which is defrayed from the proceeds of some a 212, 259. b 302, xxxiv. c 759, Oct., 1895. d 224, 1869, i., 363. Fig. 38.—Twins joined at forehead. THE "BIDDENDEN MAIDS." 175 20 acres of land, iioav yielding £35 per annum, and knoAvn as the ' Bread and Cheese Lands.' About the year 1100 there lived Eliza and Mary Chulk- hurst, Avho were joined together after the manner of the Siamese twins, and avIio lived for thirty-four years, one dying, and then being folloAved by her sister Avithin six hours. They left by their will the lands above alluded to, and their memory is perpetuated by imprinting on the cakes their effigies < in their habit as they lived.' The cakes, Avhich are simple flour and Avater, are four inches long by two inches Avide, and are much sought after as curiosi- ties. These, which are given aAvay, are distributed at the discretion of the church-Avardens, and are nearly 300 in number. The bread and cheese amounts to 540 quartern loaves and 470 pounds of cheese. The distribu- tion is made on land belonging to the charity, known as the Old Poorhouse. Formerly it used to take place in the Church, immediately after the service in the afternoon, but in consequence of the unseemly disturbance which used to ensue the practice AAras discontinued. The Church used to be filled Avith a congregation Avhose conduct Avas occa- sionally so reprehensible that some- times the church-Avardens had to use their Avands for other purposes than sym- bols of office. The impressions of the ' maids' on the cakes are of a primitive character, and are made by boxwood dies cut in 1814. They bear the date 1100, Avhen Eliza and Mary Chulkhurst arc supposed to haA7e been born, and also their age at death, thirty-four years." Ballantyne759 has summed up about all there is to be said on this national monstrosity, and his discussion of the case from its historic as avcII as tera- tologic standpoint is so excellent that his conclusions Avill be quoted :— " It may be urged that the date fixed for the birth of the Biddenden Maids is so remote as to throAV grave doubt upon the reality of the occur- rence. The year 1100 AAas, it Avill be remembered, that in Avhich William Rufus Avas found dead in the NeAV Forest, ' AA'ith the arroAv either of a hunter or an assassin in his breast.' According to the Anglo-Saxon Chronicle, sev- eral ' prodigies' preceded the death of this profligate and extravagant mon- arch. Thus it is recorded that ' at Pentecost blood Avas observed gushing from the earth at a certain toAvn of Berkshire, even as many asserted avIio Fig. 39.—Biddenden Maids' cake (Ballantyne). 176 MAJOR TERATA. declared that they had seen it. And after this, on the morning after Lam- mas Day, King William was shot.' Noav, it is just possible that the birth of the Biddenden Maids may have occurred later, but have been antedated by the popular tradition to the year above mentioned. For such a birth would, in the opinion of the times, be regarded undoubtedly as a most evi- dent prodigy or omen of evil. Still, eATen admitting that the date 1100 must be allowed to stand, its remoteness from the present time is not a convincing argument against a belief in the real occurrence of the phenomenon; for of the dicephalic Scottish brothers, Avho liA'ed in 1490, Ave have credible historic evidence. Further, Lycosthenes, in his " Chronicon Prodigiorum atque Ostentorum " (p. 397), published in 1557, states, upon Avhat authority I knoAV not, that in the year 1112 joined tAvins resembling the Biddenden phenom- enon in all points sa\7e in sex Avere born in England. The passage is as fol- Ioavs : ' In Anglia natus est puer geminus a clune ad superiores partes ita divisus, ut duo haberet capita, duo corpora integra ad renes cum suis brachiis, qui baptizatus triduo supervixit.' It is just possible that in some A\ay or other this case has been confounded Avith the story of Biddenden ; at any rate, the occurrence of such a statement in Lycosthenes' Avork is of more than pass- ing interest. Had there been no bequest of land in connection Avith the case of the Kentish Maids, the whole affair would probably soon haA'e been for- gotten. " There is, however, one real difficulty in accepting the story handed doAvn to us as authentic,—the nature of the teratologic phenomenon itself. All the records agree in stating that the Maids were joined together at the shoulders and hips, and the impression on the cakes and the pictures on the ' broadsides' shoAv this peculiar mode of union, and represent the bodies as quite separate in the space between the above-named points. The Maids are shoAvn Avith four feet and tAvo arms, the right and left respectively, Avhilst the other arms (left and right) are fused together at the shoulder accord- ing to one illustration, and a little above the elboAV according to another. Noav, although it is not safe to say that such an anomaly is impossible, I do not knoAV of any case of this peculiar mode of union ; but it may be that, as Prof. A. R. Simpson has suggested, the Maids had four separate arms, and Avere in the habit of going about Avith their contiguous arms round each other's necks, and that this gave rise to the notion that these limbs were united. If this be so, then the teratologic difficulty is remoA^ed, for the case becomes perfectly comparable Avith the Avell-knoAvn but rare type of double terata knoAvn as the pygopagous tAvins, Avhich is placed by Taruffi with that of the ischiopagous tAvins in the group dicephalus lecanopagus. Similar instances, AA'hich are well knoAvn to students of teratology, are the Hungarian sisters (Helen and Judith), the North Carolina tAvins (Millie and Christine), and the Bohemian tAvins (Rosalie and Josepha Blazek). The interspace betAveen the thoraces may, hoAvever, have simply been the addition HELEN AND JUDITH, THE HUNGARIAN SISTERS. 177 of the first artist who portrayed the Maids (from imagination'?) ; then it may be surmised that they Avere ectopagous twins. " Pygopagous twins are fetuses united together in the region of the nates and having each its OAvn pelvis. In the recorded cases the union has been usually betAveen the sacra and coccyges, and has been either osseous or (more rarely) ligamentous. Sometimes the point of junction Avas the middle line posteriorly, at other times it Avas rather a posterolateral union; and it is probable that in the Biddenden Maids it was of the latter kind ; and it is likely, from the proposal made to separate the sisters after the death of one, that it Avas ligamentous in nature. "If it be granted that the Biddenden Maids Avere pygopagous twins, a study of the histories of other recorded cases of this monstrosity serves to demonstrate many common characters. Thus, of the 8 cases Avhich Taruffi has collected, in 7 the twins were female; and if to these Ave add the sisters Rosalie and Josepha Blazek and the Maids, we have 10 cases, of which 9 were girls. Again, several of the pygopagous twins, of whom there are scientific records, survived birth and lived for a number of years, and thus resembled the Biddenden terata. Helen and Judith, for instance, Avere twenty-three years old at death ; and the North Carolina twins, although born in 1851, are still alive. There is, therefore, nothing inherently improb- able in the statement that the Biddenden Maids lived for thirty-four years. With regard also to the truth of the record that the one Maid surviA^ed her sister for six hours, there is confirmatory evidence from scientifically observed instances, for Joly and Peyrat (Bull, de l'Acad. Med., iii., pp. 51 and 383, 1874) state that in the case seen by them the one infant lived ten hours after the death of the other. It is impossible to make any statement Avith regard to the internal structure of the Maids or to the characters of their genital organs, for there is absolutely no information forth- coming upon these points. It may simply be said, in conclusion, that the phenomenon of Biddenden is interesting not only on account of the curious bequest Avhich arose out of it, but also because it was an instance of a very rare teratologic type, occurring at a Aery early period in our national history." Possibly the most famous example of twins of this type Avere Helen and Judith, the Hungarian sisters, born in 1701 at Szony, in Hungary. They were the objects of great curiosity, and Avere shoAvn successively in Holland, Germany, Italy, France, England, and Poland. At the age of nine they Avere placed in a convent, Avhere they died almost simultaneously in their tAventy-second year. During their travels all OATer Europe they Avere exam- ined by many prominent physiologists, psychologists, and naturalists ; Pope and seA'cral minor poets haA7e celebrated their existence in ATerse; Buffon speaks of them in his " Natural History," and all the works on teratology for a century or more have mentioned them. A description of them can be best 12 178 MAJOR TERATA. given by a quaint translation by Fisher of the Latin lines composed by a Hungarian physician and inscribed on a bronze statuette of them :a — Two sisters wonderful to behold, who have thus grown as one, That naught their bodies can divide, no power beneath the sun. The town of Szoenii gave them birth, hard by far-famed Komorn, Which noble fort may all the arts of Turkish sultans scorn. Lucina, woman's gentle friend, did Helen first receive ; And Judith, when three hours had passed, her mother's womb did leave. One urine passage serves for both ;—one anus, so they tell; The other parts their numbers keep, and serve their owners well. Their parents poor did send them forth, the world to travel through, That this great wonder of the age should not be hid from view. The inner parts concealed do lie hid from our eyes, alas ! But all the body here you view erect in solid brass. They were joined back to back in the lumbar region, and had all their parts separate except the anus between the right thigh of Helen and the left of Judith and a single A'tilva. Helen was the larger, better looking, the more active, and the more intelligent. Judith at the age of six became hemiplegic, and afterward was rather delicate and de- pressed. They menstruated at sixteen and continued with regularity, although one began before the other. They had a mutual affection, and did all in their poAver to alleviate the circumstances of their sad position. Judith died of cerebral and pulmonary affections, and Helen, who previously enjoyed good health, soon after her sister's first indisposition sud- denly sank into a state of collapse, although preserving her mental faculties, and expired almost immediately after her sister. They had measles and small-pox simultaneously, but Avere affected in different degree by the maladies. The emotions, inclinations, and appetites Avere not simultaneous. Eccardus, in a very inter- esting paper, discusses the physical, moral, and religious questions in refer- ence to these Avonderful sisters, such as the advisability of separation, the admissibility of matrimony, and, finally, whether on the last day they would rise as joined in life, or separated. There is an accountb of two united females, similar in conjunction to the "Hungarian sisters," who Avere born in Italy in 1700. They were killed at the age of four months by an attempt of a surgeon to separate them. a 773, 1866. b 105, v., 445. Fig. 40.—The Hungarian sisters. MILLIE-CHRISTINE—ROSA-JOSEPHA BLAZEK. 179 In 1856 there Avas reported to have been born in Texas, tAvins after the manner of Helen and Judith, united back to back, avIio lived and attained some age. They were said to have been of different natures and dispositions, and inclined to quarrel very often. Pancoast a gives an extensive report of Millie-Christine, who had been extensively exhibited in Europe and the United States. They were born of slave parents in Columbus County, N. C, July 11, 1851 ; the mother, who had borne 8 children before, was a stout negress of thirty-tAvo, Avith a large peh'is. The presentation Avas first by the stomach and afterAvard by the breech. These twins were united at the sacra pj a cartilaginous or possibly osseous union. They were exhibited in Paris in 1873, and provoked as much discussion there as in the United States. Physically, Millie was the weaker, but had the stronger Avill and the dominating spirit. They menstru- ated regularly from the age of thir- teen. One from long habit yielded instinctively to the other's move- ments, thus preserving the necessary harmony. They ate separately, had distinct thoughts, and carried on dis- tinct conversations at the same time. They experienced hunger and thirst generally simultaneously, and defe- cated and urinated nearly at the same times. One, in tranquil sleep, Avould be Avakened by a call of nature of the other. Common sensibility was ex- perienced near the location of union. They Avere intelligent and agreeable Fig. 41.—.umic-umstine (Pancoast). and of pleasant appearance, although slightly under size; they sang duets with pleasant voices and accompanied themselves with a guitar; they Avalked, ran, and danced Avith apparent ease and grace. Christine could bend over and lift Millie up by the bond of union. A recent example of the pygopagus type Avas Rosa-Josepha Blazek,b born in Skcrychov, in Bohemia, January 20, 1878. These tAvins had a broad bonv union in the loAver part of the lumbar region, the pelvis being obviously completely fused. They had a common urethral and anal aperture, but a double vaginal orifice, Avith a very apparent septum. The sensation Avas dis- tinct in each, except where the pelves joined. They Avere exhibited in Paris a 631, 1871, i. b 778, xxii., 265. 180 MAJOR TEE ATA. in 1891, being then on an exhibition tour around the Avorld. Rosa Avas the stronger, and Avhen she Avalked or ran forward she dreAV her sister Avith her, who must naturally have reversed her steps. They had independent thoughts and separate minds; one could sleep Avhile the other Avas aAvake. Many of their appetites Avere different, one preferring beer, the other Avine ; one relished salad, the other detested it, etc. Thirst and hunger Avere not simultaneous. Baudoin a describes their anatomic construction, their mode of life, and their mannerisms and tastes in a quite recent article. Fig. 42 is a reproduction of an early photograph of the tAvins, and Fig. 43 represents a recent photo- graph of these " Bohemian twins," as they are now called. Fig. 42.—Blazek sisters. The latest record Ave have of this type of monstrosity is that given by Tynberg to the County Medical Society of NeAv York, May 27, 1895. The mother Avas present Avith the remarkable tAvins in her arms, crying at the top of their A'oices. These two children Avere born at midnight on April 15th. Tynberg remarked that he believed them to be distinct and separate children, and not dependent on a common arterial system ; he also expressed his inten- tion of separating them, but did not believe the operation could be performed Avith safety before another year. Jacobi b describes in full Tynberg's instance of pygopagus. He says the confinement Avas easy ; the head of one Avas born first, soon folloAved by the feet and the rest of the twins. The placenta Avas a 728, July 8, 1891. b 165, Oct., 1895. ISCHIOPA GI 181 single and the cord consisted of tAvo branches. The twins were united beloAv the third sacral A'ertebrse in such a manner that they could lie along- side of each other. They Avere females, and had tAvo vaginae, two urethras, four labia minora, and tAvo labia majora, one anus, but a double rectum divided by a septum. They micturated independently but defecated simul- taneously. They virtually lived separate lives, as one might be asleep Avhile the other cried, etc. Class V.—-While instances of ischiopagi are quite numerous, few haAre attained any age, and, necessarily, little notoriety. Parea speaks of twins Fig. 43.—Bohemian twins. united at the pelves, Avho Avere born in Paris July 20, 1570. They were baptized, and named Louis and Louise. Their parents Avere well knoAvn in the rue des Gravelliers. According to Bateman,191 and also Rueff, in the year 1552 there Avere born, not far from Oxford, female tAvins, Avho, from the description given, Avere doubtless of the ischiopagus type. They seldom Avept, and one Avas of a cheerful disposition, Avhile the other AA'as heavy and droAvsy, sleeping continually. They only lived a short time, one expiring a day before the other. Licetus 4sr> speaks of Mrs. John Waterman, a resident of FishertoAvn, near Salisbury, England, Avho gave birth to a double female monster on October 26, 1664, Avhich evidently from the description was a 618, 1010. 182 MAJOR TERATA. joined by the ischii. It did not nurse, but took food by both the mouths ; all its actions Avere done in concert; it Avas possessed of one set of genito- urinary organs ; it only lived a short Avhile. Many people in the region flocked to see the Avonderful child, whom Licetus called " Monstrum Angli- cum." It is said that at the same accouchement the birth of this monster was followed by the birth of a Avell-formed female child, who survived. Geoffroy-Saint-Hilaire quotes a description of tAvins Avho Avere born in France on October 7, 1838, symmetrically formed and united at their ischii. One Avas christened Marie-Louise, and the other Hortense-Honorine. Their avaricious parents took the children to Paris for exhibition, the exposures of which soon sacrificed their lives. In the year 1841 there was born in the island of Ceylon, of native parents, a monstrous child that was soon Fig. 44.—Tynberg's case. brought to Columbo, Avhere it lived only two months.a It had tAvo heads and seemed to have duplication in all its parts except the anus and male generative organs. Montgomery b speaks of a double child born in County Roscommon, Ireland, on the 24th of July, 1827. It had tAvo heads, two chests with arms complete, tAvo abdominal and pelvic cavities united end to end, and four legs, placed two on either side. It had only one anus, Avhich was situated betAveen the thighs. One of the twins Avas dark haired and was baptized Mary, Avhile the other AA'as a blonde and was named Catherine. These twins felt and acted independently of each other ; they each in succes- sion sucked from the breast or took milk from the spoon, and used their limbs vigorously. One vomited without affecting the other, but the feces Avere discharged through a common opening. a 318, vol. lxi., 58. b 313, vol. xv. MINNA AND MINNIE FINLEY-" JONES TWINS." 183 Goodell a speaks of Minna and Minnie Finley, Avho Avere born in Ohio and examined by him. They Avere fused together in a common longitudinal axis, having one pelvis, two heads, four legs, and four arms. One Avas Aveak and puny and the other robust and active ; it is probable that they had but one rectum and one bladder. Goodell accompanies his description by the mention of several analogous cases. Ellis b speaks of female tAvins, born in Millville, Tenn., and exhibited in NeAV York in 1868, Avho Avere joined at the pelves in a longitudinal axis. BetAveen the limbs on either side Avere to be seen well-developed female genitals, and the sisters had been known to urinate from both sides, beginning and ending at the same time. Huffc details a description of the "Jones twins," born on June 24, 1889, in Tipton County, Indiana, Avhose spinal columns were in apposition at the loAver end. The labor, of less than two hours' duration, Avas completed Fig. 45.—The Jones twins. before the arrival of the physician. Lying on their mother's back, they could both nurse at the same time. Both sets of genitals and ani Avere on the same side of the line of union, but occupied normal positions Avith reference to the legs on either side. Their Aveight at birth Avas 12 pounds and their length 22 inches. Their mother was a medium-sized brunette of 19, and had one previous child then living at the age of tAvo ; their father Avas a finely formed man 5 feet 10 inches in height. The twins differed in complexion and color of the eyes and hair. They were publicly exhibited for some time, and died February 19 and 20, 1891, at St. John's Hotel, Buffalo, N. Y. Figure 45 slum's their appearance several months after birth. Class YI.—In our sixth class, the first record Ave have is from the Com- mentaries of Sigbert, which contains a description of a monstrosity born in the reign of the Emperor Theodosius, Avho had tAvo heads, two chests Avith four a 517, 1870. b 218,1871, 218 et seq. c 125, vol. xxii., 923. 184 MAJOR TERA TA. arms attached, but a single loAver extremity. The emotions, affections, and appetites Avere different. One head might be crying while the other laughed, or one feeding while the other Avas sleeping. At times they quarreled and occasionally came to bloAvs. This monster is said to have lived tAvo years, one part dying four days before the other, which evinced symptoms of decay like its inseparable neighbor. Roger of Wendovcr689 says that in Lesser Brittany and Normandy, in 1062, there Avas seen a female monster, consisting of tAvo Avomen joined about the umbilicus and fused into a single loAver extremity. They took their food by tAvo mouths but expelled it at a single orifice. At one time, one of the women laughed, feasted, and talked, Avhile the other Avept, fasted, and kept a religious silence. The account relates Iioav one of them died, and the survi- A'or bore her dead sister about for three years before she Avas overcome by the oppression and stench of the cadaArer. Batemen191 describes the birth of a boy in 1529, Avho had two heads, four ears, four arms, but only tAvo thighs and tAvo legs. Buchanana speaks at length of the famous " Scottish Brothers," Avho Avere the cynosure of the eyes of the Court of James III. of Scotland. This monster consisted of tAA'o men, ordinary in appearance in the superior extremities, Avhose trunks fused into a single loAver extremity. The King took diligent care of their education, and they became proficient in music, languages, and other court accomplishments. BetAveen them they Avould carry on animated coiwersations, sometimes merging into curious debates, followed by bloAvs. AboAe the point of union they had no synchronous sen- sations, Avhile beloAv, sensation Avas common to both. This monster liA^ed twenty-eight years, surviATing the royal patron, Avho died June, 1488. One of the brothers died some days before the other, and the surviA'or, after carrying about his dead brother, succumbed to " infection from putrescence." There Avas reported to have been born191 in SAvitzerland a double-headed male monster, Avho in 1538, at the age of thirty, Avas possessed of a beard on each face, the two bodies fused at the umbilicus into a single loAver extremity. These tAvo twins resembled one another in contour and countenance. They Avere so joined that at rest they looked upon one another. They had a single Avife, Avith Avhom they Avere said to have lived in harmony. In the Gentleman's Magazine about one hundred and fifty years since there AA'as given the portrait and description of a double Avoman, who Avas exhibited all over the large cities of Europe. Little can be ascertained anatomically of her construction, with the exception that it Avas stated that she had two heads, two necks, four arms, two legs, one pelvis, and one set of pelvic organs. The most celebrated monster of this type Avas Ritta-Christina (Figs. 46 and 47), Avho Avas born in Sassari, in Sardinia, ISIarch 23, 1829. These twins were the result of the ninth confinement of their mother, a Avoman of thirtv-two. Their superior extremities Avere double, but they joined in a common trunk a Kerum Scoticarum Historia, Aberdeen, 1762, L. xiii. RITTA- CHRISTINA. 185 at a point a little below the mammae. BeloAv this point they had a common trunk and single lower extremities. The right one, christened Ritta, AAas feeble and of a sad and melancholy countenance ; the left, Christina, Avas vigorous and of a gay and happy aspect. They suckled at different times, and sensations in the upper extremities Avere distinct. They expelled urine and feces simultaneously, and had the indications in common. Their parents, avIio Avere very poor, brought them to Paris for the purpose of public exhibi- tion, Avhich at first Avas accomplished clandestinely, but finally interdicted by the public authorities, who feared that it Avould open a door for psychologic discussion and speculation. This failure of the parents to secure public patronage increased their poverty and hastened the death of the children by unavoidable exposure in a cold room. The nervous system of the twins had little in common except in the line of union, the anus, and the sexual organs, Fig. 46.—Skeleton of Ritta-Christina. Fig. 47.—Ritta-Christina. and Christina was in good health all through Ritta's sickness ; when Ritta died, her sister, Avho was suckling at the mother's breast, suddenly relaxed hold and expired Avith a sigh. At the postmortem, which was secured Avith some difficulty on account of the authorities ordering the bodies to be burned, the pericardium Avas found single, covering both hearts. The diges- tive organs were double and separate as far as the loAver third of the ilium, and the cecum Avas on the left side and single, in common Avith the loAver boAvel. The liArers were fused and the uterus Avas double. The vertebral columns, Avhich Avere entirely separate above, Avere joined beloAv by a rudi- mentary os innominatum. There Avas a junction betAveen the manubrium of each. Sir Astley Cooper saAV a monster in Paris in 1792 Avhich, by his description, must have been very similar to Ritta-Christina. 186 MAJOR TERATA The Tocci brothers Avere born in 1877 in the province of Turin, Italy. They each had a well-formed head, perfect arms, and a perfect thorax to the sixth rib ; they had a common abdomen, a single anus, tAvo legs, tAvo sacra, Iavo vertebral columns, one penis, but three buttocks, the central one containing a rudimentary anus. The right boy was christened Giovanni-Batista, and the left Giacomo. Each individual had poAver over the corresponding leg on his side, but not over the other one. Walking Avas there- fore impossible. All their sensa- tions and emotions were distinctly individual and independent. At the time of the report, in 1882, they were in good health and showed every indication of attaining adult age. Figure 48 represents these tAvins as they were exhibited sev- eral years ago in Germany. McCalluma saw two female children in Montreal in 1878 named Marie - Rosa Drouin. They formed a right angle Avith their single trunk, which com- menced at the lower part of the thorax of each. They had a single genital fissure and the external organs of generation of a female. A little over three inches from the anus Avas a rudimentary limb Avith a mo\T able articulation ; it meas- ured five inches in length and tapered to a fine point, being fur- nished Avith a distinct nail, and it contracted strongly to irritation. Marie, the left child, was of fair complexion and more strongly developed than Rosa. The sen- sations of hunger and thirst were not experienced at the same time, and one might be asleep while the other AAas crying. The pulsations and the respira- tory movements Avere not synchronous. They were the products of the second gestation of a mother aged tAventy-six, whose abdomen was of such preternatural size during pregnancy that she Avas ashamed to appear in public. a 778, vol. xx., 120. Fig. 48.—The Tocci brothers. BICEPHALIC MONSTERS. 187 The order of birth Avas as folloAvs : one head and body, the lower extremity, and the second body and head. Class VII.—There are many instances of bicephalic monsters on record. Pare a mentions and gives an illustration of a female apparently sin- gle in conformation, Avith the exception of having tAvo heads and Iavo necks. The Ephemerides, Haller, Schenck, and Archenholz cite examples, and there is an old accountb of a double-headed child, each of Avhose heads Avere baptized, one called Martha and the other Mary. One AAas of a gay and the other a sad visage, and both heads received nourishment; they only lived a couple of days. There is another similar record of a Milanese girl Avho had two heads, but Avas in all other respects single, Avith the exception that after death she Avas found to have had tAvo stomachs. Besse mentions a BaArarian Avoman of t Aventy-six Avith two heads, one of Avhich Avas comely and the other extremely ugly ; Batemen191 quotes Avhat is apparently the same case—a Avoman in Bavaria in 1541 Avith two heads, one of which Avas deformed, who begged from door to door, and Avho by reason of the influence of pregnant Avomen AA'as giAren her expenses to leaATe the country. A more common occurrence of this type is that in AA'hich there is fusion of the tAA'o heads. Moreauc speaks of a monster in Spain Avhich Avas shoAvn from toAvn to toAvn. Its heads Avere fused ; it had two mouths and tAvo noses ; in each face an eye Avell conformed and placed above the nose ; there was a third eye in the middle of the forehead common to both heads; the third eye AA'as of primitive development and had tAvo pupils. Each face Avas Avell formed and had its OAvn chin. Buffon mentions a cat, the exact analogue of Moreau's case. Suttond speaks of a photograph sent to Sir James Paget in 1856 by William Budd of Bristol. This portrays a living child Avith a supernumerary head, Avhich had mouth, nose, eyes, and a brain of its OAvn (Fig. 49). The eyelids avc re abortiATe, and as there Avas no orbital caA'ity the eyes stood out in the form of naked globes on the forehead. When born, the corneas of both heads Avere transparent, but then became opaque from exposure. The brain of the supernumerary head AA'as quite visible from Avithout, and Avas covered by a membrane beginning to slough. On the right side of the head AAas a rudimentary external ear. The nurse said that Avhen the child sucked some milk regurgitated through the supernumerary mouth. The great phy- siologic interest in this case lies in the fact that every movement and every act of the natural face Avas simultaneously repeated by the supernumerary face in a perfectly consensual manner, /. e., Avhen the natural mouth sucked, the second mouth sucked ; Avhen the natural face cried, yaAvned, or sneezed, the second face did likewise ; and the eyes of the two heads moved in unison. The fate of the child is not known. Homee speaks of a child born in Bengal Avith a most peculiar fusion of a 618. 1006. b 469, 1665. c Quoted, 302, xxxiv., 171. d275^ 1895, 133. e «^ 1791,299. 188 MAJOR TERATA. the head. The ordinary head was nearly perfect and of usual volume, but fused Avith its vertex and reversed Avas a supernumerary head (Fig. oO). Each head had its oavu separate vessels and brain, and each an individual sensibility, but if one had milk first the other had an abundance of saliva in its mouth. It narroAvly escaped being burned to death at birth, as the mid- wife, greatly frightened by the monstrous appearance, threw it into the fire to destroy it, from Avhence it was rescued, although badly burned, the vicious conformation of the accessory head being possibly due to the accident. At the age of four it was bitten by a venomous serpent and, as a result, died. Its skull is in the possession of the Royal College of Surgeons in London. Fig. 49.—Infant with a supernumerary head Fig. 50.—Two-headed boy (Home's case). (after Sutton). The folloAving well-known story of EdAvard Mordake, though taken from lav sources, is of sufficient notoriety and interest to be mentioned here :— " One of the Aveirdest as Avell as most melancholy stories of human de- formity is that of EdAvard Mordake, said to have been heir to one of the noblest peerages in England. He never claimed the title, hoAveA^er, and com- mitted suicide in his twenty-third year. He lived in complete seclusion, refusing the visits even of the members of his own family. He Avas a young man of fine attainments, a profound scholar, and a musician of rare ability. His figure Avas remarkable for its grace, and his face—that is to say, his natural face—Avas that of an Antinous. But upon the back of his head Avas another face, that of a beautiful girl, ' lovely as a dream, hideous as a devil.' The female face Avas a mere mask, * occupying only a small portion of the posterior part of the skull, yet exhibiting every sign of intelligence, of a PARASITIC TERATA. 189 malignant sort, hoAvever.' It would be seen to smile and sneer Avhile Mor- dake Avas Aveeping. The eyes would folloAv the movements of the spectator, and the lips Avould ' gibber Avithout ceasing.' No voice was audible, but Mordake avers that he Avas kept from his rest at night by the hateful whis- pers of his (devil tAvin,' as he called it, ' which never sleeps, but talks to me forever of such things as they only speak of in hell. No imagination can conceive the dreadful temptations it sets before me. For some unforgiven Avickedness of my forefathers I am knit to this fiend—for a fiend it surely is. I beg and beseech you to crush it out of human semblance, even if I die for it.' Such Avere the Avords of the hapless Mordake to Manvers and Treadwell, his physicians. In spite of careful watching he managed to procure poison, whereof he died, leaving a letter requesting that the (demon face' might be destroyed before his burial, ' lest it continues its dreadful whisperings in my grave.' At his own request he was interred in a waste place, Avithout stone or legend to mark his grave." A most curious case Avas that of a Fellah AVomana who was delivered at Alexandria of a bicephalic monster of apparently eight months' pregnancy. This creature, which was born dead, had one head white and the other black, the change of color commencing at the neck of the black head. The bizarre head Avas of negro conformation and fully developed, and the colored skin Avas found to be due to the existence of pigment similar to that found in the black race. The husband of the Avoman had a light brown skin, like an ordinary Fellah man, and it was ascertained that there Avere some negro laborers in port during the woman's pregnancy ; but no definite information as to her relations Avith them could be established, and Avhether this was a ease of maternal impression or superfetation can only be a matter of conjecture. Fantastic monsters, such as acephalon, paracephalon, cyclops, pseuden- cephalon, and the janiceps (Fig. 51), prosopthoracopagus (Fig. 52), dispro- sopus (Fig. 53), etc., although full of interest, will not be discussed here, as none are ever A'iable for any length of time, and the declared intention of this chapter is to include only those beings Avho have lived. Class VIII.—The next class includes the parasitic terata, monsters that consist of one perfect body, complete in e\Tery respect, but from the neighborhood of Avhose umbilicus depends some important portion of a second body. Pare, Benivenius, and Columbus describe adults Avith acephalous monsters attached to them. Schenck mentions 13 cases, 3 of which were observed by him. Aldrovandus116 sIioavs 3 illustrations under the name of "monstrum bicorpum monocephalon." Buxtorfb speaks of a case in Avhich the nates and loAver extremities of one body proceeded out of the abdomen of the other, Avhich Avas otherAvise perfect. Reichel and Ander- son c mention a living parasitic monster, the inferior trunk of one body pro- ceeding from the pectoral region of the other. a 789, Aug. 5, 1848. b 107, vol. vii., n. xii., 101. c 629, vol. lxxix. 190 MAJOR TERATA. Parea says that there Avas a man in Paris in 1530, quite forty years of age, Avho carried about a parasite Avithout a head, which hung pendant from his belly. This individual was exhibited and drew great crowds. Pare Fig. 51.—Janiceps. Fig. 52.—Prosopthoracopagus. Fig. 53.—Disprosopus. appends an illustration, which is, perhaps, one of the most familiar in all tera- tology. He also b gives a portrait (Fig. 54) of a man who had a parasitic head Fig. 54.—Parasitic monster (after Par6). Fig. 55.—Thoracopagus. Lazarus-Joannes Baptista Colloredo. proceeding from his epigastrium, and Avho Avas born in Germany the same year that peace was made Avith the SAviss by King Francis. This creature liA^ed a 618, 1007. b618, 1012. LAZARUS-JOANNES BAPTISTA COLLOREDO. 191 to manhood and both heads Avere utilized in alimentation. Bartholinus a details a history of an individual named Lazarus-Joannes Baptista Colloredo (Fig. 55), born in Genoa in 1617, Avho exhibited himself all over Europe. From his epigastrium hung an imperfectly developed tAvin that had one thigh, hands, body, arms, and a Avell-formed head covered Avith hair, Avhich in the normal position hung loAvest. There AA'ere signs of independent existence in the parasite, moATements of respiration, etc., but its eyes Avere closed, and, although saliA'a constantly dribbled from its open mouth, nothing Avas ever ingested. The genitals were imperfect and the arms ended in badly formed hands. Bartholinus examined this monster at twenty-tAvo, and has given the best report, although while in Scotland in 1642 he Avas again examined, and ac- credited Avith being married and the father of seAeral children avIio Avere fully and admirably developed. Moreau quotes a case of an infant similar in con- formation to the foregoing monster, Avho was born in SAvitzerland in 1764, and Avhose supernumerary parts were amputated by means of a ligature. WinsloAV reported before the Academie Royale des Sciences the history of a girl of twelve Avho died at the Hotel-Dieu in 1733. She Avas of ordinary height and of fair conformation, Avith the exception that hanging from the left flank AAas the inferior half of another girl of diminutive proportions. The supernumerary body Avas immovable, and hung so heaA'ily that it Avas said to be supported by the hands or by a sling. Urine and feces Avere evacu- ated at intervals from the parasite, and receiA'ed into a diaper constantly Avorn for this purpose. Sensibility in the tAvo was common, an impres- sion applied to the parasite being felt by the girl. Winslow gives an inter- esting report of the dissection of this monster, and mentions that he had seen an Italian child of eight Avho had a small head proceeding from under the cartilage of the third left rib. Sensibility AA'as common, pinching the ear of the parasitic head causing the child Avith the perfect head to cry. Each of the tAvo heads received baptism, one being named John and the other Matthew. A curious question arose in the instance of the girl, as to Avhether the extreme unction should be administered to the acephalous fetus as Avell as to the child. In 1742, during the Ambassadorship of the Marquis de l'Hopital at Naples, he saw in that city an aged man, Avell conformed, Avith the exception that, like the little girl of Winsknv, he had the inferior extremities of a male child groAving from his epigastric region. Haller and Meckel haAre also obserA'ed cases like this. Bordat described before the Royal Institute of France, August, 1826, a Chinaman, tAA'entv-one years of age, Avho had an acephalous fetus attached to the surface of his breast (possibly " A-ke"). Dickinson b describes a Avonderful child five years old, avIio, by an extra- ordinary freak of nature, Avas an amalgamation of two children. From the body of an otherAvise perfectly formed child Avas a supernumerary head pro- a 190, hist, lviii. b 703, 1880. 192 MAJOR TERATA. truding from a broad base attached to the loAver lumbar and sacral region. This cephalic mass Avas covered Avith hair about four or five inches long, and shoAved the rudiments of an eye, nose, mouth, and chin. This child Avas on exhibition Avhen Dickinson saAV it. Montare and Reyes Avere commissioned by the Academy of Medicine of Havana to examine and report on a mon- strous girl of seven months, living in Cuba. The girl was healthy and Avell developed, and from the middle line of her body betAveen the xiphoid carti- lage and the umbilicus, attached by a soft pedicle, Avas an accessory indiA'idual, irregular, of ovoid shape, the smaller end, representing the head, being upAvard. The parasite measured a little over 1 foot in length, 9 inches about the head, and 71 inches around the neck. The cranial bones Avere distinctly felt, and the top of the head Avas coA'ered by a circlet of hair. There Avere tAvo rudi- mentary eyebroAvs; the left eye Avas represented by a minute perforation encircled Avith hair; the right eye AAas traced by one end of a mucous groove which ran down to another transverse groove representing the mouth ; the right third of this latter groove shoAved a primitive tongue and a triangular tooth, which appeared at the fifth month. There was a soft, imperforate nose, and the elements of the vertebral column could be distinguished beneath the skin; there were no legs ; apparently no vascular sounds; there Avas separate sensation, as the parasite could be pinched without attracting the per- fect infant's notice. The mouth of the parasite con- stantly dribbled saliva, but showed no indication of receiving aliment.a Louise L., known as " La dame a quatre jambes," was born in 1869, and had attached to her Fig. 56.-Louise l. pelvis another rudimentary pelvis and two atrophied legs of a parasite, Aveighing 8 kilos. The attachment AA'as effected by means of a pedicle 33 cm. in diameter, having a bony basis, and being fixed Avithout a joint. The attachment almost obliterated the vulva and the perineum Avas displaced far backAvard. At the insertion of the parasite Avere two rudimentary mammae, one larger than the other (Fig. 56). No genitalia Avere seen on the parasite and it exhibited no actiA^e move- ments, the joints of both limbs being ankvlosed. The Avoman could localize sensations in the parasite except those of the feet. She had been married five years, and bore, in the space of three years, two Avell-formed daughters. Quite recently there Avas exhibited in the museums of the United States an individual bearing the name " Laloo," who Avas born in Oudh, India, and Avas the second of four children. At the time of examination he Avas about nineteen years of age. The upper portion of a parasite Avas firmly attached a 224, 1886, i., Si. DUPLICATION OF THE LOWER EXTREMITIES. to the loAver right side of the sternum of the individual by a bony pedicle, and lower by a fleshy pedicle, and apparently contained intestines. The anus of the parasite Avas imperforate ; a well-developed penis was found, but no testi- cles ; there was a luxuriant growth of hair on the pubes. The penis of the parasite was said to show signs of erection at times, and urine passed through it Avithout the knoAvledge of the boy. Perspiration and elevation of tem- perature seemed to occur simultaneously in both. To pander to the morbid curiosity of the curious, the " Dime Mu- seum " managers at one time shrewdly clothed the parasite in female attire, calling the tAvo brother and sister; but there is no doubt that all the traces of sex were of the male type. An anal- ogous case Avas that of "A-Ke," a Chinaman, Avho Avas exhibited in London early in the century, and of whom and his parasite anatomic models are seen in our museums. Figure 58 repre- sents an epignathus, a peculiar type of parasitic monster, in which the parasite is united to the inferior maxillary bone of the autosite. Class IX.—Of "Lusus nature" none is more curious than that of dup- lication of the lower extremities. Par6a says that on January 9, 1529, there was living in Germany a male infant having four legs and four arms. In Paris, at the Academie des Sciences, on September 6, 1830, there was pre- sented by Madame Hen, a midwife, a living male child with four legs, the anus being nearly beloAv the middle of the third buttock; and the scrotum betAveen the two left thighs, the testicles not yet descended. There was a well- formed and single pelvis, and the supernumerary legs Avere immovable. AldroA'andus mentions several similar instances, and gives the figure of one born in Rome ; he also describes several quadruped birds. Bardsley b speaks of a male child Avith one head, four arms, four legs, and double generative organs. He gives a portrait of the child when it Avas a little over a year old. Heschl published in Vienna in 1878 a description of a girl of seventeen, a 618, 1012. b 781, 1838, vol. vi. 13 ________________ • | Fig. 57.—Laloo. 194 MAJOR TERATA. AA'ho instead of having a duplication of the superior body, as in " Millie- Christine, the tAvo-headed nightingale," had double parts beloAv the second lumbar vertebra. Her head and upper body resembled a comely, delicate girl of twelve. Wells a describes Mrs. B., aged twenty, still alive and healthy (Fig. 59). The duplication in this case begins just above the Avaist, the spinal column dividing at the third lumbar vertebra, beloAv this point everything being double. Micturition and defecation occur at different times, but menstrua- tion occurs simultaneously. She Avas married at nineteen, and became preg- nant a year later on the left side, but abortion aa as induced at the fourth month on account of persistent nausea and the expectation of impossible delivery. Whaley,b in speaking of this case, said Mrs. B. utilized her out- side legs for AAalking; he also remarks that Avhen he informed her that she was pregnant on the left side she replied, " I think you are mistaken; if it had been on my right side I Avould come nearer believing it;"—and after further questioning he found, from the patient's observation, that her right genitals were almost invariably used for coitus. Bechlinger of Para, Brazil,0 describes a Avoman of twenty-five, a native of Martinique, Avhose father was French and mother a quadroon, who had a modified duplication of the lower body. There Avas a third leg attached to a con- tinuation of the processus coccygeus of the sacrum, and in addition to well- Fig. 58.—Epignathus. developed mamma? regularly situated, there Avere tAvo rudimentary ones close to- gether above the pubes. There were two vaginae and two well-developed vulvae, both having equally developed sensations. The sexual appetite was markedly developed, and coitus was practised in both vaginae. A someAvhat similar case, possibly the same, is that of Blanche Dumas, born in 1860. She had a very broad pelvis, two imperfectly developed legs, and a super- numerary limb attached to the symphysis, without a joint, but with slight passive movement. There Avas a duplication of bowel, bladder, and genitalia. At the junction of the rudimentary limb Avith the body, in front, were tAvo rudimentary mammary glands, each containing a nipple (Fig. 60). Other instances of supernumerary limbs will be found in Chapter VI. Class X.—The instances of diphallic terata, by their intense interest to the natural bent of the curious mind, have always elicited much discus- sion. To many of these cases have been attributed exaggerated function a 125, 1888, 1266. b 224, 1889, i., 96. c Annals of Gynecology, 1888. DIPHALLIC TERATA. 195 Fig. 59.—Dipygus (Wells). notAvithstanding the fact that modern observation almost invariably sIioavs that the virile poAver diminishes in exact proportion to the extent of duplica- tion. Taylor757 quotes a description of a monster, exhibited in London, with tAvo distinct peniscs, but Avith only one distinct testicle on either side. He could exercise the function of either organ. Schenck, Schurig, Bartholinus, Loder, and Ollsner report instances of diphallic terata ; the latter case a AA'as in a soldier of Charles VI., tAventy-tAvo years old, who applied to the surgeon for a bubonic affec- tion, and who declared that he passed urine from the orifice of the left glans and also said that he was incapable of true coitus. Val- entini mentions an instance in a boy of four, in which the two penises were superimposed. Buc- chettonib speaks of a man with two penises placed side by side. There was an anonymous case described c of a man of ninety-three with a penis which Avas for more than half its length divided into two distinct members, the right being someAvhat larger than the left. From the middle of the penis up to the symphysis only the loAver wall of the urethra Avas split. Jenischd describes a diphallic infant, the offspring of a woman of tAventy-five who had been married five years. Her first child Avas a Avell-formed female, and the second, the infant in question, cried much during the night, and several times vomited dark-green matter. In lieu of one penis there were tAvo, situated near each other, the right one of natural size and the left larger, but not furnished Avith a prepuce. Each penis had its own urethra, from which dribbled urine and some meconium. There Avas a a Medicorum Siles. Satyrse. Lipsiae, 1736. b Anatomia, etc., p. 120, (Eniponte, 1740. c 559, 1808, Band ii., 335. d Med. Corresp.-Blatt des wurtterab. -irztl. Ver., Stuttg., 1837. Fig. 60.—Blanche Dumas. 196 MAJOR TERATA. Jr.. '^**5s'dsaf'' |,, *5kl v -:' *^-?3» i ■ '■'*£ " -kj| ■K*V '*"v j Fig. 61.—Double penis (Jenisch's case). duplication of each scrotum, but only one testicle in each, and several other minor malformations (Fig. 61). Gore, reported by Velpeau,a has seen an infant of eight and one-half months Avith two penises and three loAver extremities. The penises were 4 cm. apart and the scrotum divided, containing one testicle in each side. Each penis Avas provided with a ure- thra, urine being discharged from both simultaneously. In a similar case, spoken of by Geoffroy-Saint-Hilaire, the two organs Ave re also separate, but urine and semen escaped some- times from one, sometimes from both. The most celebrated of all the diphallic terata was Jean Baptista dos Santos, who when but six months old was spoken of by Acton. His father and mother Avere healthy and had two Avell-formed children. He Avas easily born after an uneventful pregnancy. He was good- looking, Avell proportion- ed, and had two distinct penises, each as large as that of a child of six months. Urination pro- ceeded simultaneously from both penises ; he had also two serotinus. Behind and between the legs there Avas another limb, or rather two, united throughout their length. It was con- nected to the pubis by a short stem | inch long and as large as the little finger, consisting of separ- ate bones and cartilages. on the anal aspect, and a joint freely movable. a 283, 1844. Fig. 62.—Jean Baptista dos Santos. There was a patella in the supernumerary limb This compound limb had no JEAN BAPTISTA DOS SANTOS. 197 power of motion, but Avas endoAved with sensibility. A journal in London,3 after quoting Acton's description, said that the child had been exhibited in Paris, and that the surgeons advised operation. Fisher,b to whom Ave are indebted for an exhaustive work in Teratology, received a report from Havana in July, 1865, Avhich detailed a description of Santos at twenty- two years of age, and said that he was possessed of extraordinary animal passion, the sight of a female alone being sufficient to excite him. He was said to use both penises, after finishing Avith one continuing Avith the other; but this account of him does not agree Avith later descriptions, in which no excessive sexual ability had been noticed. Hartc describes the adult Santos in full, and accompanies his article with an illustration. At this time he Avas said to have developed double genitals, and possibly a double bladder communicating by an imperfect septum. At adulthood the anus Avas three inches anterior to the os coccygeus. In the sitting or lying posture the supernumerary limb rested on the front of the inner surface of the loAver third of his left thigh. He was in the habit of wearing this limb in a sling, or bound firmly to the right thigh, to prevent its unseemly dangling when erect. The perineum proper was absent, the entire space between the anus and the posterior edge of the scrotum being occupied by the pedicle. Santos' mental and physical functions were developed above normal, and he impressed everybody with his accomplishments. Geoffroy-Saint-Hilaire records an in- stance in which the conformation was similar to that of Santos. There AAras a third loAver extremity consisting of tAvo limbs fused into one Avith a single foot containing ten distinct digits. He calls the case one of arrested twin development. Van Buren and Keyes d describe a case in a man of forty-tAvo, of good, healthy appearance. The two distinct penises of normal size were appa- rently Avell formed and were placed side by side, each attached at its root to the symphysis. Their covering of skin was common as far as the base of the glans ; at this point they seemed distinct and perfect, but the meatus of the left AAras imperforate. The right meatus Avas normal, and through it most of the urine passed, though some ahvays dribbled through an opening in the perineum at a point Avhere the root of the scrotum should have been. On lifting the double-barreled penis this opening could be seen and was of suffi- cient size to admit the finger. On the right side of the aperture was an elongated and rounded prominence similar in outline to a labium majus. This prominence contained a testicle normal in shape and sensibility, but slightly undersized, and surrounded, as was evident from its mobility, by a tunica A'aginalis. The left testicle lay on the tendon of the adductor longus in the left groin ; it Avas not fully developed, but the patient had sexual de- sires, erections, and emissions. Both penises became erect simultaneously, a 549, April, 1847, 322. b 773, 1866. c 476, 1866, i., 71. d " Surgical Diseases of the Genito-Urinary Organs," NeAv York, 1874. 198 MAJOR TERATA. the right more vigorously. The left leg was shorter than the right and con- genitally smaller ; the mammae Avere of normal dimensions. Sangalli a speaks of a man of thirty-five avIio had a supernumerary penis, furnished Avith a prepuce and capable of erection. At the apex of the glans opened a canal about 12 cm. long, through Avhich escaped monthly a serous fluid. Smithb mentions a man Avho had two penises and two bladders, on one of which lithotomy Avas performed. According to Ballantyne, Taruffi, the scholarly observer of terata, mentions a child of forty-two months and height of 80 cm. Avho had tAvo penises, each furnished Avith a urethra and well- formed scrotal sacs Avhich Avere inserted in a fold of the groin. There were two testicles felt in the right scrotum and one in the left. Fecal evacuations escaped through two anal orifices. There is also another case mentioned similar to the foregoing in a man of forty; but here there was an osseous projection in the middle line behind the bladder. This patient said that erection Avas simultaneous in both penises, and that he had not married because of his chagrin over his deformity. Colec speaks of a child with two well-developed male organs, one to the left and the other to the right of the median line, and about £ or \ inch apart at birth. The urethra bifurcated in the perineal region and sent a branch to each penis, and urine passed from each meatus. The scrotum was divided into three compartments by two raphes, and each compartment contained a testicle. The anus at birth was imperforate, but the child was successfully operated on, and at its sixtieth day weighed 17 pounds. Langed says that an infant was brought to Karg for relief of anal atresia when fourteen days old. It was found to possess duplicate penises, which communicated each to its distinct half of the bladder as defined by a median fold. The scrotum Avas divided into three portions by two raphes, and each lateral compartment contained a fully formed testicle. This child died because of its anal malformation, Avhich we notice is a frequent associate of malformations or duplicity of the penis. There is an example in an infant described e in which there were two penises, each about \ inch long, and a divided scrotal sac 2J inches long. Englischf speaks of a German of forty Avho possessed a double penis of the bifid type. Ballantyne and his associates define diphallic terata as indiA'iduals pro- vided Avith two more or less Avell-formed and more or less separate penises, Avho may show also other malformations of the adjoining parts and organs (e. g., septate bladder), but Avho are not possessed of more than tAvo loAver limbs. This definition excludes, therefore, the cases in which in addition to a double penis there is a supernumerary lower extremity—such a case, for example, as that of Jean Baptista dos Santos, so frequently described by teratologists. It also excludes the more evident double terata, and, of course, the cases of a "Lascienza a e la prat. dell. anat. patolog." Pavia, 1875, i., 117. b 775, 187s, 91. c 579, 1894, 159. d 720, 1895, 215. e 759, April, 1895. f Quoted 759, Oct., 1895. FETUS IN FETU. 199 duplication of the female genital organs (double clitoris, vulva, vagina, and uterus). Although Schurig, Meckel, Himly, Taruffi, and others give bib- liographic lists of diphallic terata, even in them erroneous references are common, and there is evidence to shoAv that many cases have been duplicated under different names. Ballantyne and Skirving a have consulted all the older original references available and eliminated duplications of reports, and, adhering to their original definition, have collected and described indi- vidually 20 cases ; they offer the folloAving conclusions :— 1. Diphallus, or duplication of the penis in an otherwise apparently single individual, is a very rare anomaly, records of only 20 cases having been found in a fairly exhaustive search through teratologic literature. As a distinct and Avell-authenticated type it has only quite recently been recognized by teratologists. 2. It does not of itself interfere Avith intrauterine or extrauterine life ; but the associated anomalies (e. g., atresia ani) may be sources of danger. If not noticed at birth, it is not usually discovered till adult life, and even then the discovery is commonly accidental. 3. With regard to the functions of the pelvic viscera, urine may be passed by both penises, by one only, or by neither. In the last instance it finds exit by an aperture in the perineum. There is reason to believe that semen may be passed in the same way; but in most of the recorded cases there has been sterility, if not inability to perform the sexual act. 4. All the degrees of duplication have been met with, from a fissure of the glans penis to the presence of tAvo distinct penises inserted at some dis- tance from each other in the inguinal regions. 5. The tAAO penises are usually someAvhat defective as regards prepuce, urethra, etc.; they may lie side by side, or more rarely may be situated anteroposteriorly; they may be equal in size, or less commonly one is dis- tinctly larger than the other ; and one or both may be perforate or imperforate. 6. The scrotum may be normal or split; the testicles, commonly two in number, may be normal or atrophic, descended or undescended; the prostate may be normal or imperfectly developed, as may also the vasa deferentia and Aresiculse seminales. 7. The commonly associated defects are : More or less completely septate bladder, atresia ani, or more rarely double anus, double urethra, increased breadth of the bony pelvis Avith defect of the symphysis pubis, and possibly duplication of the loAver end of the spine, and hernia of some of the abdom- inal contents into a perineal pouch. Much more rarely, duplication of the heart, lungs, stomach, and kidneys has been noted, and the loAver limbs may be shorter than normal. Class XI.—Cases of fetus in fetu, those strange instances in which one might almost say that a man may be pregnant Avith his brother or sister, or in a 759, 1895. 200 MAJOR TERATA. which an infant may carry its twin Avithout the fact being apparent, Avill next be discussed. The older cases Avere cited as being only a repetition of the process by which Eve Avas born of Adam. Figure 63 represents an old engraving shoAving the birth of Eve. Bartholinus, the Ephemerides, Otto, Paullini, Schurig, and Plot speak of instances of fetus in fetu. Ruysch a describes a tumor contained in the abdomen of a man Avhich Avas composed of hair, molar teeth, and other evidences of a fetus. Huxham reported to the Royal Society in 1748 the history of a child Avhich Avas born Avith a tumor near the anus larger than the Avhole body of the child ; this tumor contained rudiments of an embryo. Youngb speaks of a fetus Avhich lay encysted betAveen the laminae of the transArerse mesocolon, and Highmore published a report of a fetus in a cyst communicating Avith the duodenum. Dupuytren gives an example in a boy of thirteen, in whom Avas found a fetus. Gaetano-Nocito, cited by Philipeaux,302 has the history of a man of twenty-seven AA'ho was taken Avith a great pain in the right hypochondrium, and from which issued subsequently fetal bones and a mass of macerated embryo. His mother had had several double pregnancies, and from the length of the respectiA^e tibiae one of the fetuses seemed to be of two months' and the other of three months' intrauterine life. The man died five years after the Fig. 63.-Birth of Eve (after an old engraving). abscess had burst spontaneously. Brodie c speaks of a case in Avhich fetal remains Avere taken from the abdomen of a girl of two and one-half years. Gaither d describes a child of tAvo years and nine months, supposed to be affected Avith ascites, who died three hours after the physician's arrival. In its abdomen was found a fetus Aveighing almost two pounds and connected to the child by a cord resembling an umbilical cord. This child Avas healthy for about nine months, and had a precocious longing for ardent spirits, and drank freely an hour before its death. Blundell e says that he knew " a boy avIio was literally and Avithout evasion Avith child, for the fetus Avas contained in a sac communicating Avith the ab- domen and Avas connected to the side of the cyst by a short umbilical cord • nor did the fetus make its appearance until the boy Avas eight or ten years a 698, Tome ii. b 550, i., 234. c 550, 1819. d 598, 1809, i., 170 et seq. e 476) 1828-1829, 260. FETUS IN FETU. 201 old, when after much enlargement of pregnancy and subsequent flooding the boy died." The fetus, removed after death, on the whole not very imper- fectly formed, was of the size of about six or seA^en months' gestation. Bury a cites an account of a child that had a second imperfectly developed fetus in its face and scalp. There was a boy by the name of Bissieub who from the earliest age had a pain in one of his left ribs ; this rib was larger than the rest and seemed to have a tumor under it. He died of phthisis at fourteen, and after death there Avas found in a pocket lying against the transverse colon and communicating with it all the evidences of a fetus. At the Hopital de la Charite in Paris, Velpeau startled an audience of 500 students and many physicians by saying that he expected to find a rudi- mentary fetus in a scrotal tumor placed in his hands for operation. His diagnosis proved correct, and brought him resounding praise, and all Avon- dered as to his reasons for expecting a fetal tumor. It appears that he had read with care a report by Fattic of an operation on the scrotum of a child which had increased in size as the child grew, and was found to contain the ribs, the vertebral column, the lower extremities as far as the knees, and the two orbits of a fetus ; and also an accountd of a similar operation performed by Wendt of Breslau on a Silesian boy of seven. The left testicle in this case was so swollen that it hung almost to the knee, and the fetal remains removed weighed seven ounces. Sulikowski e relates an instance of congenital fetation in the umbilicus of a girl of fourteen, who recovered after the removal of the anomaly. Are- taeos described to the members of the medical fraternity in Athensf the case of a woman of twenty-two, avIio bore two children after a seven months' preg- nancy. One Avas very rudimentary and only 2 J inches long, and the other had an enormous head resembling a case of hydrocephalus. On opening the head of the second fetus, another, three inches long, was found in the medulla oblongata, and in the cranial cavity Avith it were two additional fetuses, neither of which Avas perfectly formed. Broca g speaks of a fetal cyst being passed in the urine of a man of sixty- one ; the cyst contained remnants of hair, bone, and cartilage. Atlee h sub- mits quite a remarkable case of congenital ventral gestation, the subject being a girl of six, who recovered after the discharge of the fetal mass from the abdomen. Mclntyrei speaks of a child of eleven, playing about and feeling Avell, but whose abdomen progressively increased in size 1J inches each day. After ten davs there Avas a large fluctuating mass on the right side; the abdomen Avas opened and the mass enucleated ; it was found to contain a fetal mass Aveighing nearly five pounds, and in addition ten pounds of fluid Avere remoATed. The child made an early recovery. Rogers ■> mentions a fetus that a 490, 1834. b 302, iv., 179. c 240, 1826. ^240, 1829. e 233,' 1851-2, 17, 143. f 536, April 16, 1862. 8 362, No. 26, 1868. h768, 1879. l 616, Feb., 1894. J 131, 1875. 202 MAJOR TERATA. was found in a man's bladder. Bouchacourt a reports the successful extir- pation of the remains of a fetus from the rectum of a child of six. Miner b describes a successful excision of a congenital gestation. Modern literature is full of examples, and nearly every one of the fore- going instances could be paralleled from other sources. Rodriguez c is quoted as reporting that in July, 1891, several neAvspapers in the city of Mexico published, under the head of " A Man-mother," a Avonderful story, accom- panied by wood-cuts, of a young man from whose body a great surgeon had extracted a " perfectly developed fetus." One of these wood-cuts represented a tumor at the back of a man opened and containing a crying baby. In commenting upon this, after revieAving several similar cases of endocymian monsters that came under his observation in Mexico, Rodriguez tells Avhat the case Avhich had been so grossly exaggerated by the lay journals really was : An Indian boy, aged twenty-two, presented a tumor in the sacrococ- cygeal region measuring 53 cm. in circumference at the base, haAring a ATertical diameter of 17 cm. and a transverse diameter of 13 cm. It had no pedicle and was fixed, shoAving unequal consistency. At birth this tumor was about the size of a pigeon's egg. A diagnosis of dermoid cyst was made and two operations were performed on the boy, death following the second. The skeleton showed interesting conditions; the rectum and pelvic organs were natural, and the contents of the cyst verified the diagnosis. Quite similar to the cases of fetus in fetu are the instances of dermoid Cysts. For many years they have been a mystery to physiologists, and their origin now is little more than hypothetic. At one time the fact of finding such a formation in the ovary of an unmarried Avoman Avas presumptive evidence that she was unchaste; but this idea was dissipated as soon as examples were reported in children, and to-day Ave have a Avell-defined difference between congenital and extrauterine pregnancy. Dermoid cysts of the ovary may consist only of a wall of connective tissue lined Avith epidermis and contain- ing distinctly epidermic scales Avhich, hoAvever, may be rolled up in firm masses of a more or less soapy consistency; this A'ariety is called by Orth epidermoid cyst; or, according to Warren, a form of cyst made up of skin containing small and ill-defined papillae, but rich in hair follicles and seba- ceous glands. Even the erector pili muscle and the sudoriparous gland are often found. The hair is partly free and rolled up into thick balls or is still attached to the Avails. A large mass of sebaceous material is also found in these cysts. Thomson reports a case of dermoid cyst of the bladder con- taining hair, AA'hich cyst he removed. It was a pedunculated groAvth, and it Avas undoubtedly vesical and not expelled from some ovarian source through the urinary passage, as sometimes occurs. The simpler forms of the ordinary dermoid cysts contain bone and teeth. The complicated teratoma of this class may contain, in addition to the pre- a 368, 1850. b 230, 1874. c 791, April, 1893. PLATE 3. Dermoid cyst laid open, showing maxillary bone containing teeth ; the head of one of the Ion" bones : skin with hair growing from its surface ; serous membrane (probe passed under- neath) : mucous membrane <>f stomach directly next to serous membrane (Baldy). DERMOID CYSTS. 203 viously mentioned structures, cartilage and glands, mucous and serous mem- brane, muscle, nerves, and cerebral substance, portions of eyes, fingers with nails, mammae, etc. Figure 64 represents a cyst containing long red hair that was removed from a blonde Avoman aged forty-four years Avho had giA'en birth to six children. Cullingworth reports the history of a woman in whom both ovaries were apparently involved by dermoids, who had given birth to 12 children and had three miscarriages—the last, three months before the removal of the groAvths. The accompanying illustration (PI. 3), taken Fig. 64.—Dermoid cyst containing long red hair, removed from a light-haired woman aged forty-four years (Montgomery). from Baldy,a pictures a dermoid cyst of the complicated variety laid open and exposing the contents in situ. Mears of Philadelphia reports a case of ovarian cyst remoA7ed from a girl of six and a half by Bradford of Kentucky in 1875. From this age on to adult life many similar cases are recorded. Nearly every medical museum has preserved specimens of dermoid cysts, and almost all physicians are well acquainted Avith their occurrence. The curious formations and contents and the bizarre shapes are of great variety. Graves b mentions a dermoid cyst containing the left side of a human a " An American Text-Book of Gynecology," Philadelphia, 1894. *> 533, 1895, 212. 204 MAJOR TERATA. face, an eye, a molar tooth, and various bones. Dermoid cysts are found also in regions of the body quite remote from the ovary. The so-called " orbital wens are true inclusion of the skin of a congenital origin, as are the nasal dermoids and some of the cysts of the neck. Weil reported the case of a man of twenty-tAvo years avIio was born Avith Avhat Avas supposed to be a spina bifida in the lower sacral region. Accord- ing to Senn, the SAvelling never caused any pain or inconvenience until it in- flamed, Avhen it opened spontaneously and suppurated, discharging a large quantity of offensiAre pus, hair, and sebaceous material, thus proA'ing it to have been a dermoid. The cyst Avas freely incised, and there were found numer- ous openings of sAA'eat glands, from which drops of perspiration escaped Avhen Fig. 65.—Large lingual dermoid protruding from the mouth Museum of St. Bartholo- (afterGray)- mew's Hospital in London there is a congenital tumor which was removed from the anterior mediastinum of a woman of twenty- one, and contained portions of skin, fat, sebaceous material, and two pieces of bone similar to the superior maxilla, and in which several teeth were found. Dermoids are found in the palate and pharynx, and open dermoids of the conjunctiva are classified by Sutton with the moles. According to Senn, Barker collected sixteen dermoid tumors of the tongue. Bryk successfully removed a tumor of this nature the size of a fist. Wellington Gray removed an enormous lingual dermoid from the mouth of a negro. It con- tained 40 ounces of atheromatous material (Fig. 65). Dermoids of the rectum are reported. Dtiyse a reports the history of a case of labor during which a rectal dermoid was expelled. The dermoid contained a cerebral vesicle, a a La Flandre Med., March 14, 1895. MULTIPLE DERMOID CYSTS. 205 rudimentary eye, a canine and a molar tooth, and a piece of bone. There is little doubt that many cases of fetus in fetu reported Avere really dermoids of the scrotum. Ward a reports the successful removal of a dermoid cyst weighing 30 pounds from a Avoman of thirty-tAvo, the mother of tAvo children aged ten and tAvelve, respectively. The report is briefly as folloAvs : " The patient has always been in good health until Avithin the last year, during AA'hich time she has lost flesh and strength quite rapidly, and Avhen brought to my hospital by her physician, Dr. James of Williamsburg, Kansas, was quite weak, although able to Avalk about the house. A tumor had been groAving for a number of years, but its growth Avas so gradual that the patient had not considered her condition critical until quite recently. The tumor was diagnosed to be cystoma of the left ovary. Upon opening the sac Avith the trocar we were confronted by complications entirely unlooked for, and its use had to be abandoned entirely because the thick contents of the cyst Avould not flow freely, and the presence of sebaceous matter blocked the in- strument. As much of the fluid as possible AA'as removed, and the abdominal incision was enlarged to alloAv of the removal of the large tumor. An ovarian hematoma the size of a large orange Avas remoAred from the right side. We Avashed the intestines quite as one Avould Avash linen, since some of the contents of the cyst had escaped into the abdominal cavity. The ab- domen was closed without drainage, and the patient placed in bed without experiencing the least shock. Her recoArery Avas rapid and uneventful. She returned to her home in four weeks after the operation. " The unusual feature in this case Avas the nature of the contents of the sac. There Avas a large quantity of long straight hair groAving from the cyst Avail and an equal amount of loose hair in short pieces floating through the tumor- contents, a portion of AA'hich formed nuclei for Avhat Ave re called 'moth-balls,' of which there Avere about 1J gallons. These balls, or marbles, varied from the size of moth-balls, as manufactured and sold by druggists, to that of small walnuts. They seemed to be composed of sebaceous matter, and Avere evi- dently formed around the short hairs by the motion of the fluid produced by walking or riding. There Avas some tissue resembling true skin attached to the inner aauII of the sac." There are several cases of multiple dermoid cysts on record, and they may occur all over the body. Jamieson b reports a case in Avhich there Avere 250, and in Maclarcn's case there Avere 132. According to Crocker, Hebra and Rayer also each had a case. In a case of Sangster, reported by Politzer, although most of the dermoids, as usual, Avere like fibroma-nodules and therefore the color of normal skin, those over the mastoid processes and clavicle Avere lcmon-yelloAV, and Avere generally thought to be xanthoma until they were excised, and Politzer found they were typical dermoid cysts Avith the usual contents of degenerated epithelium and hair. a Internat. Med. Magaz., Phila., July, 1895. b 318, Sept., 1873, 223. 206 MAJOR TERATA. Hermaphroditism.—Some writers claim that Adam was the first herma- phrodite and support this by Scriptural evidence.3 We find in some of the ancient poets traces of an Egyptian legend in AA'hich the goddess of the moon Avas considered to be both male and female. From mythology avc learn that Hermaphroditus Avas the son of Hermes, or Mercury, and Venus Aphrodite, and had the poAvers both of a father and mother. In speaking of the fore- going Ausonius Avrites, "Cujus erat facies in qua paterst pronounced, then the individual could call himself a man. " Hermaphro- dites an ad testamentum adhiberi possit qualitas sexus incalescentis ostendit." There is a peculiar case on record b in which the question of legal male inheritance was not settled until the individual had lived as a female for fifty- one years. This person was married when twenty-one, but finding coitus impossible, separated after ten years, and though dressing as a female had coitus with other women. She finally lived with her brother, with whom she eventually came to blows. She prosecuted him for assault, and the brother in return charged her with seducing his wife. Examination ensued, and at this ripe age she Avas declared to be a male. The literature on hermaphroditism is so extensive that it is impossible to select a proper representation of the interesting cases in this limited space, and the reader is referred to the modern French works on this subject, in which the material is exhaustive and the discussion thoroughly scientific. ' a 302, xxi., 104. b 359> July ^ 1Qg5 CHAPTER VI. MINOR TERATA. Ancient Ideas Relative to Minor Terata.—The ancients viewed with great interest the minor structural anomalies of man, and held them to be divine signs or Avarnings in much the same manner as they considered more pronounced monstrosities. In a most interesting and instructive article, Ballantyne a quotes Ragozin in saying that the Chaldeo-Babylonians, in addi- tion to their other numerous subdivisions of divination, dreAV presages and omens for good or evil from the appearance of the liver, boAvels, and viscera of animals offered for sacrifice and opened for inspection, and from the natural defects or monstrosities of babies or the young of animals. Ballan- tyne names this latter subdh-ision of divination fetomancy or teratOSCOpy, and thus renders a special chapter as to omens derived from monstrous births, given by Lenormant:— " The prognostics which the Chaldeans claimed to draw from monstrous births in man and the animals are Avorthy of forming a class by themselves, insomuch the more as it is the part of their divinatory science with which, up to the present time, Ave are best acquainted. The development that their astrology had given to ' gen6thliaque,' or the art of horoscopes of births, had led them early to attribute great importance to all the teratologic facts Avhich Avere there produced. They claimed that an experience of 470,000 years of observations, all concordant, fully justified their system, and that in nothing Avas the influence of the stars marked in a more indubitable manner than in the fatal laAV AA'hich determined the destiny of each individual according to the state of the sky at the moment when he came into the world. Cicero, by the very terms Avhich he uses to refute the Chaldeans, shoAvs that the result of these ideas Avas to consider all infirmities and mon- strosities that neAV-born infants exhibited as the inevitable and irremediable consequence of the action of these astral positions. This being granted, the observation of similar monstrosities gave, as it were, a reflection of the state of the sky, on Avhich depended all terrestrial things ; consequently, One might read in them the future Avith as much certainty as in the stars themsehres. For this reason the greatest possible importance Avas attached to the terato- logic auguries Avliich occupy so much space in the fragments of the great a 759, i., 127. 213 214 MINOR TERATA. treatise on terrestrial presages Avhich have up to the present time been pub- lished." The rendering into English of the account of t>2 teratologic cases in the human subject Avith the prophetic meanings attached to them by Chaldean diviners, after the translation of Opport, is given as folloAvs by Ballantyne, some of the Avords being untranslatable :— " When a woman gives birth to an infant— (1) that has the ears of a lion, there will be a powerful king in the country; (2) that wants the right ear, the days of the master (king) will be prolonged (reach old age) ; (3) that wants both ears, there will be mourning in the country, and the country will be lessened (diminished); (4) whose right ear is small, the house of the man (in whose house the birth took place) will be destroyed; (5) whose ears are both small, the house of the man will be built of bricks; (6) whose right ear is mudissu tehaat (monstrous), there will be an androgyne in the house of the newdiorn; (7) whose ears are both mudissu (deformed), the country will perish and the enemy rejoice ; (8) whose right ear is round, there will be an androgyne in the house of the new-born ; (9) whose right ear has a wound below, and tar re ut of the man, the house will be destroyed; (10) that has two ears on the right side and none on the left, the gods will bring about a stable reign, the country will flourish, and it will be a land of repose ; (11) whose ears are both closed, sa a au; (12) that has a bird's beak, the country will be peaceful; (13) that has no mouth, the mistress of the house will die ; (14) that has no right nostril, the people of the world will be injured ; (15) whose nostrils are absent, the country will be in affliction, and the house of the man will be ruined; (16) whose jaws are absent, the days of the master (king) will be prolonged, but the house (where the infant is born) will be ruined. When a woman gives birth to an infant— (17) that has no lower jaw, mut ta at mat, the name will not be effaced ; (20) that has no nose, affliction will seize upon the country, and the master of the house will die; (21) that has neither nose nor virile member (penis), the army of the king will be strong, peace will be in the land, the men of the king will be sheltered from evil influences, and Lilit (a female demon) shall not have power over them ; (22) whose upper lip overrides the lower, the people of the world will rejoice {or good augury for the troops); (23) that has no lips, affliction will seize upon the land, and the house of the man will he destroyed; (24) whose tongue is huri aat, the man will be spared (?); (25) that has no right hand, the country will be convulsed by an earthquake ; (26) that has no fingers, the town will have no births, the bar shall be lost; (27) that has no fingers on the right side, the master (king) will not pardon his adversary {or shall be humiliated by his enemies) ; (28) that has six fingers on the right side, the man will take the lukunu of the house ; (29) that has six very small toes on both feet, he shall not go to the lukunu; (30) that has six toes on each foot, the people of the world will be injured (calamity to the troops); ANCIENT IDEAS RELATIVE TO MINOR TERATA. 215 (31) that has the heart open and that has no skin, the country will suffer from calamities ; (32) that has no penis, the master of the house will be enriched by the harvest of his field ; (33) that wants the penis and the umbilicus, there will be ill-will in the house, the woman (wife) will have an overbearing eye (be haughty); but the male descent of the palace will be more extended. When a woman gives birth to an infant— (34) that has no well-marked sex, calamity and affliction will seize upon the land ; the master of the house shall have no happiness ; (35) whose anus is closed, the country will suffer from want of nourishment; (36) whose right testicle (?) is absent, the country of the master (king) will perish ; (37) whose right foot is absent, his house will be ruined and there will be abundance in that of the neighbor ; (38) that has no feet, the canals of the country will be cut (intercepted) and the house ruined ; (39) that has the right foot in the form of a fish's tail, the booty of the country of the humble will not be imas sa bir; (40) whose hands and feet are like four fishes' tails (fins), the master (king) shall perish (?) and his country shall be consumed ; (41) whose feet are moved by his great hunger, the house of the su su shall be destroyed ; (42) whose foot hangs to the tendons of the body, there will be great prosperity in the land; (43) that has three feet, two in their normal position (attached to the body) and the third between them, there will be great prosperity in the land ; (44) whose legs are male and female, there will be rebellion ; (45) that wants the right heel, the country of the master (king) will be destroyed. When a woman gives birth to an infant— (46) that has many white hairs on the head, the days of the king will be prolonged ; (47) that has much ipga on the head, the master of the house will die, the house will be destroyed; (48) that has much pinde on the head, joy shall go to meet the house (that has a head on the head, the good augury shall enter at its aspect into the house) ; (49) that has the head full of hali, there will be ill-will toward him and the master (king) of the town shall die ; (50) that has the head full of siksi, the king will repudiate his masters; (51) that has some pieces of flesh (skin) hanging on the head, there shall be ill-will; (52) that has some branches (?) (excrescences) of flesh (skin) hanging on the head, there shall be ill-will, the house will perish ; (53) that has some formed fingers (horns ?) on the head, the days of the king will be less and the years lengthened (in the duration of his old age); (54) that has some kali on the head, there will be a king of the land ; (55) that has a----of a bird on the head, the master of the house shall not prosper ; (56) that has some teeth already through (cut), the days of the king will arrive at old age, the country will show itself powerful over (against) strange (feeble) lands, but the house where the infant is born will be ruined ; (57) that has the beard come out, there will be abundant rains ; (58) that has some birta on the head, the country will be strengthened (reinforced) ; (59) that has on the head the mouth of an old man and that foams (slabbers), there will be great prosperity in the land, the god Bin will give a magnificent harvest (inundate the land with fertility), and abundance shall be in the land ; (60) that has on one side of the head a thickened ear, the first-born of the men shall live a long time (?); 216 MINOR TERATA. (61) that has on the head two long and thick ears, there will be tranquility and the pacifi- cation of litigation (contests); (62) that has the figure in horn (like a horn ?) . . ." As ancient and as obscure as are these records, Ballantyne has carefully gone over each, and gives the following lucid explanatory comments :— " What 'ears like a lion' (No. 1) may have been it is difficult to determine ; but doubt- less the direction and shape of the auricles were so altered as to give them an animal appearance, and possibly the deformity was that called 'orechio ad ansa' by Lornbroso. The absence of one or both ears (Nos. 2 and 3) has been noted in recent times by Virchow (Archiv fur path. Anat., xxx., p. 221), Gradenigo (Taruffi's ' Storia della Teratologia,' vi., p. 552), and others. Generally some cartilaginous remnant is found, but on this point the Chaldean record is silent. Variations in the size of the ears (Nos. 4 and 5) are well known at the present time, and have been discussed at length by Binder (Archiv fur Psychiatrie und Nervenkrankheiten, xx., 1887) and others. The exact malformation indicated in Nos. 6 and 7 is, of course, not to be determined, although further researches in Assyriology may clear up this point. The 'round ear' (No. 8) is one of Binder's types, and that with a ' wound below' (No. 9) probably refers to a case of fistula auris congenita (Toyn- bee, 'Diseases of the Ear,' 1860). The instance of an infant born with two ears on the right side (No. 10) was doubtless one of cervical auricle or preauricular appendage, whilst closure of the external auditory meatus (No. 11) is a well-known deformity. "The next thirteen cases (Nos. 12-24) were instances of anomalies of the mouth and nose. The 'bird's beak' (No. 12) may have been a markedly aquiline nose; No. 13 was a case of astoma; and Nos. 14 and 15 were instances of stenosis or atresia of the anterior nares. Fetuses with absence of the maxillae (Nos. 16 and 17) are in modern terminology called agnathous. Deformities like that existing in Nos. 20 and 21 have been observed in paracephalic and cyclopia fetuses. The coincident absence of nose and penis (No. 21) is interesting, especially when taken in conjunction with the popular belief that the size of the former organ varies with that of the latter. Enlargement of the upper lip (No. 22), called epimacrochelia by Taruffi, and absence of the lips (No. 23), known now under the name of braehychelia, have been not unfrequently noticed in recent times. The next six cases (Nos. 25-30) were instances of malformations of the upper limb : Nos. 25, 26, and 27 were prob- ably instances of the so-called spontaneous or intrauterine amputation; and Nos. 28, 29, and 30 were examples of the comparatively common deformity known as Polydactyly. No. 31 was probably a case of ectopia cordis. "Then follow five instances of genital abnormalities (Nos. 32-36), consisting of absence of the penis (epispadias ?), absence of penis and umbilicus (epispadias and exomphalos ?), hermaphroditism, imperforate anus, and nondescent of one testicle. The nine following cases (Nos. 37-45) were anomalies of the lower limbs : Nos. 37, 38, and 42 may have been spontaneous amputations; Nos. 39 and 40 were doubtless instances of webbed toes (syn- dactyly), and the deformity indicated in No. 45 was presumably talipes equinus. The infant born with three feet (No. 43) was possibly a case of parasitic monstrosity, several of which have been reported in recent teratologic literature ; but what is meant by the state- ment concerning ' male and female legs ' it is not easy to determine. "Certain of the ten following prodigies (Nos. 46-55) cannot in the present state of our knowledge be identified. The presence of congenital patches of white or gray hair on the scalp, as recorded in No. 46, is not an unknown occurrence at the present time ; but what the Chaldeans meant by ipga, pinde, hali, siksi, and kali on the head of the new-born infant it is impossible to tell. The guess may be hazarded that cephalhematoma, hydro- cephalus, meningocele, nevi, or an excessive amount of vernix caseosa were the conditions indicated, but a wider acquaintance with the meaning of the cuneiform characters is neces- sary before any certain identification is possible. The ' pieces of skin hanging from the ABNORMAL ELASTICITY OF THE SKIN. 217 head' (No. 51) may have been fragments of the membranes ; but there is nothing in the accompanying prediction to help us to trace the origin of the popular belief in the good luck following the baby born with a caul. If No. 53 was a case of congenital horns on the head, it must be regarded as a unique example, unless, indeed, a form of fetal ichthyosis be indicated. "The remaining observations (No. 56-62) refer to cases of congenital teeth (No. 56), to deformity of the ears (Nos. 60 and 61), and a horn (No. 62)." From these early times almost to the present day similar significance has been attached to minor structural anomalies. In the following pages the individual anomalies Avill be discussed separately and the most interesting examples of each Avill be cited. It is manifestly evident that the object of this chapter is to mention the most striking instances of abnormism and to give accompanying descriptions of associate points of interest, rather than to offer a scientific exposition of teratology, for which the reader is referred elsewhere. Congenital defect of the epidermis and true skin is a rarity in pathology. Pastorelloa speaks of a child which lived for tAvo and a half hours Avhose hands and feet Avere entirely destitute of epidermis ; the true skin of those parts looked like that of a dead and already putrefying child. Hanks b cites the history of a case of antepartum desquamation of the skin in a living fetus. Hochstetterc describes a full-term, living male fetus Avith cutaneous defect on both sides of the abdomen a little above the umbilicus. The placenta and membranes were normal, a fact indicating that the defect Avas not due to amniotic adhesions; the child had a club-foot on the left side. The mother had a fall three weeks before labor. Abnormal Elasticity of the Skin.—In some instances the skin is affixed so loosely to the underlying tissues and is possessed of so great elas- ticity that it can be stretched almost to the same extent as India rubber. There have been individuals who could take the skin of the forehead and pull it down OA^er the nose, or raise the skin of the neck over the mouth. They also occasionally haA'e an associate muscular development in the sub- cutaneous tissues similar to the panniculus adiposus of quadrupeds, giving them preternatural motile power over the skin. The man recently exhibited under the title of the " Elastic-Skin Man " was an example of this anomaly. The first of this class of exhibitionists Avas seen in Buda-Pesth some years since and possessed great elasticity in the skin of his Avhole body ; even his nose could be stretched. Figure 70 represents a photograph of an exhibi- tionist named Felix Wehrle, Avho besides having the power to stretch his skin could readily bend his fingers backward and forward. The photograph was taken in January, 1888. In these congenital cases there is loose attachment of the skin without hypertrophy, to Avhich the term dermatolysis is restricted by Crocker. Job van Meekren,560 the celebrated Dutch physician of the seventeenth century, a 153, July, 1845. b 125, 1880, 595. c 263, 1894, 542. 218 MINOR TERATA. states that in 1657 a Spaniard, Georgius Albes, is reported to have been able to draw the skin of the left pectoral region to the left ear, or the skin under the face over the chin to the vertex. The skin over the knee could be extended half a yard, and when it retracted to its normal position it was not in folds. Seiffert examined a case of this nature in a young man of nineteen, and, contrary to Kopp's supposition, found that in some skin from OA'er the left second rib the elastic fibers were quite normal, but there avus transforma- tion of the connective tissue of the dermis into an unformed tissue like a myxoma, with total disappearance of the connective-tissue bundles. Laxity of the skin after distention is often seen in multipara, both in the breasts and in the abdominal Avails, and also from obesity, but in all such cases the skin falls in folds, and does not have a normal appear- ance like that of the true " elastic-skin man. Occasionally abnormal development of the scalp is noticed. McDowall a records an instance in an epileptic idiot of twenty-two. On each side of the median line of the head there were five deep furroAVS (Fig. 71), more curved and shorter as the distance from the median line increased. In the illustration the hair in the furrows is left longer than that on the rest of the head. The patient AAas distinctly microcephalic and the right side of the body was markedly Avasted. The folds were due to hyper- trophy of the muscles and scalp, and the same sort of furrowing is noticed Avhen a dog " pricks his ears." This ease may possibly be considered as an example of reversion to inferior types. CoAvan b records two cases of the foregoing nature in idiots. The first case (Fig. 72) Avas a paralytic idiot of thirty-nine, Avhose cranial development Avas small in proportion to the size of the face and body ; the cranium was oxycephalic ; the scalp Avas lax and redundant and the hair thin ; there were 13 furrows, five on each side running anteroposteriorly, and three in the occipital region running transversely. The occipitofrontalis muscle had no action on them. The second case Avas that of an idiot of forty-four of a more degraded type than the previous one. The cranium Avas round and bullet-shaped and the hair a 465, Jan., 1893. b 465, Oct., 1893. Fig. 70.—An "elastic-skin man." IMPERVIOUS SKIN. 219 generally thick. The scalp Avas not so lax as in the other case, but the furroAvs avc re more crooked. By tickling the scalp over the back of the neck the two median furroAvs irn'oluntarily deepened. Impervious Skin.—There have been individuals who claimed that their skin Avas impervious to ordinary puncture, and from time to time these indi- viduals have appeared in some of the larger medical clinics of the Avorld for inspection. According to a recent number of the London Graphic, there is in Berlin a Singhalese Avho baffles all investigations by physicians bv the impenetrability of his skin. The bronzed Easterner, a Hercules in shape, claims to have found an elixir Avhich Avill render the human skin imperious to any metal point or sharpened edge of a knife or dagger, and calls himself the " Man Avith Iron Skin." He is noAv exhibiting himself, and his greatest feat is to pass Avith his entire body through a hoop the inside of Avhich is hardly Fig. 71.—Abnormal development of scalp (McDowall). Fig. 72.—Abnormal development of scalp (Cowan). big enough to admit his body and is closely set with sharp knife-points, dag- gers, nails, and similar things. Through this hoop he squeezes his body with absolute impunity. The physicians do not agree as to his immunity, and some of them think that Rhannin, Avhich is his name, is a fakir who has by long practice succeeded in hardening himself against the impressions of metal upon his skin. The professors of the Berlin clinic, hoAvever, consid- ered it Avorth Avhile to lecture about the man's skin, pronouncing it an inex- plicable matter. This individual performed at the London Alhambra in the latter part of 1895. Besides climbing Avith bare feet a ladder Avhose rungs Avere sharp-edged sAvords, and lying on a bed of nail points Avith four men seated upon him, he curled himself up in a barrel, through Avhose inner edges nails projected, and Avas rolled about the stage at a rapid rate. Emerging from thence uninjured, he gracefully boAvs himself off the stage. 220 MINOR TERATA. Some individuals claim immunity from burns and show many interesting feats in handling fire. As they are nothing but skilful " fire jugglers" they deserve no mention here. The immunity of the participants in the savage fire ceremonies Avill be discussed in Chapter IX. Albinism is characterized by the absolute or relative absence of pigment of the skin, due to an arrest, insufficiency, or retardation of this pigment. FolloAving Trelat and Guinard, Ave may divide albinism into tAvo classes,— general and partial. As to the etiology of albinism, there is no knoAvn cause of the com- plete form. Heredity plays no part in a num- ber of cases investigated by the authors. D'Aub6, by his observations on Avhite rabbits, believes that the influence of con- sanguinity is a marked factor in the production of albinism; there are, however, many instances of heredity in this ano- maly on record, and this idea is possibly in har- mony Avith the majority of obserATers. Geoffroy- Saint-Hilaire has noted that albinism can also be the consequence of a pathologic condition having its origin in ad- verse surroundings, the circumstances of the parents, such as the Avant of exercise, nourishment, light, etc. Lesser kneAV a family in Avhich six out of seven Avere albinos, and in some tropical countries, such as Loango, LoAver Guinea, it is said to be endemic. It is exceptional for the parents to be affected ; but in a case of Schlegel, quoted by Crocker, the grandfather Avas an albino, and Mareya describes the case of the Cape May albinos, in AA'hich the mother and father Avere " fair emblems of the African race," and of their children three Avere black and three Avere Avhite, born in the folloAving order: tAvo consecutive black boys, a 124, 1839. Fig. 73.—An albino family. ALBINISM. 221 tAvo consecutive white girls, one black girl, one white boy. Svm of Edin- burgh a relates the history of a family of seven children, avIio Avere alternately white and black. All but the seventh were living and in good health and mentally without defect. The parents and other relatives Avere dark. Figure 73 portrays an albino family by the name of Cavalier avIio exhibited in Minneapolis in 1887. Examples of the total absence of pigment occur in all races, but particu- larly is it interesting Avhen seen in negroes Avho are found absolutely Avhite but preserving all the characteristics of their race, as, for instance, the kinky, avooIIv hair, flattened nose, thick lips, etc. Rene Caille, in his " Voyage a Tombouctou," says that he suav a white infant, the offspring of a negro and negress. Its hair was white, its eyes blue, and its lashes flaxen. Its pupils Avere of a reddish color, and its physiognomy that of a Man dingo. He says such cases are not at all uncommon; they are really negro albinos. Thomas Jefferson, in his "History of Virginia," has an excellent description of these negroes, Avith their tremulous and Aveak eyes ; he remarks that they freckle easily. Buffon speaks of Ethiops Avith Avhite tAvins, and says that albinos are quite common in Africa, being generally of delicate constitution, twinkling eves, and of a Ioav degree of intelligence ; they are despised and ill-treated by the other negroes. Prichard, quoted by Sedgwick, speaks of a case of ataA'ic transmission of albinism through the male line of the negro race. The grandfather and the grandchild Avere albinos, the father being black. There is a case b of a brother and sister avIio Avere albinos, the parents being of ordinary color but the grandfather an albino. Coinde, quoted by Sedgwick, speaks of a man avIio, by tAvo different Avives, had three albino children. A description of the ordinary type of albino Avould be as folloAvs : The skin and hair are deprived of pigment; the eyebrows and eyelashes are of a brilliant Avhite or are yellowish ; the iris and the choroid are nearly or entirely deprived of coloring material, and in looking at the eye we see a roseate zone and the ordinary pink pupil; from absence of pigment they neces- sarily keep their eyes three-quarters closed, being photophobic to a high degree. They are amblyopic, and this is due partially to a high degree of ametropia (caused by crushing of the eyeball in the endeavor to shut out light) and from retinal exhaustion and nystagmus. Many authors haATe claimed that they have little intelligence, but this opinion is not true. Ordi- narily the reproductive functions arc normal, and if Ave exclude the results of the union of tAvo albinos we may say that these individuals are fecund. Partial albinism is seen. The parts most often affected are the genitals, the hair, the face, the top of the trunk, the nipple, the back of the hands and fingers. Folkerc reports the history of a case of an albino girl having pink eyes and red hair, the rest of the family having pink eyes and Avhite a 47G, July 11, 1891. *> 580, Aug., 1888. « 476, 1876, i., 795. 222 MINOR TERATA. hair. Partial albinism, necessarily congenital, presenting a piebald appear- ance, must not be confounded Avith leukoderma, which is rarely seen in the young and AA'hich Avill be described later. Albinism is found in the lower animals, and is exemplified ordinarily by rats, mice, croAvs, robins, etc. In the Zoologic Garden at Baltimore tAvo years ago Avas a pair of pure albino opossums. The Avhite elephant is cele- brated in the religious history of Oriental nations, and is an object of A^enera- tion and Avorship in Siam. White monkeys and Avhite roosters are also worshiped. In the Natural History Museum in London there are stuffed examples of albinism and melanism in the loAver animals. Melanism is an anomaly, the exact contrary of the preceding. It is characterized by the presence in the tissues and skin of an excessive amount of pigment. True total melanism is unknoAvn in man, in whom is only observed partial melanism, characterized simply by a pronounced coloration of [tart of the integument. Some curious instances have been related3 of an infant with a two-colored face, and of others with one side of the face white and the other black; whether they were cases of partial albinism or partial melanism cannot be ascertained from the descriptions. Such epidermic anomalies as ichthyosis, scleroderma, and molluscum sim- plex, sometimes appearing shortly after birth, but generally seen later in life, Avill be spoken of in the chapter on Anomalous Skin Diseases. Human horns are anomalous outgroAvths from the skin and are far more frequent than ordinarily supposed. Nearly all the older writers cite exam- ples. Aldrovandus, Amatus Lusitanus, BoerhaaA'e, Dupre, Schenck, Rh'er- ius, Vallisneri, and many others mention horns on the head. In the ancient times horns Avere symbolic of wisdom and power. Michael Angelo in his famous sculpture of Moses has given the patriarch a pair of horns. Rho- dius fi80 observed a Benedictine monk Avho had a pair of horns and who Avas addicted to rumination. Fabricius333 saw a man with horns on his head, Avhose son ruminated; the son considered that by A'irtue of his ruminating characteristics his father had transmitted to him the peculiar anomaly of the family. Fabricius Hildanus334 saw a patient with horns all over the body and another Avith horns on the forehead. Gastaherb speaks of a horn from the left temple ; Zacutus Lusitanus831 saw a horn from the heel; Wroe,629 one of considerable length from the scapula ; Cosnard, one from the bregma; the Ephemerides, from the foot; Borellus, from the face and foot, and Ash,c horns all OArer the body. Home, Cooper, and Treves have collected examples of horns, and there is one 11 inches long and 2J in circumference in a London museum. Lozes collected reports of 71 cases of horns,—37 in females, 31 in males, and three in infants. Of this number, 15 Avere on the head, eight on the face, 18 on the lower extremities, eight on the trunk, and three on the glans a 683, 1696, 254. b 418, 1776. c 629, 176. HUMAN HORNS. 223 penis. Wilson* collected reports of 90 cases,—44 females, 39 males, the sex not being mentioned in the remainder. Of these 48 Avere on the head, four on the face, four on the nose, 11 on the thigh, three on the leg and foot, six on the back, five on the glans penis, and nine on the trunk. Lebert's 482 col- lection numbered 109 eases of cutaneous horns. The greater frequency among females is admitted by all authors. Old age is a predisposing cause. Several patients over seventy have been seen and one of ninety-seven.b Instances of cutaneous horns, Avhen seen and reported by the laity, gh'e rise to most amusing exaggerations and descriptions. The folloAving accountc is given in New South AVales, obviously embellished Avith apocryphal details by some facetious journalist: The child, five weeks old, Avas born Avith hair tAvo inches long all over the body; his features were fiendish and his eyes shone like beads beneath his shaggy broAvs. He had a tail 18 inches long, horns from the skull, a full set of teeth, and claw-like hands; he snapped like a dog and crawled on all fours, and refused the natural suste- nance of a normal child. The mother almost became an imbecile after the birth of the monster. The country people about Bomballa considered this devil-child a punishment for a rebuff that the mother gave to a JeAvish peddler selling Crucifixion-pictures. Vexed by his persistence, she said she would sooner have a devil in her house than his picture. Lampreyd has made a minute examination of the much-spoken-of " Horned Men of Africa." He found that this anomaly Avas caused by a congenital malformation and remarkable development of the infraorbital ridge of the maxillary bone (Fig. 74). He described several cases, and through an interpreter found that they were congenital, folloAved no history of traumatism, caused little inconA'enience, and Avere unassociated Avith dis- turbance of the sense of smell. He also learned that the deformity Avas quite rare in the Cape Coast region, and received no information tending to prove the conjecture that the tribes in West Africa used artificial means to produce the anomaly, although such custom is preA'alent among many aborigines. Probably the most remarkable case of a horn Avas that of Paul Rodrigues, a Mexican porter,e Avho, from the upper and lateral part of his head, had a horn 14 inches in circumference and divided into three shafts, Avhich he concealed by constantly Avearing a peculiarly shaped red cap. There is in Paris a Avax model of a horn, eight or nine inches in length, remoATed from an old woman by the celebrated Souberbielle. Figure 75 is from a Avax model supposed to haA'e been taken from life, shoAving an enormous grayish-black horn proceeding from the forehead. Warren mentions a case under the care of Dubois, in a Avoman from whose forehead greAV a horn six inches in diam- eter and six inches in height. It was hard at the summit and had a fetid a 550, vol. xxvii., p. 60. b 418, 1776, i., 311. c Quoted in 759, April, 1894. <1 224, 1S87, ii., 1273. e New York Medical Repository, 1820. 224 MINOR TERATA. odor. In 1696 there was an old woman in France Avho constantly shed long horns from her forehead, one of Avhich Avas presented to the king. Bartholinus mentions a horn 12 inches long. Voigtc cites the ease of an old Avoman avIio had a horn branching into three portions, coming from her fore- head. Sands a speaks of a woman who had a horn 6£ inches long, groAving from her head. There is an accountb of the extirpation of a horn nearly ten inches in length from the forehead of a Avoman of eighty-tAVO. Bojau c describes a woman of forty from Avhom he excised an excrescence resembling a ram's horn, groAving from the left parietal region. It curved forward and nearly reached the corresponding tuberosity. It Avas eight cm. long, tAvo cm. broad at the base, and 1J cm. at the apex, and AA'as quite mobile. It began to grow at the age of eleven and had constantly increased. Yidal presented Fig. 74.—" African horned man " (Lamprey). Fig. 75.—Wax model of a large frontal horn. before the Academie de Medecine in 1886 a twisted horn from the head of a Avoman. This excrescence was ten inches long, and at the time of presenta- tion reproduction of it AAas taking place in the woman. Figure 76 shoAvs a case of ichthyosis cornea pictured in the Lancet, 1850.d There Avas a Avoman of seventy-five, living near York,e Avho had a horny groAvth from the face Avhich she broke off and which began to reproduce, the illustration (Fig. 77) representing the growth during twelve months. Lallf mentions a horn from the cheek ; Gregory reports one that measured 7| inches long that was removed from the temple of a Avoman in Edinburgh; Chariere of Barnstaple saAV a horn that measured seven inches growing from the nape of a av Oman's neck ; Kameya lAva g speaks of a dermal horn of the a 597, 1851. b 124, 1857. 0 749, 1886, 487. d 476, 1850, ii., 342. e 779, xvi., 267. f 435,1883. 8 Tokei Iji Shinshi, 1881. HUMAN HORNS. 225 auricle ; Saxton of NeAv York has excised several horns from the tympanic membrane of the ear; Noyes a speaks of one from the eyelid; Bigelowb Fig. 76.—Ichthyosis cornea. Fig. 77.—Facial horn. mentions one from the chin; Minotc speaks of a horn from the lower lip, and Doran d of one from the neck. Goulde cites the instance of a horn growing from an epitheliomatous penis. The patient was fifty- two years of age and the victim of congenital phimosis. He Avas circumcised four years previously, and shortly after the wound healed there ap- peared a small wart, folloAved by a horn about the size of a marble. JcAvett speaks of a penile horn 3J inches long and 3f inches in diameter; Pick mentions one 2 J inches long (Fig. 78). There is an accountf of a Russian peasant boy Avho had a horn on his penis from earliest childhood. Johnson s mentions a case of a horn from the scrotum, Avhich Avas of sebaceous origin and AA'as subsequently sup- planted by an epithelioma. Ash reported the case of a girl named Annie Jackson, living in Waterford, Ireland, AA'ho had horny excres- a 538, 1869. b 331; l867) voi. xix. c 218, 1864. d 779^ 1881. e 476, 1887, i., 421. f 224, Aug. 13, 1887. 8 476, 1844. 15 Fig. 78. —Horn of the penis (after Pick). 226 MINOR TERATA. cences from her joints, arms, axilhe, nipples, ears, and forehead. Locke speaks of a boy at the Hopital de la Charite in Paris, avIio had horny excrescences four inches long and 1| inches in circumference groAving from his fingers and toes. Wagstatfea presents a horn Avhich greAV from the middle of the leg six inches beloAv the knee in a woman of eighty. It was a flattened spiral of more than two turns, and during forty years' groAvth had reached the length of 14.3 inches. Its height was 3.8 inches, its skin-attachment 1.5 inches in diameter, and it ended in a blunt extremity of 0.5 inch in diameter. Stephens b mentions a dermal horn on the buttocks at the seat of a carcino- matous cicatrix. Harris0 and Domonceaud speak of horns from the leg. Cruveilhiere saAV a Mexican Indian Avho had a horn four inches long and eight inches in circumference groAving from the left lumbar region. It had been saAved off twice by the patient's son and Avas finally extirpated by Faget. The length of the pieces Avas 12 inches. Bellamyf saAV a horn on the clitoris about the size of a tiger's claAV in a woman of seventy. It had its origin from beneath the preputium clitoridis. Horns are generally soli- tary, but cases of multiple formation are known. LeAvin and Heller record a syphilitic case with eight cutaneous horns on the palms and soles. A female patient of Manzu- roff had as many as 185 horns. Pancoast s reports the case of a man Avhose nose, cheeks, forehead, and lips Avere coArered Avith horny growths, Avhich had apparentlv undergone epitheliomatous degeneration. The patient AA'as a sea-captain of seventy-eight, and had been exposed to the Avinds all his life. He had suffered three attacks of erysipelas from prolonged exposure. When he consulted Pancoast the horns had nearly all fallen off and Avere brought to the physician for inspection ; and the photograph (Fig. 79) Avas taken after the patient had tied the horns in situ on his face. Anomalies of the Hair.—Congenital alopecia is quite rare, and it is seldom that Ave see instances of individuals Avho have been totally destitute of hair from birth. Danz h knew of two adult sons of a Jewish family Avho Fig. 79.—Cutaneous horns. Showing beginning epitheliomatous degeneration of the base (after Pancoast). a 779, 1870. d 462, xiv., 145. g 631, 1878. b 435, 1872. e Anat. patholog. du corps humain. c 527, 1842. f 779, 1870. h160, 1792. ANOMALIES OF THE HAIR. 227 neA'er had hair or teeth. Sedgwick a quotes the case of a man of fifty-eight avIio ever since birth Avas totally devoid of hair and in whom sensible perspira- tion and tears were absent. A cousin on his mother's side, born a year before him, had precisely the same peculiarity. Buffon says that the Turks and some other people practised depilatory customs by the aid of ointments and pomades, principally about the genitals. Atkinson b exhibited in Philadel- phia a man of forty avIio never had any distinct growth of hair since birth, was edentulous, and destitute of the sense of smell and almost of that of taste. He had no apparent perspiration, and when Avorking actively he was obliged to wet his clothes in order to moderate the heat of his body. He could sleep in wet clothes in a damp cellar Avithout catching cold. There was some hair in the axillse and on the pubes, but only the slightest down on the scalp, and even that was absent on the skin. His maternal grandmother and uncle were similarly affected ; he was the youngest of 21 children, had never been sick, and though not able to cheAV food in the ordinary manner, he had never suffered from dyspepsia in any form. He Avas married and had eight children. Of these, two girls lacked a number of teeth, but had the ordinary quantity of hair. Hillc speaks of an aboriginal man in Queensland who Avas entirely devoid of hair on the head, face, and every part of the body. He had a sister, since dead, who was similarly hairless. Hill men- tions the accounts given of another black tribe, about 500 miles west of Brisbane, that contained hairless members. This is very strange, as the Australian aboriginals are a very hairy race of people. Hutchinson d mentions a boy of three and a half in whom there was con- genital absence of hair and an atrophic condition of the skin and appendages. His mother was bald from the age of six, after alopecia areata. Schede re- ports two cases of congenitally bald children of a peasant woman (a boy of thirteen and a girl of six months). They had both been born quite bald, and had remained so. In addition there were neither eyebrows nor eyelashes and noAvhere a trace of lanugo. The children were otherwise healthy and well formed. The parents and brothers were healthy and possessed a full growth of hair. Thurman e reports a case of a man of fifty-eight, who was almost devoid of hair all his life and possessed only four teeth. His skin was very delicate and there Avas absence of sensible perspiration and tears. The skin Avas peculiar in thinness, softness, and absence of pigmentation. The hair on the croAvn of the head and back was very fine, short, and soft, and not more in quantity than that of an infant of three months. There was a similar pecu- liarity in his cousin-german. Williams mentions the case of a young lady of fifteen Avith scarcely any hair on the eyebrows or head and no eyelashes. She was edentulous and had never sensibly perspired. She improved under tonic treatment. a 222, 1863, i., 453. b 218, March 29, 1883. c 224, 1881. i., 177. d 650, 1885-6, ii., 116. e 550, xxxi., 71. 228 MINOR TERATA. Rayer quotes the case of Beauvais, avIio Avas a patient in the Hopital de la Charitein 1827. The skin of this man's cranium was apparently completely naked, although in examining it narroAvly it was found to be beset Avith a quantity of very Avhite and silky hair, similar to the down that covers the scalp of infants ; here and there on the temples there were a feAV black specks, occa- sioned by the stumps of several hairs AA'hich the patient had shaved off. The eyebrows Avere merely indicated by a feAV line and very short hairs ; the free edges of the eyelids were Avithout cilia, but the bulb of each of these Avas indi- cated by a small, Avhitish point. The beard was so thin and Aveak that Beauvais clipped it off only every three Aveeks. A few straggling hairs avc re observed on the breast and pubic region, as in young people on the approach of puberty. There was scarcely any under the axillae. It Avas rather more abundant on the inner parts of the legs. The voice was like that of a full-groAvn and avcII- constituted man. Beauvais was of an amorous disposition and had had syph- ilis twice. His mother and both sisters had good heads of hair, but his father presented the same defects as Beauvais. Instances are on record of Avomen devoid of hair about the genital region. Riolan says that he examined the body of a female libertine avIio was totally hairless from the umbilical region doAvn. Congenital alopecia is seen in animals. There is a species of dog, a native of China but now bred in Mexico and in the United States, which is distinguished for its congenital alopecia. The same fact has been observed occasionally in horses, cattle, and dogs. Heusner a has seen a pigeon desti- tute of feathers, and which engendered a female which in her turn transmitted the same characteristic to two of her young. Sexualism and Hair Growth.—The groAvth or development of the hair may be accelerated by the state of the organs of generation. This is peculiarly noticeable in the pubic hairs and the beard, and is fully exemplified in the sec- tion on precocious development (Chapter VII.); however, Moreau de la Sarthe shoAved a child to the Medical Faculty of Paris in whom precocious develop- ment of the testicles had influenced that of the hair to such a degree that, at the age of six, the chest of this boy Avas as thickly set Avith hair as is usually seen in adults. It is Avell knoAvn that eunuchs often lose a great part of their beards, and after removal of the ovaries Avomen are seen to develop an extra quantity of hair. Gerberonb tells of an infant Avith a beard, and Paullinic and the Ephemerides mention similar instances. Bearded women are not at all infrequent. Hippocrates mentions a female Avho greAv a beard shortly after menstruation had ceased. It is a well-recognized fact that after the menopause Avomen become more hirsute, the same being the case after removal of any of the functional generative apparatus. Vicat saw a virgin who had a beard, and Jochd a 390, 153. b 215, ann.,ii. c 620, cent, iii., obs. 64. d Dissert., etc., Jenae. BEARDED WOMEN. 229 speaks of " fceminis barbati." Leblonda says that certain Avomen of Ethiopia and South America have beards and little or no menstruation. He also says that sterility and exces- sive chastity are causes of female beards, and cites the case of Schott of a young widoAv who secluded herself in a cloister and soon had a beard. Barbara Urster, Avho lived in the 16th century, had a beard to her girdle. The most celebrated " bearded Avoman " Avas Rosine- Marguerite Muller, Avho died in a hospital in Dresden in 1732, with a thick beard and heavy mustache. Julia Pastrana had her face covered Avith thick hair and had a full beard and mus- tache. She exhibited defective dentition in both jaAvs, and the teeth present Avere arranged in an irregular fashion. She had pronounced prognathism, which gave her a simian appearance (Fig. 80). Ecker examined in 1876 a Avoman who died at Fribourg, whose face contained a full beard and a luxuriant mustache. Fig. 80.—Julia Pastrana. Fig. 81. Fig. 82. Harris b Lunatic a 302, Bearded insane women (Harris). reports seAreral eases of bearded Avomen, inmates of the Coton Hill .Vsvlum. One of the patients Avas eighty-three years of age and had iii. 9. b 224, June 2, 1894. 230 MINOR TERATA. been insane forty-four years following a puerperal period. She Avould not permit the hair on her face to be cut, and the curly white hairs had attained a length of from eight to ten inches on the chin, while on the upper lip the hairs Avere scarcely an inch. This patient Avas quite womanly in all her senti- ments (Fig. 81). The second case Avas a woman of thirty-six, insane from emotional melancholia. She had tufts of thick, curly hair on the chin two inches long, light yellowish in color, and a few straggling hairs on the upper lip. The third ease (Fig. 82) was that of a woman of sixty-four, who exhibited a strong passion for the male sex. Her menstruation had been regular until the menopause. She plaited her beard, and it was seven or eight inches long on the chin and one inch on the lip. This Avoman had extremely hairy legs. Another case Avas that of a Avoman of sixty- two, Avho, though bald, developed a beard before the climacteric. Her structural proportions were feminine in character, and it is said that her mother, Avho was sane, had a beard also. A curious case AA'as that of a Avoman of twenty- three (Mrs. Viola M.), Avho from the age of three had a considerable quantity of hair on the side of the cheek Avhich eventually became a full beard. She Avas quite feminine and Avas free from excessh'e hair elsewhere, her nose and forehead being singularly bare. Her voice Avas A'ery sAveet; she was married at seventeen and a half, having two normal children, and nursed each for one month. " The bearded woman " of every circus side-show is an evidence of the curious interest in which these Avomen are held. The accompanying illustration (Fig. 83) is a representation of a " bearded Avoman " born in Bracken County, Ky. Her beard measured 15 inches in length. There is a class of anomalies in Avhich there is an exaggerated develop- ment of hair. We Avould naturally expect to find the primitive peoples, Avho are not proAdded Avith artificial protection against the wind, supplied Avith an extra quantity of hair or having a hairy coat like animals ; but this is some- times found among civilized people. This abnormal presence of hair on the human body has been knoAvn for many years; the description of Esau in the Fig. 83.—"Bearded woman/ EXAGGERATED DEVELOPMENT OF HAIR. 231 Bible is an early instance. AldroA'andus says that in the sixteenth century there came to the Canary Islands a family consisting of a father, son, and tAvo daughters, Avho were covered all over their bodies by long hair, and their portrait, certainly reproduced from life, resembles the modern instances of " dog men." In 1883 there Avas sIioavu in England and France, afterward in America, a girl of seven named " Krao," a native of Indo-China. The Avhole body of this child Avas covered with black hair. Her face Avas of the prognathic tvpc, and this, with her extraordinary prehensile poAvers of feet and lips, gave her the title of " Danvin's missing link." In 1875 there Avas exhibited in Paris, under the name of " l'homme-chien" Adrien Jeftichew, a Russian Fig. 84.—Two examples of extreme hirsuties in a family. peasant of fifty-five, whose face, head, back, and limbs were covered with a broAvn hairy coat looking like avooI and several centimeters long. The other parts of the body were also covered Avith hair, but less abundantly. This individual had a son of three, Theodore, Avho was hairy like himself. A family living in Burmah (Shive-Maon, whose history is told by Craw- ford and Yule), consisting of a father, a daughter, and a granddaughter, were nearly covered Avith hair. Figure 84 represents a somewhat similar family Avho Avere exhibited in this country. Teresa Cambardella, a young girl of tAvelve, mentioned by Lombroso, was covered all over the body, with the exception of the hands and feet, by thick, bushy hair. This hypertrichosis Avas exemplified in this country only a few months since by a person Avho went the rounds of the dime museums under 232 MINOR TERATA. the euphonious name of " Jo-Jo, the dog-face bov." His face Avas truly that of a skye-terrier (Fig. 85). Sometimes the hairy anomalies are but instances of naevus pilosus. The Indian ourang-outang Avoman examined at the office of the Lancet was an example of this kind. Hcbra, Hildebrandt, Jablokoff, and Klein describe similar cases. Many of the older " wild men" Avere individuals bearing extensive hairy moles. Rayer remarks that he has seen a young man of sixteen avIio exhibited himself to the public under the name of a neAV species of Avild man AA'hose breast and back Avere covered Avith light broAvn hair of considerable length. Fig. 85.—"Jo-Jo." Fig. 86.—" Woman with a mane" (nsevus pilosus). The surface upon Avhich it grew was of a brownish hue, different from the color of the surrounding integument. Almost the whole of the right arm was covered in the same manner. On the lower extremity several tufts of hair were observed implanted upon broAvn spots from seven to eight lines in diameter symmetrically disposed upon both legs. The hair was broAvn, of the same color as that of the head. Bichata informs us that he saw at Paris an un- fortunate man who from his birth was afflicted Avith a hairy covering of his face like that of a wild boar, and he adds that the stories Avhich were current among the vulgar of individuals with a boar's head, Avolf's head, etc., un- a Anat. Generate, Paris, 1812, T. iv., 827. N.EVUS PILOSUS. 233 doubtedly referred to cases in Avhich the face Avas covered to a greater or less degree Avith hair. Villerme saAV a child of six at Poitiers in 1808 Avhose body, except the feet and hands, Avas covered with a great number of promi- nent broAvn spots of different dimensions, beset with hair shorter and not so strong as that of a boar, but bearing a certain resemblance to the bristles of that animal. These spots occupied about one-fifth of the surface of this child's skin. Campaignac in the early part of this century exhibited a case in Avhich there was a large tuft of long black hair groAving from the shoulder. Dufour a has detailed a case of a young man of twenty Avhose sacral region contained a tuft of hair as long and black, thick and pliant, as that of the head, and, particularly remarkable in this case, the skin from Avhich it greAV was as fine and white as the integument of the rest of the body. There Avas a Avoman exhibited recently, under the advertisement of " the lady with a mane," who had groAving from the center of her back betAveen the shoulders a veritable mane of long, black hair, which doubtless proceeded from a form of nsevus (Fig. 86). Duyse b reports a case of extensive hypertrichosis of the back in a girl aged nine years ; her teeth were normal; there was pigmentation of the back and numerous pigmentary ne\Ti on the face. Below each scapula there were tumors of the nature of fibroma molluscum. In addition to hairy nevi on the other parts of the body there was localized ichthyosis. Ziemssen figures an interesting case of nsevus pilosus resembling "bathing tights" (Fig. 87). There were also present several benign tumors (fibroma molluscum) and numerous smaller nevi over the body. Schulz first observed the patient in 1878. This individual's name was Blake, and he stated that he was born with a large nsevus spread- ing over the upper parts of the thighs and loAver parts of the trunk, like bathing-tights, and resembling the pelt of an animal. The same Avas true of the small hairy parts and the larger and smaller tumors. Subsequently the altered portions of the skin had gradually become somewhat larger. The skin of the large hairy nsevus, as Avell as that of the smaller ones, Avas stated by Schulz to have been in the main thickened, in part uneven, verrucose, from very light to intensely dark brown in color; the consistency of the larger mammiform and smaller tumors soft, doughy, and elastic. The case was really one of large congenital nse\Tus pilosus and fibroma molluscum combined. A Peruvian boy Avas shoAvn at the Westminster Aquarium with a dark, hairy mole situated in the loAver part of the trunk and on the thighs in the position of bathing tights. Nevins Hyde records two similar cases with a 162, T. xxvi., 274. b La Flandre Med., Oct. 4, 1894. Fig. 87.—Large nae- vus pilosus resembling " bathing-tights." 234 MINOR TERATA. dermatolytic groAvths.* A sister of the Peruvian boy referred to had a still larger groAvth, extending from the nucha all over the back. Both she and her brother had hundreds of smaller hairy groAvths of all sizes scattered irregularly over the face, trunk, and limbs. According to Crocker, a still more extraordinary case, with extensive dermatolytic groAvths all over the back and nevi of all sizes elsewhere, is described and engraved in " Lavater's Physiognomy," 1848. Bakerb describes an operation in which a large mole occupying half the forehead Avas removed by the knife. In some instances the hair and beard is of an enormous length. Erasmus Wilson of Lon- don saw a female of thirty- eight, Avhose hair measured 1.6 5 meters long. Leonard of Philadelphia speaks of a man in the interior of this country whose beard trailed on the ground when he stood upright, and measured 2.24 meters long. Not long ago there appeared the famous so-called " Seven Suther- land Sisters," whose hair touched the ground, and with whom nearly every one is familiar through a hair tonic which they extensive- ly advertised. In Nature, January 9, 1892, is an ac- count of a Percheron horse whose mane measured 13 feet and whose tail meas- ured almost ten feet, prob- ably the greatest example of excessive mane development on record. Figure 88 represents Miss Owens, an exhibitionist, whose hair measured eight feet three inches. In Leslie's Weekly, January 2, 1896, there is a portrait of an old negress named Nancy Garrison whose woolly hair was equally as long. The Ephemeridesc contains the account of a woman who had hair from the mons veneris which hung to the knees; it was affected with plica polo- nica, as Avas also the other hair of the body. Rayer saAV a Piedmontese of tAventy-eight, with an athletic build, Avho had a 445, iii., 93. b 550, lxi. c 101, dec. 2, an. vi., 1688. Fig. 88.—Example of excessive growth of hair. ANOMALIES OF THE COLOR OF THE HAIR. 235 but little beard or hair on the trunk, but whose scalp Avas covered Avith a most extraordinary crop. It AA'as extremely fine and silky, Avas artificially frizzled, dark broAvn in color, and formed a mass nearly five feet in circum- ference. Certain pathologic conditions may give rise to accidental growths of hair. Boyer was accustomed to quote in his lectures the case of a man who, having an inflamed tumor in the thigh, perceived this part becoming covered in a short time with numerous long hairs. Raver speaks of several instances of this kind. In one the part affected by a blister in a child of tAvo became covered with hair. Another instance was that of a student of medicine, who after bathing in the sea for a length of time, and exposing himself to the hot sun, became affected Avith coppery patches, from which there sprang a growth of hair. Brichcteau, quoted by the same authority, speaks of a Avoman of tAventy-four, having Avhite skin and hair of deep black, who after a long ill- ness occasioned by an affection analogous to marasmus became covered, especially on the back, breast, and abdomen, Avith a multitude of small eleva- tions similar to those which appear on exposure to cold. These little elevations became brownish at the end of a few days, and short, fair, silky hair Avas observed on the summit of each, which grew so rapidly that the whole surface of the body with the exception of the hands and face became velvety. The hair thus evolved was afterward thrown out spontaneously and Avas not afterward reproduced. Anomalies of the Color of the Hair.—New-born infants sometimes have tufts of hair on their heads which are perfectly Avhite in color. Schenck speaks of a young man whose beard from its first appearance grew Avhite. Young men from eighteen to twenty occasionally become gray ; and accord- ing to Rayer, paroxysms of rage, unexpected and unwelcome news, diseases of the scalp such as favus, wounds of the head, habitual headache, over- indulgence of the sexual appetite, mercurial courses too frequently repeated, too great anxiety, etc., have been knoAvn to blanch the hair prematurely. The Avell-accepted fact of the sudden changing of the color of the hair from violent emotions or other causes has always excited great interest, and many ingenious explanations have been devised to account for it. There is a record in the time of Charles Y. of a young man who was committed to prison in 1546 for seducing his girl companion, and while there Avas in great fear and grief, expecting a death-sentence from the Emperor the next day. When brought before his judge, his face was wan and pale and his hair and beard gray, the change having taken place in the night. His beard Avas filthy Avith drivel, and the Emperor, moved by his pitiful condition, pardoned him. There Avas a clergyman a of Nottingham Avhose daughter at the age of thirteen experienced a change from jet-blackness of the hair to Avhite in a single night, but this Avas confined to a spot on the back of the head 1| a 564, iii., 515. 236 MINOR TERATA. inches in length. Her hair soon became striped, and in seven years Avas totally white. The same article speaks of a girl in Bedfordshire, Maria Seeley, aged eight, Avhose face Avas sAvarthy, and avIiosc hair Avas long and dark on one side and light and short on the other. One side of her body Avas also broAvn, while the other side Avas light and fair. She aa as seen by the faculty in London, but no cause could be established. Yoigtel mentions the occurrence of canities almost suddenly. Bichat had a personal acquaintance Avhose hair became almost entirely gray in conse- quence of some distressing neAVS that reached him. Cassan n records a similar case. According to Raver, a Avoman by the name of Perat, sum- moned before the Chamber of Peers to give evidence in the trial of the assassin Louvel, Avas so much affected that her hair became entirely white in a single night. Byron makes mention of this peculiar anomaly in the open- ing stanzas of the " Prisoner of Chillon : "— " My hair is gray, but not with years, Nor grew it white In a single night, As men's have grown from sudden fears." The commentators say that Byron had reference to Ludovico Sforza and others. The fact of the change is asserted of Marie Antoinette, the Avife of Louis XYL, though in not quite so short a period, grief and not fear being the cause, Ziemssen cites Landois' case of a compositor of thirty-four who was admitted to a hospital July 9th with symptoms of delirium tremens ; until improvement began to set in (July 13th) he was continually tormented by terrifying pictures of the imagination. In the night preceding the day last mentioned the hair of the head and beard of the patient, formerly blond, became gray. Accurate examination by Landois showed the pigment con- tents of the hair to be unchanged, and led him to believe that the Avhite color was solely due to the excessive development of air-bubbles in the hair shaft. Popular belief brings the premature and especially the sudden Avhitening into connection with depressing mental emotions. We might quote the German expression—" Sich graue Haare etwas Avachsen lassen " (" To Avorry one's self gray"). Brown-Sequard observed on several occasions in his OAvn dark beard hairs which had turned white in a night and Avhich he epilated. He closes his brief communication on the subject Avith the belief that it is quite possible for black hair to turn white in one night or even in a less time, although Hebra and Kaposi discredit sudden canities (Duhring). Raymond and Yulpian b observed a lady of neurotic type Avhose hair during a seA7ere paroxysm of neuralgia folloAving a mental strain changed color in five hours over the entire scalp except on the back and sides ; most of the hair changed from black to red, but some to quite Avhite, and in tAvo days a 162, Jan., 1827. b 476, Oct. 14, 1882. SUDDEN CHANGING OF THE COLOR OF THE HAIR. 237 all the red hair became Avhite and a quantity fell off. The patient recovered her general health, but Avith almost total loss of hair, only a few red, Avhite, and black hairs remaining on the occipital and temporal regions. Crocker cites the case of a Spanish cock Avhich Avas nearly killed by some pigs. The morning after the adventure the feathers of the head had become completely white, and about half of those on the back of the neck Avere also changed. Deweesa reports a case of puerperal convulsions in a patient under his care which was attended Avith sudden canities. From 10 A. m. to 4 p. m. 50 ounces of blood were taken. Between the time of Dr. Dewees' visits, not more than an hour, the hair anterior to the coronal suture turned white. The next day it Avas less light, and in four or five days was nearly its natural color. He also mentions two cases of sudden blanching from fright. Fowlerb mentions the case of a healthy girl of sixteen who found one morning while combing her hair, Avhich Avas black, that a strip the Avhole length of the back hair was Avhite, starting from a surface about two inches square around the occipital protuberance. Two Aveeks later she had patches of ephelis over the whole body. Prentiss, in Science, October 3, 1890, has collected numerous instances of sudden canities, several of which will be gh'en :— "In the Canada Journal of Medical Science, 1882, p. 113, is reported a case of sudden canities due to business-worry. The microscope shoAved a great many air-A'esicles both in the medullary substance and betAveen the medullary and cortical substance. " In the Boston Medical and Surgical Journal, 1851, is reported a case of a man thirty years old, Avhose hair 'Avas scared' white in a day by a grizzly bear. He was sick in a mining camp, was left alone, and fell asleep. On Avaking he found a grizzly bear standing over him. " A second case is that of a man of twenty-three years who was gambling in California. He placed his entire savings of $1100 on the turn of a card. He Avas under tremendous nervous excitement while the cards were being dealt. The next day his hair Avas perfectly Avhite. " In the same article is the statement that the jet-black hair of the Pacific Islanders does not turn gray gradually, but when it does turn it is sudden, usually the result of fright or sudden emotions." D'Alben, quoted by Fournicr,0 describes a young man of twenty-four, an officer in the regiment of Touraine in 1781, Avho spent the night in carnal dissipation Avith a mulatto, after Avhich he had violent spasms, rendering flex- ion of the body impossible. His beard and hair on the right side of the body Avas found as AA'hite as snoAV, the left side being unchanged. He appeared be- fore the Facult6 de Montpelier, and though cured of his nervous symptoms his hair Avas still AAmite, and no suggestion of relief was offered him. Louis of BaA'aria, avIio died in 1294, on learning of the innocence of his a Phila. Med. Museum, iii., 219. b 476, 1853, i., 556. c 302, iv., 176. 238 MINOR TERATA. Avife, Avhom he had put to death on a suspicion of her infidelity, had a change of color in his hair, AA'hich became Avhite almost immediately. Yauvilliers, the celebrated Hellenist, became Avhite-haired almost immediately after a terri- ble dream, and Brizard, the comedian, experienced the same change after a narroAv escape from droAvning in the Phone. The beard and the hair of the Duke of BrunsAvick Avhitened in twenty-four hours after hearing that his father had been mortally Avounded at the battle of Auerstadt. De ScliAveinitz a speaks of a Avell-formed and healthy brunette of eighteen in Avhom the middle portion of the cilia of the right upper eyelid and a number of the hairs of the lower lid turned white in a Aveek. Both eyes were myopic, but no other cause could be assigned. Another similar case is cited by Hirsh- berg, b and the authors have seen similar cases. Thornton of Margate records the case of a lady in Avhom the hair of the left eyebroAV and eyelashes began 4e-turn Avhite after a fortnight of sudden grief, and Avithin a Aveek all the hair of these regions was quite white and remained so. No other part Avas affected nor Avas there any other symptom. After a traumatic ophthalmitis of the left and sympathetic inflammation of the right eye in a boy of nine, Schenck obserA^ed that a group of cilia of the right upper lid and nearly all the lashes of the upper lid of the left eye, which had been enucleated, turned silvery-Avhite in a short time. Liuhvig has known the eyelashes to become Avhite after small-pox. Communications are also on record of local decolor- ization of the eyebrows and lashes in neuralgias of isolated branches of the trigeminus, especially of the supraorbital nerve. Temporary and Partial Canities.—Of special interest are those cases in which Avhiteness of the hair is only temporary. Thus, Compagne mentions a case in Avhich the black hair of a Avoman of thirty-six began to fade on the twenty-third day of a malignant fever, and on the sixth day following Avas perfectly Avhite, but on the seventh day the hairs became darker again, and on the fourteenth day after the change they had become as black as they were originally. Wilson records a case in Avhich the hair lost its color in winter and regained it in summer. Sir John Forbes, according to Crocker, had gray hair for a long time, then suddenly it all turned white, and after remaining so for a year it returned to its original gray. Grayness of the hair is sometimes only partial. According to Crocker an adult Avhose hair Avas generally brown had a tuft of Avhite hair over the tem- ple, and several like cases are on record. Lorry tells us that grayness of one side only is sometimes occasioned by severe headache. Hagedorn has knoAvn the beard to be black in one place and Avhite in another. Brandis mentions the hair becoming Avhite on one side of the face Avhile it continued of its former color on the other. Raver quotes cases of canities of the Avhole of one side of the body. Richclot obser\red Avhite mottling of hair in a girl sick with chlorosis. a 792, May, 1889. b 262, 1888. ANOMALOUS COLOR CHANGES OF THE HAIR. 239 The whitening extended from the roots to a distance of tAvo inches. The prob- able cause Avas a temporary alteration of the pigment-forming function. When the chlorosis Avas cured the natural color returned. Paullini and Riedlin, as Avell as the Ephemerides, speak of different colored hair in the same head, and it is not at all rare to see individuals Avith an anomalously colored patch of hair on the head. The members of the ancient house of Rohan Avere said to possess a tuft of Avhite hair on the front of their heads. Michelson of Konigsberg describes a curious case in a barrister of twenty- three affected Avith partial canities. In the family of both parents there was stated to be congenital premature canities, and some Avhite hairs had been observed even in childhood. In the fifteenth year, after a grave attack of scarlet fever, the hair to a great extent fell out. The succeeding groAvth of hair Avas stated to have been throughout lighter in tissue and color and fissured at the points. Soon after bunches of white hair appeared on the occiput, and in the succeeding years small patches of decolored hairs were observed also on the anterior and lateral portions of the scalp. In the spring of 1880 the patient exhibited signs of infiltration of the apex of the right lung, and afterAvard a violent headache came on. At the time of the report the patient presented the ap- pearance sIioavii in Figure 89. The com- plexion Avas delicate throughout, the eye- lashes and eyelids dark brown, the mous- tache and whiskers blond, and in the latter Avere a few groups of white hair. The Avhite patches Avere chiefly on the left side of the head. The hairs groAving on them Avere unpigmented, but otherAvise normal. head never sweated. He was stout and exhibited no signs of internal disease, except at the apex of the right lung. Anomalous Color Changes of the Hair.—The hair is liable to undergo certain changes of color connected Avith some modification of that part of the bulb secreting its coloring-matter. Alibert, quoted by Rayer, gives us a report of the case of a young lady avIio, after a severe fever Avhich folloAved a very difficult labor, lost a fine head of hair during a discharge of viscid fluid, Avhich inundated the head in every part. He tells us, further, that the hair greAV again of a deep black color after the recovery of the patient. The same Avriter tells of the case of James B—, born Avith brown hair, who, having lost it all during the course of a sickness, had it replaced with a crop of the brightest red. White and gray hair has also, under peculiar circumstances, Fig. 89.—Mottled hair (Michelson). The patient stated that his 240 MINOR TERATA. been replaced by hair of the same color as the individual had in youth. We are even assured by Bruley that in 1798 the white hair of a woman sixty years of age changed to black a feAV days before her death. The bulbs in this case were found of great size, and appeared gorged with a substance from which the hair derived its color. The Avhite hairs that remained, on the con- trary, grew from shriveled bulbs much smaller than those producing the black. This patient died of phthisis.3 A very singular case, published early in the century, was that of a woman Avhose hair, naturally fair, assumed a tawny red color as often as she Avas affected with a certain fever, and returned to its natural hue as soon as the symptoms abated.b ATillerme302 alludes to the case of a young lady, sixteen years of age, Avho had never suffered except from trifling headaches, and who, in the winter of 1817, perceived that the hair began to fall out from several parts of her head, so that before six months Avere over she became entirely bald. In the beginning of January, 1819, her head became covered with a kind of black avooI over those places that were first denuded, and light brown hair began to develop from the rest of the scalp. Some of this fell out again Avhen it had groAvn from three to four inches ; the rest changed color at different distances from its end and grew of a chestnut color from the roots. The hair, half black, half chestnut, had a very singular appearance. Alibert and Beigel relate cases of Avomen with blond hair which all came off after a severe fever (typhus in one case), and Avhen it grew again it was quite black. Alibert also saw a young man who lost his broAvn hair after an illness, and after restoration it became red. According to Crocker, in an idiotic girl of epileptic type (in an asylum at Edinburgh), with alternating phases of stupidity and excitement, the hair in the stupid phase was blond and in the excited condition red. The change of color took place in the course of two or three days, beginning first at the free ends, and remaining of the same tint for seven or eight days. The pale hairs had more air-spaces than the darker ones. There was much structural change in the brain and spinal cord. Smyly of Dublin reported a case of suppurative disease of the temporal bone, in Avhich the hair changed from a mouse-color to a reddish- broAvn ; and Squire records a congenital case in a deaf mute, in Avhom the hair on the left side Avas in light patches of true auburn and dark patches of dark broAvn like a tortoise-shell cap; on the other side the hair was a dark broAvn. Crocker mentions the changes which have occurred in rare instances after death from dark broAvn to red. Chemic colorations of ATarious tints occur. Blue hair is seen in workers in cobalt mines and indigo Avorks ; green hair in copper smelters ; deep red- broAvn hair in handlers of crude anilin ; and the hair is dyed a purplish- broAvn wheneATer chrysarobin applications used on a scalp come in contact Avith an alkali, as when washed with soap. Among such cases in older a 458, T. iv., 290. b 454^ t. v., 59. ANOMALIES OF THE NAILS. 241 literature Blanchard and Marcellus Donatus speak of green hair; Rosse saAV tAvo instances of the same, for one of Avhich he could find no cause ; the other patient Avorked in a brass foundry. Many curious causes are given for alopecia. Gilibert and Merleta mention sexual excess ; Marcellus Donatusb gives fear; the Ephemerides speaks of baldness from fright; and Leo Africanus, in his description of Barbary, describes endemic baldness. Xeyronis0 makes the folloAving ob- servation : A man of seArenty-three, convalescent from a feA'er, one morning, about six months after recoA7ery perceived that he had lost all his hair, even his eyelashes, eyebrows, nostril-hairs, etc. Although his health continued good, the hair Avas never reneAved. The principal anomalies of the nails observed are absence, hyper- trophy, and displacement of these organs. Some persons are born Avith finger-nails and toe-nails either very rudimentary or entirely absent; in others they are of great length and thickness. The Chinese nobility allow their finger-nails to groAV to a great length and spend much time in the care of these nails. Some savage tribes have long and thick nails resembling the claws of beasts, and use them in the same way as the loAver ani- mals. There is a description of a person Avith finger-nails that resembled the horns of a goat. d ° Fig. 90.—Deformed toe-nails. Neuhof, in his books on Tartary and China, says that many Chinamen have tAvo nails on the little toe, and other instances of double nails have been reported. The nails may be reversed or arise from anomalous positions. Bartho- linus6 speaks of nails from the inner side of the digits; in another case, in Avhich the fingers were Avanting, he found the nails implanted on the stumps. Tulpius says he kneAV of a case in which nails came from the articulations of three digits ; and many other curious arrangements of nails are to be found. Rouhuot sent a description and draAving of some monstrous nails to the Academic des Sciences de Paris (Fig. 90). The largest of these Avas the left great toe-nail, Avhich, from its extremity to its root, measured 4f inches; the laminae of Avhich it consisted Avere placed one OA'er the other, like the tiles on a roof, only rtwersed. This nail and several of the others Avere of unequal thickness and Avere variously curved, probably on account of the pressure of the shoe or the neighboring digits. Raver mentions two nails sent to him by Briehcteau, physician of the Hopital Necker, belonging to an old a Diss, calvites, Paris, 1662. b 306, L. i., cap. i., p. 15. c 403, v., 73. d282, Nov., 1734, 173. e 190, cent, ii., hist. 44. 16 242 MINOR TERATA. woman who had lived in the Salpetriere. They were very thick and spirally twisted, like the horns of a ram. Saviard informs us that he saAV a patient at the Hotel Dieu who had a horn like that of a ram, instead of a nail, on each great toe, the extremities of Avhich Avere turned to the metatarsus and overlapped the Avhole of the other toes of each foot. The skeleton of Simore, preserved in Paris, is remarkable for the ankylosis of all the articulations and the considerable size of all the nails. The fingers and toes, spread out and ankylosed, ended in nails of great length and nearly of equal thickness. A woman by the name of Melin, living in the last century in Paris, Avas surnamed " the Avoman with nails ;" according to the description given by Saillant in 1776 she presented another and not less curious instance of the excessh'e groAvth of the nails. Musaeus a gh'es an account of the nails of a girl of twenty, which grew to such a size that some of those of the fingers were five inches in length. They were composed of several layers, Avhitish interiorly, reddish-gray on the ex- terior, and full of black points. These nails fell off at the end of four months and Avere succeeded by others. There Avere also horny laminae on the knees and shoulders and elboAvs Avhich bore a resemblance to nails, or rather talons. They were sensitive only at the point of insertion into the skin. Yarious other parts of the body, particularly the backs of the hands, pre- sented these horny productions. One of them AAas four inches in length. This horny groAvth appeared after small-pox. Ash, in the Philosophical Trans- actions, records a somewhat similar case in a girl of twelve. Anomalies of the Teeth.—Pliny, Colombus, van Saa ieten, Haller, Mar- cellus Donatus, Baudelocque, Soemmering, and Gardien all cite instances in which children haA'e come into the Avorld with several teeth already erupted. Haller400 has collected 19 cases of children born with teeth. Polydorus Yirgilus describes an infant who was born with six teeth. Some celebrated men are supposed to have been born Avith teeth ; Louis XIY. was accredited with having two teeth at birth. Bigot, a physician and philosopher of the six- teenth century ; Boyd, the poet; Yalerian, Richard III., as well as some of the ancient Greeks and Romans, were reputed to have had this anomaly. The significance of the natal eruption of teeth is not always that of vigor, as many of the subjects succumb early in life. There were two cases typical of fetal dentition shoAvn before the Academie de Medecine de Paris. One of the subjects had two middle incisors in the lower jaw and the other had one tooth well through. LcA'ison b saAV a female born with two central incisors in the loAver jaw. Thomasc mentions a case of antenatal deATelopment of nine teeth. Puech, Mattei, Dumas, Belluzi, and others report the eruption of teeth in the neAv- born. In Dumas' case the teeth had to be extracted on account of ulceration of the tongue. a Diss, de unguibus monstrosis, Hafhiae, 1716. b 476) 1846, ii., 699. c 125) vii., 501. EDENTUL 0 USNESS. 243 Instances of triple dentition late in life are quite numerous, many occur- ring after a hundred years. Mentzelius speaks of a man of one hundred and ten who had nine iicav teeth. Lord Bacon cites the case of a Countess Desmond, Avho when over a century old had tAvo new teeth ; Hufeland saAV an instance of dentition at one hundred and sixteen; Nitzsch speaks of one at one hundred, and the Ephemerides contain an account of a triple dentition at one hundred and twenty. There is an accounta of a country laborer Avho lost all his teeth by the time he arrived at his sixtieth year of age, but about a half year after- Avard a neAV set made their appearance. Bissetb mentions an account of an old woman Avho acquired tAvelve molar teeth at the age of ninety-eight. Carre c notes a case of dental eruption in an individual of eighty-five. Mazzoti speaks of a third dentition, and Ysabeau d Avrites of dentition of a molar at the age of ninety-two. There is a record of a physician of the name of Slave who retained all his second teeth until the age of eighty, Avhen they fell out; after five years another set appeared, which he retained until his death at one hundred. In the same reporte there is mentioned an old Scotchman Avho died at one hundred and ten, Avhose teeth Avere renewed at an advanced age after he had lost his second teeth. One of the older journals282 speaks of dentition at seventy, eighty-four, ninety, and one hundred and fourteen. The Philosophical Transactions of London contain accounts of dentition at seventy- five and eighty-one. Bassettf tells of an old Avoman avIio had twelve molar teeth at the age of eighty-eight. In France there is recorded dentition at eighty- five g and an account of an old man of seventy-three Avho had six neAV teeth. b Yon Helmont relates an instance of triple dentition at the same age. There is recorded in Germany an account of a Avoman of ninety who had dentition at forty-seven and sixty-seATen, each time a new set of teeth appearing; Hunter and Petrequin have observed similar cases. Carter* describes an ex- ample of third dentition. Lisonj makes a curious observation of a sixth dentition. Edentulousness.—AVe have already noticed the association of congenital alopecia Avith edentulousness, but, strange to say, Magitot has remarked that " l'homme-chien," Avas the subject of defective dentition. Borellus found atrophy of all the dental follicles in a Avoman of sixty who never had pos- sessed any teeth. Fanton-ToiiATet saAV a boy of nine Avho had never had teeth, and Fox a Avoman Avho had but four in both jaws ; Tomes cites several similar instances. Hutchinson k speaks of a child Avho Avas perfectly edentulous as to temporary teeth, but avIio had the permanent teeth duly and fully erupted. Guilford1 describes a man of forty-eight, Avho Avas edentulous from birth, Avho also totally lacked the sense of smell, and was almost Avithout the sense a 534, 1784, iii., 105. b 504, Lond., 1787, viii., 370. c 368, 1860, xv., 585. a 460, xxxv., 316 (1766). e 302, vol. iv. f 524, 787. 6 368, I860. b 363, Oct. 9, 1875. i 133, 1876. J 235, xiii., 190. k 476, 1883, i., 894. 1296,1883. 244 MINOR TERATA. of taste ; the surface of his body avus covered Avith fine hairs and he had never had visible perspiration. This is probably the same case quoted in the foregoing paragraph in regard to the anomalies of hair. Otto, quoted by Sedgwick, speaks of tAvo brothers avIio Avere both totally edentulous. It might be interesting in this connection to note that Oudet found in a fetus at term all the dental follicles in a process of suppuration, leaving no doubt that, if the fetus had been born viable, it Avould have been edentulous. Giraldes mentions the absence of teeth in an infant of sixteen months. Bronzet describes a child of twelve, Avith only half its teeth, in Avhom the alveolar borders receded as in age. Baumes remarks that he had seen a man Avho neA'cr had any teeth. The anomalies of excessive dentition are of several varieties, those of simple supernumerary teeth, double or triple toavs, and those in anomalous positions. Ibbetson saw a child Avith five incisors in the inferior maxillary bone, and Fanton-Touvet describes a young lady avIio possessed five large in- cisors of the first dentition in the superior maxilla. Rayer a notes a case of dentition of four canines, Avhich first made their appearance after pain for eight days in the jaAvs and associated Avith convulsions. In an Ethiopian Soem- mering has seen one molar too many on each side and in each jaw. Ploucquet and Tesmer have seen five incisors and Fanchard six. Many persons have the supernumerary teeth parallel Avith their neighbors, anteriorly or posteriorly. Costa b reports a case in which there were five canine teeth in the upper jaw, tAvo placed laterally on either side, and one on the right side behind the other tAvo. The patient was twenty-six years of age, well formed and in good health. In some cases there is fusion of the teeth. Pliny, Bartholinus, and Melanthon pretend to have seen the union of all the teeth, making a continu- ous mass. In the " Musee de l'ficole dentaire de Paris " there are several milk-teeth, both of the superior and inferior maxilla, which are fused together. Bloch cites a case in which there were two rows of teeth in the superior maxilla. Helhvig 414 has observed three rows of teeth, and the Ephemerides contain an account of a similar anomaly. Extraoral Dentition.—Probably the most curious anomaly of teeth is that in Avhich they are found in other than normal positions. Albinus speaks of teeth in the nose and orbit; Borellus, in the palate ; Fabricius Hildanus,334 under the tongue; Schenck, from the palate; and there are many similar modern records. Heister in 1743 Avrote a dissertation on extraoral teeth. The folloAving is a recent quotation :c — "In the Norsk Magazin fur Laegevidenskaben, January, 1895, it is reported that Dr. Dave, at a meeting of the Medical Society in Christiania, showed a tooth removed from the nose of a Avoman aged fifty-three. The patient had consulted him for ear-trouble, and the tooth Avas found acci- dentally during the routine examination. It Avas easily removed, having a 302, viii., 411. b 353, March, 1895. c 224, 1895, ii., 512. EXTRAORAL DENTITION. 245 been situated in a small depression at the junction of the floor and external Avail of the nasal caA'ity, 22 mm. from the external nares. This patient had all her teeth ; they were placed someAvhat far from each other. The tooth resembled a milk canine; the end of the imperfect root Avas C0ATered Avith a fold of mucous membrane, Avith stratified epithelium. The speaker suggested that part of the mucous membrane of the mouth Avith its tooth-germ had become impacted betAveen the superior and premaxillary bones and thus cut off from the cavity of the mouth. Another speaker criticised this fetal dislocation and belieA'ed it to be due to an inversion—a development in the Avrong direction—by Avhich the tooth had groAvn upAvard into the nose. The same speaker also pointed out that the stratified epithelium of the mucous membrane did not proA'e a connection Avith the cavity of the mouth, as it is knoAvn that cylindric epithelium-cells after irritative processes are replaced by flat ones." Delpech saAV a young man in 1829 avIio had an opening in the palatine vault occasioned by the extraction of a tooth. This opening communicated with the nasal fossa by a fracture of the palatine and maxillary bones ; the employment of an obturator Avas necessary. It is not rare to sec teeth, generally canine, make their eruption from the A'ault of the palate ; and these teeth are not generally supernumerary, but examples of A'ice and deA'ia- tion of position. Fanton-Toiwet, hoAveAer, gives an example of a super- numerary tooth implanted in the palatine arch. Branch a describes a little negro boy Avho had tAvo large teeth in the nose ; his dentition Avas otherAvise normal, but a portion of the nose Avas destroyed by ulceration. Royb describes a Hindoo lad of fourteen Avho had a tooth in the nose, supposed to have been a tumor. It Avas of the canine type, and Avas coAcred Avith enamel to the junction Avith the root, Avhich Avas deeply imbedded in the side and upper part of the antrum. The boy had a perfect set of permanent teeth and no deformity, sAvelling, or cystic formation of the jaAV. This Avas clearly a case of extra follicular deA'elopment and eruption of the tooth in an anomalous position, the peculiarity being that AA'hile in other similar cases the ctoavii of the tooth sIioavs itself at the floor of the nasal cavity from beloAv upward, in this instance the dental follicle Avas transposed, the eruption being from above doAvmvard. Hallc cites an instance in Avhich the right upper canine of a girl erupted in the nose. The subject shoAved marked evidence of hereditary syphilis. Carverd describes a child Avho had a tooth groAving from the loAver right eyelid. The number of deciduous teeth Avas perfect; although this tooth Avas canine it had a someAvhat bulbulous fang. Of anomalies of the head the first to be considered Avill be the anen- cephalous monsters AA'ho, strange to say, have been knoAvn to survive birth. Clericuse cites an example of life for five days in a child without a cere- a 51S, 1884, i., 425. b 476, 1883, ii., 772. <= 471;, 1883, ii., 862. d 476, 1887, ii., 763. e 215, 1781. 246 MINOR TERATA. brum. Hoysham* records the birth of a child Avithout a cerebrum and re- marks that it was kept alive for six days. There Avas a child born alive in Italy in 1831 Avithout a brain or a cerebellum—in fact, no cranial cavity—and yet it lived eleven hours.b A someAvhat similar case is recorded in the last cen- tury.108 In the Philosophical Transactions0 there is mentioned a child virtually born Avithout a head avIio lived four days ; and Le Due records a case of a child born Avithout brain, cerebellum, or medulla oblongata, and who lived half an hour. Brunetd describes an anencephalous boy born at term who survived his birth. Saviard469 delivered an anencephalous child at term which died in thirty-six hours. LaAvrence e mentions a child Avith brain and cranium deficient that lived five days. Putnamf speaks of a female mesencephalons monster that lived tAventy-nine hours. Angell and Eisner in March, 1895,230 reported a case of anencephaly, or rather pseudencephaly, associated Avith double divergent strabismus and limbs in a state of constant spastic contraction. The infant lh'ed eight days. Geoffroy-Saint-Hilaire cites an example of anencephaly Avhich lived a quarter of an hour. FauA'cl mentioned one that lived two hours, and Sue describes a similar instance in which life persisted for scatcii hours and distinct motions were noticed. Mala- carne saAV life in one for twelve hours, and Mery has gh'en a description of a child born Avithout brain that lived almost a full day and took nourishment. In the Hotel-Dieu in Paris in 1812 Serres saAV a monster of this type which lived three days, and Avas fed on milk and sugared water, as no nurse could be found Avho Avas Avilling to suckle it, Fraser g mentions a brother and sister, aged twenty and thirty, respectively, who from birth had exhibited signs of defective development of the cere- bellum. They lacked power of coordination and walked with a drunken, staggering gait; they could not touch the nose Avith the finger when their eyes Avere shut, etc. The parents of these unfortunate persons were perfectly healthy, as Avere the rest of their family. Cruveilhier cites a case of a girl of eleven Avho had absolutely no cerebellum, with the same symptoms Avhich are characteristic in such cases. There is also recorded the history of a manh who Avas deficient in the corpus callosum; at the age of sixty-two, though of feeble intelligence, he presented no signs of nervous disorder. Claude Bernard made an autopsy on a woman Avho had no trace of olfactory lobes, and after a minute inquiry into her life he found that her sense of smell had been good despite her deficiency. Buhring relates the history of a case someAvhat analogous to viability of anencephalous monsters. It Avas a bicephalous child that lived thirty-two hours after he had ligated one of its heads.' Wardj mentions an instance of congenital absence of the corpora callo- a 524, iii., 250. b 476, 1832-3, i., 570. c 629, 1700, 23. d pr0gres de la .Aled., 1698. e 550, 1814. t Archiv. Scientif. and Prac. M. & S., 1873, 342. g 381,1880, 199. b 212, 158. i 827, Oct., 1843. J 490, 1846, ii., 575. MICROCEPHALY. 247 sum. Paget a and Henry mention cases in which the corpora callosum, the fornix, and septum lucidumwere imperfectly formed. Maunoirb reports con- genital malformation of the brain, consisting of almost complete absence of the occipital lobe. The patient died at the twenty-eighth month. Combettes c reports the case of a girl avIio died at the age of eleven Avho had complete absence of the cerebellum in addition to other minor structural defects; this Avas probably the case mentioned by Cruveilhier.d Diminution in volume of the head is called microcephaly. Probably the most remarkable case on record is that mentioned by Lombroso. The Fig. 91.—Microcephalic "Aztec man." individual Avas called " l'homme-oiseau," or the human bird, and his cranial capacity AAas only 390 c. c. Lombroso speaks of another individual a 550, xxix., 55. b 242, 1876, i., 163. c 242, 1830, v., 148. d The argument that the brain is not the sole organ of the mind is in a measure sub- stantiated by a wonderful case of a decapitated rooster, reported from Michigan.1 A stroke of the knife had severed the larynx and removed the whole mass of the cerebrum, leaving the inner aspect and base of the skull exposed. The cerebrum was partly removed ; the external auditory meatus was preserved. Immediately after the decapitation the rooster was left to its supposed death struggles, but it ran headless to the barn, where it was secured and subsequently fed by pushing corn do%vn its esophagus, and allowing water to trickle into this tube from the spout of an oil-can. The phenomena exhibited by the rooster were quite interesting. It made all the motions of pecking, strutted about, flapped its wings, attempted to crow, but, of course, without making any sound. It exhibited no signs of incoordination, but did not seem to hear. A ludicrous exhibition was the absurd, sidelong pas seul made toward the hens. 1632, 1880, ii., 5. 248 MINOR TERATA. called " l'homme-lapin," or man-rabbit, Avhose cranium aa;is only slightly larger than that of the other, measuring 490 mm. in circumference. Castelli alludes to endemic microcephaly among some of the peoples of Asia. \\ e also find it in the Caribbean Islands, and from the skulls and portraits of the ancient Aztecs avc are led to believe that they avc re also microcephalic. Tavo creatures of celebrity Avere Maximo and Bartola, avIio for twenty- five years have been sIioavu in America and in Europe under the name of the "Aztecs" or the "Aztec children" (Fig. 91). They were male and female and very short, Avith heads resembling closely the bas-reliefs on the ancient Aztec temples of Mexico. Their facial angle AA'as about 45°, and they had jutting lips and little or no chin. They Avorc their hair in an enormous bunch to magnify the deformity. These curiosities were born in Central America and avc re possibly half Indian and Negro. They Avere little better than idiots in point of intelligence. Figure 92 represents a microcephalic youth knoAvn as the " Mexican Avild bov," Avho Avas shoAvn Avith the Wallace circus. VirchoAV a exhibited a girl of four- teen Avhose face avus no larger than that of a neAV-born child, and whose head AA'as scarcely as large as a man's fist. Magitot reported a case of a micro- cephalic Avoman of thirty Avho weighed 70 pounds. Hippocrates and Strabonius both speak of head-binding as a custom in- ducing artificial microcephaly, and some tribes of North American Indians Fig. 92.-Microcephalic boy. still retain this CUStom. As a rule, microcephaly is attended Avith associate idiocy and arrested development of the rest of the body. ()ssification of the fontanelles in a mature infant Avould necessarily prevent full development of the brain. Osiander and others have noticed this anomaly. There are cases on record in Avhich the fontanelles haAre remained open until adulthood. Augmentation of the volume of the head is called macrocephaly, and there are a number of curious examples related. Benvenuti describes an individual, otherwise Avell formed, Avhose head began to enlarge at a Quoted 538, 1884, 522. MACROCEPHALY. 249 seven. At tAventy-seven it measured over 37 inches in circumference and the man's face Avas 15 inches in height; no other portion of his body increased abnormally ; his voice was normal and he Avas very intelligent. He died of apoplexy at the age of thirty.* Fournierb speaks of a cranium in the cabinet of the Natural History Museum of Marseilles of a man by the name of Borghini, who died in 1616. At the time he Avas described he was fifty years old, four feet in height; his head measured three feet in circumference and one foot in height. There Avas a proverb in Marseilles, " Apas mai de sen que Borghini," meaning in the local dialect, " Thou hast no more Avit than Borghini." This man, Avhose fame became knoAvn all over France, AA'as not able, as he greAV older, to maintain the Aveight of his head, but carried a cushion on each shoulder to prop it up. Fournier also quotes the history of a man avIio died in the same city in 1807 at the age of sixty-seven. His head Avas enormous, and he neArer lay on a bed for thirty years, passing his nights in a chair, generally reading or writing. He only ate once in tAventy-four or thirty hours, neATer warmed himself, and never used Avarm Avater. His knoAvledge Avas said to have been great and encyclopedic, and he pretended never to have heard the proverb of Borghini. There is related the account of a Moor, Avho Avas seen in Tunis early in this century, thirty-one years of age, of middle height, Avith a head so prodigious in dimensions that crowds flocked after him in the streets. His nose Avas quite long, and his mouth so large that he could eat a melon as others Avould an apple. He Avas an imbecile. William Thomas AndrcAvs Avas a dAvarf seventeen years old, Avhose head measured in circumference 35 inches; from one external auditory meatus to another, 27^- inches; from the chin oA'cr the cranial summit to the suboccipital protuberance, 37^ inches ; the distance from the chin to the pubes Avas 20 inches; and from the pubes to the soles of the feet, 16 ; he Avas a monorchid.0 James Cardinal, av!io died in Guy's Hospital in 1825, and Avho Avas so celebrated for the size of his head, only measured 321 inches in head-circumference. The largest healthy brains on record, that is, of men of prominence, are those of Cuvier, Aveighing 64J ounces ;d of Daniel Webster, Aveighing 63f ounces (the circumference of Avhose head Avas 23f inches); e of Abercrombie, Aveighing 03 ounces, and of Spurzheim, Aveighing 55^ ounces. Byron and CroniAvell had abnormally heaA'y brains, shoAving marked ewidence of disease. A curious instance in this connection is that quoted by Pigne/ Avho gives an account of a double brain found in an infant. Keen reports finding a fornix Avhich, instead of being solid from side to side, consisted of tAAO lateral hah'es Avith a triangular space betAveen them. When the augmentation of the volume of the cranium is caused by an abundant quantity of serous fluid the anomaly is knoAvn as hydrocephaly. a Actes de la society imper. des curieux de la nature, torn. viii. b 302, iv., 142. e 593, 1856, xiii., 778. d 678, Dec, 1S83. e 124, 1853, 110. * 242, 1846, xxi., 144. 250 MINOR TERATA. In this condition there is usually no change in the size of the brain-structure itself, but often the cranial bones are rent far asunder. Minot speaks of a hydro- cephalic infant avIiosc head measured 27J inches in cir- cumference ; Bright describes one Avhose head measured 32 inches; and Klein, one 43 inches. Figure 93 represents a child of six AA'hose head cir- cumference AA'as 36 inches. Figure 94 sIioavs a hydro- cephalic adult who was ex- hibited through this country. There is a recorda of a curious monster born of healthy half-caste African parents. The deformity was caused by a deficiency of osseous ma- There Avas considerable arrest of develop- ing. 93.—Hydrocephalic child. terial of the bones of the head. m ■ft I s'^tk i. .mm f i ■ *""■ Fig. 94.—Hydrocephaly in an adult. ment of the parietal, temporal, and superior maxillary bones, in consequence of which a very small amount of the cerebral substance could be protected by a 778, 1868, ix., 31. ANOMALIES OF THE INFERIOR MAXILLA. 251 the membranous expansion of the cranial centers. The inferior maxilla and the frontal bone were both perfect; the ears Avere well developed and the tongue strong and active ; the nos- trils Avere imperforate and there was no roof to the mouth nor floor to the nares. The eyes were curi- ously free from eyelashes, eyelids, or brows. The cornea threatened to slough. There was double hare- lip on the left side ; the second and third fingers of both hands were webbed for their Avhole length ; the right foot wanted the distal phalanx of the great toe and the left foot was clubbed and draAvn iiiAvard. The child sAvallowed when fed from a spoon, appeared to hear, but ex- hibited no sense of light. It died shortly after the accompanying sketch (Fig. 95) Avas made. Occasionally a deficiency in the osseous material of the cranium or an abnormal dilatation of the fon- tanelles gives rise to a hernia of the meninges, Avhich, if accompanied by cerebrospinal fluid in any quantity, causes a large and peculiarly shaped tumor called meningocele (Fig. 96). If there is a protrusion of brain-substance itself, a condition known as hernia cerebri results. Complete absence of the inferior maxilla is much rarer in man than in animals. Xi colas and Prenant have described a curious case of this anomaly in a sheep. Gurlt has named subjects presenting the total or partial absence of the inferior maxilla, agna- thes or hemiagnathes. Simple atrophy of the inferior maxilla has been seen in man as Avell as in the loAver animals, but is much less frequent than atrophy of the superior maxilla. Langenbeck reports the case of a young man Avho had the inferior maxilla so atrophied Fig. 96.—Meningocele. that in infancy it was impossible for him to take milk from the breast. He had also almost complete im- mobility of the jaAvs. Boullard a reports a deformity of the visage, resulting in a deficiency of the condyles of the lower jaw. Mauriceb made an observa- a 242, 1849, xxiv., 281. b 146, 1861, i., 696. Fig. 95.—Monster from deficiency of the bones of the head. 252 MINOR TERATA. tion on a vice of conformation of the loAver jaAV Avhich rendered lactation impossible, probably causing the death of the infant on this account. Tomes gives a description of a loAver jaAV the development of the left ramus of which had been arrested. Canton a mentions arrest of development of the left perpendicular ramus of the loAver juav combined Avith malformation of the external car. Exaggerated prominence of the maxillaries is called prognathism ; that of the superior maxilla is seen in the North American Indians. Inferior prognathism is observed in man as Avell as in animals. The bull-dog, for example, displays this, but in this instance the deformity is really superior brachygnathism, the superior maxilla being arrested in development. Congenital absence of the nose is a very rare anomaly. Maisonneuve has seen an example in an individual in Avhich, in place of the nasal appen- dix, there Avas a plane surface perforated by two small openings a little less than one mm. in diam- eter and three mm. apart. Exaggeration in volume of the nose is quite frequent. Ballonius185 speaks of a nose six times larger than ordinary. Viewing the Poman celebri- ties, Ave find that Numa, to Avhom AA'as giA'en the surname Pompilius, had a nose which measured six inches. Plutarch, Lycurgus, and Solon had a similar enlargement, as had all the kings of Italy except Tarquin the Superb. Early in the last century a man, Thomas Wed- ders (or AVadhouse), with a nose 7^ inches long, Avas exhibited throughout Yorkshire. This man expired Fig. 97.—Thomas wedders. as he had liA'ed, in a condition of mind best de- scribed as the most abject idiocy. The accompany- ing illustration (Fig. 97) is taken from a reproduction of an old print and is supposed to be a true likeness of this unfortunate individual. There are curious pathologic formations about the nose Avhich increase its volume so enormously as to interfere Avith respiration and e\Ten Avith alimen- tation ; but these Avill be spoken of in another chapter. There have been some celebrities whose noses Avere undersized. The Due de Guise, the Dauphin d'Auvergne, and William of Orange, celebrated in the romances of chivalry, had extremely short noses. There are a feAV recorded cases of congenital division of the nose. Bartholinus,b Borellus, and the Ephemerides speak of duplex noses. Thomas of Tours has observed congenital fissure of the nose. Rikerc reports the case of an infant of three Aveeks who possessed a supernumerary nose on the right nasal bone near the inner canthus of the eye. It Avas pear-shaped, Avith a 779, xii., 237. b 190, cent, i., hist. xxv. c 176, 1878, 196. ANOMALIES OF THE MOUTH. 253 its base doAvn, and Avas the size of the natural nose of an infant of that a^e and air passed through it. Hubbell, Ronaldson,a and Luscha speak of con- genital occlusion of the posterior nares. Smithb and Jarvisc record cases of congenital occlusion of the anterior nares. Anomalies in size of the mouth are not uncommon. Founder quotes the history of a man who had a mouth so large that Avhen he opened it all his back teeth could be seen. There is a history of a boy of seventeen d Avho had a preternaturally-sized mouth, the transverse diameter being 6| inches. The mother claimed that the boy Avas born with his foot in his mouth and to this fact attributed his deformity. The negro races are noted for their large mouths and thick lips. A negro called " Black Diamond," recently exhibited in Philadelphia, could put both his fists in his mouth. Morgane reports tAvo cases of congenital macrostoma accompanied by Fig. 98.—Macrostoma by ascending Fig. 99.—Macrostoma by lateral lateral fissure. fissures. malformation of the auricles and by auricular appendages. Van Duysef mentions congenital macrostoma Avith preauricular tumors and a dermoid of 'the eye. Macrostoma is sometimes produced by lateral fissures (Fig. 99). In other cases this malformation is unilateral and the fissure ascends (Fig. 9S_), in Avhich instance the fissure may be accompanied by a fistula of the duct of Stcnsen. Sometimes there is associated Avith these anomalies curious termi- nations of the salivary ducts, either through the cheek by means of a fistula or on the anterior part of the neck. Microstoma.—There are a feAV cases on record in AA'hich the mouth has been so small or ill-defined as not to admit of alimentation. Molliere kneAV an individual of forty AA'hose mouth Avas the exact size of a ten-centime piece. Buchnerus « records a case of congenital atresia of the mouth. Cay ley, a 318, 1880, xxvi., 1035. b 54a 1863, i., 320. c 597, xivi., 536. <* 206, vol. iv., part iii. e 548, 1881, ii., 613. * Ann. Soc. de med. de Gand., 1882, 141. 8 105, 1730, ii., 210. 254 MINOR TERATA. Smith,* Sourrouille,b and StankieAvicz of WarsaAV discuss atresia of the mouth. Cancrum oris, scarlet fever, burns, scurvy, etc., are occasional causes that have been mentioned, the atresia in these instances taking place at any time of life. Anomalies of the Lips.—The aboriginal tribes are particularly noted for their large and thick lips, some of Avhich people consider enormous lips signs of adornment. Elephantiasis or other pathologic hypertrophy of the labial tissues can produce revolting deformity, such as is seen in Figure 100, representing an individual Avho was exhibited several years ago in Philadel- phia. We have in English the expression, " pulling a long lip." Its origin is said to date back to a semimythical hero of King Arthur's time, who, " Avhen sad at heart and melancholic," Avould let one of his lips drop below his Avaist, Avhile he turned the other up like a cap on his head. Blotc records a case of monstrous congenital hypertrophy of the superior lip in an infant of eight months. Buck d successfully treated by surgical operations a case of congenital hypertrophy of the under lip, and Detmold e mentions a similar result in a young lady with hypertrophy of the lip and lower part of the nose. Murrayf reports an undescribed malforma- tion of the lower lip occurring in one family. Weiss has reported cases of exstrophy of the lips. Hare-lip may be unilateral or double, and may or may not include the palatine arch. In the Avorst cases it extends in fissures on both sides to the orbit (Fig. 101). In other cases the minimum degree of this deformity is seen (Fig. 102). Congenital absence of the tongue does not necessarily make speech, taste, or deglutition impossible. Jussieu cites the case of a girl who was born Avithout a tongue but AA'ho spoke very distinctly. Berdotg describes a case in Avhich the tongue was deficient, without apparent disturbance of any of the functions. Riolan mentions speech after loss of the tongue from small-pox. Boddington h gives an account of Margaret Cutting, who spoke readily and intelligibly, although she had lost her tongue. Saulquin* has an observation of a girl Avithout a tongue who spoke, sang, and SAvallowed normally. Aur- ran, Bartholinus, Louis, Parsons, Tulpius, and others mention speech Avith- out the presence of a tongue. Fig. 100.—Elephantiasis of the face, with hypertrophy of the upper lip. a 476, 1876, L, 13. b 363, lvi., 707. <= Bull. Soc. de chir. de Par., 1873, ii., 332. d 773. 1882, 171. e 594, 1844, iii., 38. f 222, 1860, xxvi., 502. g 107, vol. viii.. 185. b 629, 1732-44, ix., 126. * 460, 1764, xx.. 328. ANOMALIES OF THE TONGUE. 255 Philib a reports a ease in Avhich mutism, almost simulating that of one con- genitally deaf, Avas due to congenital adhesions of the tongue to the floor of the buccal cavity. Speech Avas established after remoA'al of the abnormal adhesion. Routier speaks of ankylosis of the tongue of seventeen years' duration. Juristb records such abnormal mobility of the tongue that the patient Avas able to project the tongue into the nasopharynx. Wherry and WinsloAV record similar instances. There have been individuals Avith bifid tongues, after the normal type of serpents and saurians, and others Avho possessed a supernumerary tongue. Rev. Henry Wharton, Chaplain to Archbishop Sancroft, in his journal, writ- ten in the seventeenth century, says that he was born with Iavo tongues and Fig. 101.—Double hare-lip. Fig. 102.—Slight hare-lip, with fissure of the lower eyelid (Kraske). passed through life so, one, hoAvever, gradually atrophying. In the poly- clinic of Schnitzer in Vienna in 1X92 Hajek observed in a lad of twelve an accessory tongue 2.4 cm. in length and eight mm. in breadth, forming a tumor at the base of the normal tongue. It was removed by scissors, and on histo- logic examination proved to be a true tongue with the typical tissues and constituents. Borellus, Ephemerides, Eschenbach, Mortimer,0 Penada, and Schenck speak of double tongues, and Avicenna and Schenck have seen fis- sured tongues. Dolaeusd records an instance of double tongue in a paper entitled "De puella bilingui," and Beaudry and Brotherse speak of cleft n 454, 1829, xxxiii., 265. b 538, xxviii., 539. c 629, 486. d 280, 1755, iii., 411. e 538, xxxiii., 109. 256 MINOR TERATA. tongue. Braine a records a case in Avhich there was a large hypertrophied fold of membrane coming from each side of the upper lip. In some cases there is marked augmentation of the volume of the tongue. Founder b has seen a juggler Avith a tongue so long that he could extrude it six inches from his mouth. He also refers to a Avoman in Berlin with a long tongue, but it was thinner than that of a cat. When she laughed it hung over her teeth like a curtain, and Avas ahvavs extremely cold to the touch. In the same article there is a description of a man Avith a very long neck avIio could touch his tongue to his chest Avithout reclining his head. Congenital and acquired hypertrophy of the tongue Avill be discussed later. Amatus Lusitanus c and Portald refer to the presence of hair on the tongue, and later there Avas an account of a medical student e avIio com- plained of dyspepsia and a sticky sensation in the mouth. On examination a considerable groAvth of hair was found on the surface of the tongue. The hairs Avould be detached in vomiting but Avould groAV again, and Avhen he Avas last seen they Avere one inch long. Such are possibly nevoid in formation. The ordinary anomalies of the palate are the fissures, unilateral, bilat- eral, median, etc. : they are generally associated with hare-lip. The median fissure commencing betAveen the middle incisors is quite rare. Many curious forms of obturator or artificial palate are employed to remedy congenital defects. Sercombef mentions a case in which destruction of the entire palate Avas successfully relie\Ted by mechanical means. In some instances among the lower classes these obturators are simple pieces of Avood, so fashioned as to fit into the palatine cleft, and not infrequently the obturator has been sAvalloAved, causing obstruction of the air-passages or occluding the esophagus. Abnormalism of the Uvula.—Examples of double uvula are found in the older Avriters, and Hagendorn speaks of a man who was born Avithout a uvula. The Ephemerides and Salmuth describe uvulse so defective as to be hardly noticeable. Bolster, Delius, Hodges, Mackenzie of Baltimore, Orr, Riedel, Schufeldt, and Tidy man are among observers reporting bifurcated and double uvula, and they are quite common. Ogle g records instances of congenital absence of the uvula. Anomalies of the Epiglottis.—Morgagni mentions a man Avithout an epiglottis Avho ate and spoke Avithout difficulty. He thought the arytenoids Avere so strongly developed that they replaced the functions of the missing organ. Enos of Brooklyn in 1X54 reported absence of the epiglottis Avith- out interference Avith deglutition.h Manifold * speaks of a case of bifur- cated epiglottis. DebloisJ records an instance of congenital web of the a Proc. M. Soe. Lond., 1874-5, ii., 21. b 302, iv., 149. c 119, cent, vi., cur. 65. d 639, iv., 507. e 611, Aug. 13, 1842. f 550, xxxix., 91. S 548, 1865, ii., 414. h 230. 1864. iv., 353. i 476, 1851, i., 10. i 597, xxxix., 660. DOUBLE VOICE. 257 vocal bands. Mackenziea removed a congenital papillomatous web Avhich had united the vocal cords until the age of twenty-three, thus establish- ing the voice. Poore also recorded a case of congenital Aveb in the larynx. Elsberg and Scheff mention occlusion of the rima glottidis by a membrane. Instances of duplication of the epiglottis attended with a species of double voice possess great interest. Frenchb described a man of thirty, by occupation a singer and contortionist, Avho became possessed of an extra voice Avhen he Avas sixteen. In high and falsetto tones he could run the scale from A to F in an upper and lower range. The compass of the low voice Avas so small that he could not reach the high notes of any song Avith it, and in sing- ing he only used it to break in on the falsetto and produce a sensation. He was supposed to possess a double epiglottis.0 Roe d describes a young lady Avho could Avhistle at Avill Avith the loAver part of her throat and Avithout the aid of her lips. Laryngeal examination showed that the fundamental tones Avere produced by vibrations of the edges of the vocal cords, and the modifications were effected by a minute adjust- ment of the ventricular bands, which regulated the laryngeal opening above the cord, and pressing firmly doAvn closed the ventricle and acted as a damper, preventing the vibrations of the cords except in their middle third. Morgan in the same journal mentions the case of a boy of nineteen, Avho seemed to be affected with laryngeal catarrh, and Avho exhibited distinct diphthongia. He Avas seen to have two glottic orifices Avith associate bands. The treatment was directed to the catarrh and consequent paresis of the posterior bands, and he soon lost his eAddences of double A'oice.e Complete absence of the eyes is a A-cry rare anomaly. Wordsworthf describes a baby of seven Aveeks, othenvise well formed and healthy, which had congenital absence of both eyes. The parents of this child were in every respect healthy. There are some cases of monstrosities Avith closed, adherent eyelids and absence of eyes.B Holmes h reports a case of congenital absence of both eyes, the child otherAvise being strong and perfect. The child died of a 224, 1874, i., 317. b Quoted 224, 1880, ii., 311. o 148, vol. ii., 271. d Archives of Laryngology, Jan. 1, 1882. e The following is a description of the laryngeal formation of a singer who has recently acquired considerable notice by her ability to sing notes of the highest tones and to display the greatest compass of A'oice. It is extracted from a Cleveland, Ohio, newspaper: "She has unusual development of the larynx, which enables her to throw into vibration and with different degrees of rapidity the entire length of the vocal cords or only a part thereof. But of greatest interest is her remarkable control over the muscles which regulate the division and modification of the resonant cavities, the laryngeal, pharyngeal, oral, and nasal, and upon this depends the quality of her voice. The uvula is bifurcated, and the two divisions some- times act independently. The epiglottis during the production of the highest notes rises upward and backward against the posterior pharyngeal wall in such a way as almost entirely to separate the pharyngeal cavities, at the same time that it gives an unusual conformation to those resonant chambers." f 476, 1881, ii., 875. 8 240, 1828. h 268, 1869, xxvi., 163. 17 258 MINOR TERATA. cholera infantum. He also reports a ease very similar in a female child of American parents. In a girl of eight, of (Jerman parents, he reports defi- ciency of the external Avails of each orbit, in addition to great deformity of the side of the head. He also gives an instance of congenital paralysis of the levator palpebrae muscles in a child Avhose vision Avas perfect and avIio Avas otherAvise perfect. Holmes also reports a case of enormous congenital ex- ophthalmos, in AA'hich the right eye protruded from the orbit and Avas no longer covered by the cornea. Kinneya has an account of a child born without eyeballs. The delivery Avas normal, and there Avas no history of any maternal impression ; the child Avas otherwise healthy and well formed. Landesb reports the case of an infant in Avhich both eyes were absent. There Avere six fingers on each hand and six toes on each foot. The child lived a feAV Aveeks. In some instances of supposed absence of the eyeball the eye is present but diminutive and in the posterior portion of the orbit. There are instances of a single orbit with no eyes and also a single orbit containing two eyes.c Again we may have tAvo orbits Avith an absence of eyes but the presence of the lacrimal glands, or the eyes may be present or very imperfectly developed. Mackenzie mentions cases in which the orbit was more or less completely Avanting and a mass of cellular tissue in each eye. Cases of living cyclopia, or individuals Avith one eye in the center of the forehead after the manner of the mythical Cyclops, are quite rare. Yal- lentini in 1884 d reports a case of a male cyclopic infant which lh'ed for seventy-three hours. There Avere median fissures of the upper lip, pre- auricular appendages, oral deformity, and absence of the olfactory proboscis. The fetus Avas therefore a cyelops arrhynchus, or cyclocepbalus. Bloke de- scribes a neAV-born infant AA'hich lived for six or seven hours, having but one eye and an extremely small mouth. The " Four-eyed Man of Cricklade" was a celebrated English mon- strosity of Avhom little reliable information is obtainable. He was visited by W. Drury, avIio is accredited with reporting the folloAving :— " ' So Avondrous a thing, such a lusus naturae, such a scorn and spite of nature I haATe never seen. It was a dreadful and shocking sight.' This unfortunate had four eyes placed in pairs, ' one eye aboA'e the other and all four of a dull broAvn, encircled Avith red, the pupils enormously large.' The A'ision in each organ appeared to be perfect. ' He could shut any particular eye, the other three remaining open, or, indeed, as many as he chose, each several eye seeming to be controlled by his Avill and acting independently of the remainder. He could also reArolve each eye separately in its orbit, look- ing backAvard Avith one and forward Avith another, upAvard Avith one and a 218, 1854, li., 25. b 538, Nov. 3, 1894. c 418, 1751, 49. d Atti dell' Accad. med.-chir. di Perugia, vi., fasc. 3 & 4, 1894. e Weekblad van het Nederlandsch Tijdschr. voor Geneeskunde, xxx., 2d part, 414, Sept., 1894 ; also extracted in 759. MULTIPLE PUPILS. 259 doAviiAvard Avith another simultaneously.' He Avas of a savage, malignant disposition, delighting in ugly tricks, teasing children, torturing helpless ani- mals, uttering profane and blasphemous Avords, and acting altogether like the monster, mental and physical, that he Avas. ' He could play the fiddle, though in a silly sort, having his notes on the left side, Avhile closing the right pair of eyes. He also sang, but in a rough, screeching A'oice not to be listened to Avithout disgust.' " There is a recent reporta of a child born in Paris with its eyes in the top of its head. The infant seemed to be doing Avell and crowds of people haAre flocked to see it. Recent reports speak of a child born in Portland, Ore- gon, Avhich had a median rudimentary eye between two no/mal eyes. Four- nier describes an infant born with perfectly formed eyes, but Avith adherent eyelids and closed ocular aperture. Forlenze has seen the pupils adherent to the conjunctiva, and by dissection has given sight to the subject. Duboisb cites an instance of supernumerary eyelid. At the external angle of the eyelid Avas a fold of conjunctiva Avhich extended 0.5 cm. in front of the conjunctiva, to Avhich it did not adhere, therefore constituting a fourth eyelid. Fanoc presents a similar case in a child of four months, in whom no other anomaly, either of organs or of vision, was obserA'ed. On the right side, in front of the external half of the sclerotic, Avas observed a semilunar fold Avith the concavity inward, and Avhich projected much more Avhen the loAver lid Avas depressed. When the eyelid rolled iiiAvard the fold rolled Avith the globe, but neA^er reached so far as the circumference of the cornea and did not interfere with vision. Total absence of both irides has been seen in a man of eighteen. d Dixon reports a case of total aniridia Avith excellent sight in a Avoman of thirty-scvcn.e In Guy's Hospital there Avas seen a case of complete con- genital absence of the iris.392 Hentzschelf speaks of a man AA'ith congenital absence of the iris av1io had five children, three of Avhom exhibited the same anomaly Avhile the others Avere normal. Benson, Burnett, Demaux, Lawson, Morison, Reuling, Samelson, and others also report congenital deficiency of the irides in both eyes. JeaffresonU5 describes a female of thirty, living in India, Avho Avas affected with complete ossification of the iris. It Avas immovable and quite beautiful Avhen seen through the transparent cornea; the sight Avas only slightly impaired. Xo cause Avas traceable. Multiple Pupils.—More than one pupil in the eye has often been noticed, and as many as six have been seen. They may be congenital or due to some pathologic disturbance after birth. Marcellus Donatus30G speaks of tAvo pupils in one eve. Beer, Fritsche, and Heuermann are among the older Avriters avIio have noticed supernumerary pupils. Higgens in 1X85 described a Amer. Med. Review, Dec, 1895. b 145, vol. xxxiv. c 145, 1863, 1. d 476, 1SS:>, i., 205. e 548, 1858, ii., 35. f Quoted 476, 1830-1, i., 384. 260 MINOR TERATA. a boy whose right iris AA'as perforated by four pupils,—one above, one to the inner side, one beloAv, and a fourth to the outer side. The first three avc re slit-shaped ; the fourth was the largest and had the appearance as of the separation of the iris from its insertion. There Avere tAvo pupils in the left eye, both to the outer side of the iris, one being slit-like and the other resem- bling the fourth pupil in the right eye. All six pupils commenced at the periphery, extended imvard, and Avere of different sizes. The fundus could be clearly seen through all of the pupils, and there Avas no posterior staphy- loma nor any choroidal changes. There was a rather high degree of myopia. This peculiarity Avas evidently congenital, and no traces of a central pupil nor marks of a past iritis could be found. Clinical Sketches a contains quite an extensive article on and several illustrations of congenital anomalies of the iris. Double crystalline lenses are sometimes seen. Fritsch and Valisneri have seen this anomaly and there are modern references to it. WordsAvorth b presented to the Medical Society of London six members of one family, all of Avhom had congenital displacement of the crystalline lens outAvard and upAvard. The family consisted of a Avoman of fifty, tAvo sons, thirty-five and thirty-seven, and three grandchildren—a girl of ten and boys of five and seven. The irides Avere tremulous. Clarkc reports a case of congenital dislocation of both crystalline lenses. The lenses moAred freely through the pupil into the anterior cham- bers. The condition remained unchanged for four years, Avhen glaucoma supervened. Differences in Color of the Two Eyes.—It is not uncommon to see people Avith different colored eyes. Anastasius I. had one black eye and the other blue, from Avhence he derived his name " Dicore," by which this Emperor of the Orient Avas generally known. Two distinct colors have been seen in an iris. Berry gives a colored illustration of such a case. The varieties of strabismus are so common that, they will be passed with- out mention. Kuhn d presents an exhaustive analysis of 73 cases of congeni- tal defects of the movements of the eyes, considered clinically and didacti- cally. Some or all of the muscles may be absent or two or more may be amalgamated, Avith anomalies of insertion, false, double, or degenerated, etc. The influence of heredity in the causation of congenital defects of the eye is strikingly illustrated by De Beck.e In three generations tAveh-e members of one family had either coloboma iridis or irideremia. He per- formed tAvo operations for the cure of cataract in two brothers. The opera- tions were attended Avith difficulty in all four eyes and folloAved by cyclitis. The result was good in one eye of each patient, the eye most recently blind. Poseyf had a case of coloboma in the macular region in a patient Avho had a a 275, April, 1895. b 476, 1878, i., 86. c 765, 1894. d Beit. z. Augenh., Heft xix., 1895. e Trans. 765, 1894. f 792, Nov., 1894. ANOMALIES OF THE EARS. 261 supernumerary tooth. He believes the defects were inherited, as the patient's mother also had a supernumerary tooth. Xunnelya reports cases of congenital malformation in three children of one family. The globes of two of them (a boy and a girl) Avere smaller than natural, and in the boy in addition Avere flattened by the action of the recti muscles and Avere soft; the sclera Avere very vascular and the cornese conical, the irides dull, thin, and tremulous; the pupils Avere not in the axis of vision, but Avere to the nasal side. The elder sister had the same congeni- tal condition, but to a lesser degree. The other boy in the family had a total absence of irides, but he could see fairly well with the left eye. Anomalies Of the Ears.—Bilateral absence of the external ears is quite rare, although there is a species of sheep, native of China, called the " Yung- ti," in Avhich this anomaly is constant. Bartholinus, Lycosthenes, Pare, Schenck, and Oberteuffer have remarked on deficient external ears. Guys, the celebrated Marseilles litterateur of the eighteenth century, Avas born with only one ear. Chantreuilb mentions obliteration of the external auditory canal in the neAV-born. Bannofont reports a case of congenital imperforation of the left auditory canal existing near the tympanic membrane Avith total deaf- ness in that ear. Lloydc described a fetus shoAving absence of the external auditory meatus on both sides. Munro d reports a case of congenital absence of the external auditory meatus of the right ear; and Richardsone speaks of congenital malformation of the external auditory apparatus of the right side. There is an instancef of absence of the auditory canal with but par- tial loss of hearing. Mussey g reports several cases of congenitally deficient or absent aural appendages. One case was that in which there was con- genital absence of the external auditory meatus of both ears without much impairment of hearing. In neither ear of N. W. Goddard, aged twenty- seven, of "Vermont, reported in 1834, Avas there a vestige of an opening or passage in the external ear, and not even an indentation. The Eustachian tube was closed. The integuments of the face and scalp Avere capable of receiving acoustic impressions and of transmitting them to the organs of hear- ing. The authors knoAV of a student of a prominent Xew York University Avho is congenitally deficient in external ears, yet his hearing is acute. He hides his deformity by Avearing his hair long and combed oA'er his ears. The knowledge of anomalous auricles is lost in antiquity. Figure 103 represents the head of an iEgipan in the British Museum showing a super- numerary auricle. As a rule, supernumerary auricles are preauricular appendages. Warner, in a report of the examination of 50,000 children, quoted by Ballantyne, describes 33 Avith supernumerary auricles, represented by sessile or pedunculated outgroAvths in front of the tragus. They are more commonly unilateral, ahvays congenital, and can be easily removed, giving rise a 550, xlv., 43. b 242, 1807, xiii., 149. c 779, 1846, i., 139. d 476, 1869, ii., 41. e 476, 1882, i., 465. f 218, xi., 419. 8 124, 1837, xxi., 378. 262 MINOR TERATA. to no unpleasant symptoms. They have a soft and elastic consistency, and are usually composed of a hyaline or reticular cartilaginous axis covered Avith connective or adipose tissue and skin bearing fine hairs; sometimes both cartilage and fat are absent. They are often associated Avith some form of de- fective audition—harelip, ocular disturb- ance, club-feet, congenital hernia, etc. These supernumerary members vary from one to five in number and are sometimes hereditary. Reverdin describes a man having a supernumerary nipple on the right side of his chest, of whose five children three had preauricular append- ages. Figure 104 represents a girl Avith a supernumerary auricle in the neck, de- scribed in the Lancet, 1888.a A little girl under Birkett's care in Guy's Hos- pital more than answered to Macbeth's requisition, " Had I three ears I'd hear thee !" since she possessed two super- fluous ones at the sides of the neck, somewhat lower than the angle of the jaAV, which Avere well developed as to their external contour and made up of fibrocartilage.b There is mentioned the case of a boy of six months c Fig. 103.—iEgipan with supernumerary auricle (British Museum). Fig. 104.—Supernumerary auricle in the neck. Fig. 105.—Supernumerary auricle. on the left side of Avhose neck, over the middle anterior border of the sterno- cleidomastoid muscle, was a nipple-like projection \ inch in length ; a rod of a 476, 1888, i., 312. b 543, 1858, 528. c 476, 1889, ii., 1003. ABSENCE OF THE LIMBS. 263 cartilage Avas prolonged into it from a thin plate, which Avas freely moA'able in the subcutaneous tissue, forming a striking analogue to an auricle (Fig. 105). Moxhay a cites the instance of a mother avIio Avas frightened by the sight of a boy Avith hideous contractions in the neck, and Avho gave birth to a child Avith two perfect ears and three rudimentary auricles on the right side, and on the left side tAvo rudimentary auricles. In some people there is an excessive development of the auricular muscles, enabling them to move their ears in a manner similar to that of the lower animals. Of the celebrated instances the Abbe de Marolles, says Yigneul-Marville, bears Avitness in his "Memoires" that the Regent Crassot could easily move his ears. Saint Augustine mentions this anomaly. Double tympanitic membrane is spoken of by Loeseke.489 There is sometimes natural perforation of the tympanum in an otherAvise perfect ear, which explains how some people can bloAV tobacco-smoke from the ear. Founderb has seen several Spaniards and Germans who could perform this feat, and knew one man who could smoke a whole cigar without losing any smoke, since he made it leave either by his mouth, his ears, or in both ways. Fournier in the same article mentions that he has seen a woman with ears over four inches long. Strange to say, there have been reports of cases in which the ossicles were deficient without causing any imperfection of hearing. Caldanic mentions a case with the incus and malleus deficient, and Scarpa715 and Torreau d quote instances of deficient ossicles. Thomka in 1895 reported a case of supernumerary tympanic ossicle, the nature of Avhich avus unknown, although it was neither an inflammatory product nor a remnant of Meckel's cartilage. Absence of the Limbs.—Those persons born Avithout limbs are cither the subjects of intrauterine amputation or of embryonic malformation. Prob- ably the most celebrated of this class was Marc Cazotte, otherwise knoAvn as " Pepin," Avho died in Paris in the last century at the age of sixty-two of a chronic intestinal disorder. He had no arms, legs, or scrotum, but from very jutting shoulders on each side were Avell-formed hands. His abdomen ended in a flattened buttock Avith badly-formed feet attached. He Avas exhibited before the public and Avas celebrated for his dexterity. He performed nearly all the necessary actions, exhibited skilfulness in all his movements, and Avas credited Avith the ability of coitus. He Avas quite intellectual, being able to Avritc in several languages. His skeleton is preserved in the Musee Dupuy- tren (Fig. 106). Flachsland e speaks of a Avoman who three times had borne children Avithout arms and legs. Hastingsf describes a living child born Avithout any traces of arms or legs (Fig. 107). Garlick g has seen a child Avith neither upper nor Ioavci* extremities. In place of them Avere short stumps three or four inches long, closely resembling the ordinary stumps after " 224, 1870. b 302, iv., 148. c 401, vi., 142. d379, vi., 321. e Observat. patholog. Anat., p. 44. t 776, 1826, ii., 39. g 656, 1849. 264 MINOR TEL'ATA. amputation. The head, chest, body, and male genitals were avcII formed, and the child survived. Hutchinson a reports the history of a child born Avithout extremities, probably the result of intrauterine amputa- tion. The flaps Avere healed at the deltoid insertion and just beloAv the groin. Pareb savs he saAV in Paris a man Avithout arms, avIio bv means of his head and neck could crack a Avhip or hold an axe. He ate by means of his feet, dealt and played cards, and threw dice Avith the same members, exhibiting such dex- terity that finally his companions refused to play Avith him. He Avas proved to be a thief and a murderer and Avas finally hanged at Gueldres (Fig. 108). Pare also relates having seen a Avoman in Paris Avho seAved, embroidered, and did other things Avith her feet. Jansen470 speaks of a man in Spain, born Avithout arms, who could use his feet as well as most people use their arms. Schenck and Lotichius give descriptions of armless people. Hulke c describes a child of four Avhose upper limbs were absent, a small dimple only Fig. 106.—"Pepin" (Musee Dupuytren). , . . , . , TT being in their place. He had free movement of the shoulders in every direction, and could grasp objects betAveen his cheeks and his acromian process ; the prehensile power of the toes was Avell developed, Fig. 107.—Limbless child. as he could pick up a coin thrown to him. A monster of the same conforma- a 779, 1853, 343. b 618, 1020. c 550. 1877. 65. ABSENCE OF THE LIMBS. 265 tion Avas the celebrated painter, Ducornet (Fig. 109), Avho Avas born at Lille on the 10th of January, 1806. He Avas completely deprived of arms, but the rest of the body Avas Avell formed Avith the exception of the feet, of Avhich the second toe Avas faulty. The deformity of the feet, however, had the happiest result, as the space between the great toe and its neighbor was much larger than ordinary and the toes much more mobile. He became so skilful in his adopted profession that he finally painted a picture eleven feet in height (repre- senting Mary Magdalene at the feet of Christ after the resurrection), Avhich was purchased by the Government and given to the city of Lille. Broca describes James LeedgAvood, avIio Avas deprived of his arms and had only one leg. He ex- hibited great dexterity Avith his single foot, Avrote, discharged a pistol, etc.; he was said to haATe been able to pick up a seAving-needle on a slippery surface Avith his eyes blindfolded. Capitan described to the Societe d'anthropologie de Paris a young man Avithout arms, Avho AA'as said to play a violin and cornet Avith his feet. He was able to take a kerchief from his pocket and to blow his nose ; he could make a cigarette, light it, and put it in his mouth, play cards, drink from a glass, and eat Avith a fork by the aid of his dexterous toes. There Avas a creature exhibited some time since in the principal cities of France, Avho was called the " l'homme tronc." He Avas totally deprived of all his members. Curran a describes a Hindoo, a prostitute of forty, Avith congenital absence of both upper extremities. A slight fleshy protuberance depended from the cicatrix of the humerus and shoulder-joint of the left side, and until the age of ten there Avas one on the right side. She performed many tricks Avith her toes (Fig. 110). Caldani speaks of a monster Avithout arms, Davis b mentions one, and Smith c describes a boy of four Avith his upper limbs Breschet has seen a child of nine Avith only portions of the Fig. 108.—Armless man (after Par6). Fig. 109.—Caesar Ducornet. entireh' absent. upper arms and deformity of loAver extremities and pelvis. Pare d says that •i 536, 1887, i., 116. b 530, 1885, 338. e 767, 1873, 89. d 618, 1018. 266 MINOR TERATA. 110.—Hindoo armless woman (Curran). he saAV in Paris in 1573, at the gate of St. Andrew des Arts, a boy of nine, a native of a small village near Guise, avIio had no legs and Avhose left foot Avas represented by a fleshy body hanging from the trunk ; he had but tAvo fingers hanging on his right hand, and had between his legs what resembled a virile penis. Pare attributes this anomaly to a de- fault in the quantity of semen. The figure and skeleton of Harvey Leach, called " Hervio Nono," is in the museum of the University College in London. The pelvis was comparatively weak, the femurs hardly to be recognized, and the right tibia and foot defective ; the left foot Avas better developed, although far from being in due proportion to the trunk above. He Avas one of the most remarkable gymnasts of his day, and not- withstanding the distortion of his loAver limbs had marvelous power and agility in them. A s an arena- horseman, either standing or sitting, he Avas scarcely excelled. He Avalked and even ran quite well, and his poAver of leaping, partly with his feet and partly with his hands, was unusual. His loAver limbs Avere so short that, erect, he touched the floor with his fingers, but he earned his lh^elihood as much with his loAver as with his upper limbs. In his skeleton his left lower limb, between the hip and heel, measured 16 inches, while the right, between the same points, measured nine inches (Fig. 111).a Hare b mentions a boy of five and a half Avhose head and trunk Avere the same as in any other child of like age. He Avas 22^ inches high, had no spinal curva- ture, but Avas absolutely deA7oid of loAver extremities. The right arm was tAvo inches long and the left 24;. Each contained the head and a small adjoining por- tion of the humerus. The legs Avere represented bv masses of cellular tissue and fat covered by skin AAiiich projected about an inch. He was intelligent, had a good memory, and exhibited considerable activity. He seemed to have had more than usual mobility and poAver of flexion of the loAver lumbar region. When on his back he was unable to rise up, but resting on the lower part of the pelvis he Avas able to maintain himself erect. He usually picked up objects Avith his teeth, and could hold a coin in the axilla as he rolled from place to place. a 476, 1864, ii., 60. b 779, is3fc- 617, iii., obs. 48. 276 MINOR TERATA. not confined to man alone; apes, dogs, and other lower animals possess it. Bucephalus, the celebrated horse of Alexander, and the horse of CYesar Avere said to have been cloven-hoofed. Hypertrophy of the digits is the result of many different processes, and true hypertrophy or gigantism must be differentiated from acromegaly, elephantiasis, leontiasis, and arthritis deformans, for Avhich distinction the reader is referred to an article by Park.a Park also calls attention to the difference between acquired gigantism, particularly of the finger and toes, and another condition of congenital gigantism, in which either after or before birth there is a relatively disproportionate, sometimes enormous, overgrowth of perhaps one finger or two, perhaps of a limited portion of a hand or foot, or possibly of a part of one of the limbs. The best collection of this kind of specimens is in the College of Sur- geons in London. Curlingb quotes a most peculiar instance of hypertrophy of the fingers in a sickly girl (Fig. 127). The mid- dle and ring fingers of the right hand were of unusual size, the middle fin- ger measuring 5 J inches in length and four inches in circumference. On the left hand the thumb and middle fin- gers were hypertrophied and the in- dex finger was as long as the middle one of the right hand. The middle finger had a lateral curvature out- ward, due to a displacement of the extensor tendon. This affection re- Fig. i27.-HypertroPhied fingers. sembled acromegaly. Curling cites similar cases, one in a Spanish gentle- man, Governor of Luzon, in the Philippine Islands, in 1850, Avho had an extraordinary middle finger, which he concealed by carrying it in the breast of his coat. Hutchinson619 exhibited a photograph shoAving the absence of the radius and thumb, with shortening of the forearm. Conditions more or less approaching this had occurred in several members of the same family. In some they Avere associated Avith defects of development in the loAver extremi- ties also. The varieties of club-foot—talipes varus, valgus, equinus, equino-varus, etc.—are so well knoAvn that they Avill be passed with mention only of a feAV persons avIio have been noted for their activity despite their deformity. Tyrtee, Parini, Byron, and Scott are among the poets who were club-footed; a Inter. Med. Mag., Phila., July, 1895. b 550, 1845, xxviii., 623. HUMAN TAILS. 277 some writers say that Shakespeare suffered in a slight degree from this de- formity. Agesilas, Genserie, Robert II., Duke of Normandy, Henry II., Emperor of the AYest, Otto II., Duke of BrunsAvick, Charles II., King of Naples, and Tamerlane Avere A'ictims of deformed feet. Mile. Valliere, the mistress of Louis XIV., Avas supposed to have both club-foot and hip-disease. Genu valgum and genu varum are ordinary deformities and quite common in all classes. Transpositions of the character of the vertebrae are sometimes seen. In man the lumbar vertebrae have sometimes assumed the character of the sacral vertebrae, the sacral vertebrae presenting the aspect of lumbar vertebrae, etc. It is quite common to see the first lumbar vertebra presenting certain characteristics of the dorsal. Numerical anomalies of the vertebrae are quite common, generally in the lumbar and dorsal regions, being quite rare in the cervical, although there have been instances of six or eight cervical A'crtebrae. In the lower animals the A'crtebrae are prolonged into a tail, Avhich, hoAvever, is sometimes absent, particularly Avhen hereditary influence exists. It has been noticed in the class of dogs Avhose tails are habitually amputated to improve their appearance that the tail gradually decreases in length. Some breeders deny this fact. Human Tails.—The prolongation of the coccyx sometimes takes the shape of a caudal extremity in man. Broca and others claim that the sacrum and the coccyx represent the normal tail of man, but examples are not infrequent in Avhich there has been a fleshy or bony tail appended to the coccygeal region. Traditions of tailed men are old and Avidespread, and tailed races Avere supposed to reside in almost every country. There Avas at one time an ancient belief that all Cornishmen had tails, and certain men of Kent Avere said to have been afflicted Avith tails in retribution for their insults to Thomas a Becket. Struys, a Dutch traveler in Formosa in the seventeenth century, describes a Avild man caught and tied for execution who had a tail more than a foot long, Avhich Avas covered Avith red hair like that of a coav. The Niam Niams of Central Africa are reported to have tails smooth and hairy and from tAvo to ten inches long. Hubsch of Constantinople remarks that both men and Avomen of this tribe have tails. Carpus, or Berengarius Carpensis, as he is called, in one of his Commentaries said that there were some people in Hibernia Avith long tails, but Avhether they were fleshy or cartilaginous could not be known, as the people could not be approached. Certain supposed tailed races Avhich have been described by sea-captains and voyagers are really only examples of people Avho Avear artificial appendages about the Avaists, such as palm-leaves and hair. A certain AAresleyan mission- ary, George BroAvn, in 1876 spoke of a formal breeding of a tailed race in Kali, off the coast of NeAV Britain. Tailless children Avere slain at once, as they Avould be exposed to public ridicule. The tailed men of Borneo are 278 MINOR TERATA. people afflicted Avith hereditary malformation analogous to sexdigitism. A tailed race of princes have ruled Rajoopootana, and are fond of their ances- tral mark.638 There are fabulous stories told of canoes in the Fast Indies Avhich have holes in their benches made for the tails of the roAvers. At one time in the East the presence of tails Avas taken as a sign of brute force. There Avas reported from Caracas11 the discovery of a tribe of Indians in Paraguay avIio Avere proA'ided Avith tails. The narrative reads someAvhat after this manner : One day a number of workmen belonging to Tacura Tuyn Avhile engaged in cutting grass had their mules attacked by some Guayacuyan In- dians. The workmen pursued the Indians but only succeeded in capturing a boy of eight. He Avas taken to the house of Scnor Francisco Galeochoa, at Posedas, and Avas there discovered to haA'e a tail ten inches long. On inter- rogation the boy stated that he had a brother who had a tail as long as his oavu, and that all the tribe had tails. Actios, Bartholinus, Falk, Harvey, Kolping, Hesse, Paulinus, Strauss, and Wolff giATe descriptions of tails. Blanchard 213 says he suav a tail fully a span in length ; and there is a description in 1690 of a man by the name of Emanuel Konig, a son of a doctor of huvs,570 avIio had a tail half a span long, which grew directly downAvard from the coccyx and Avas coiled on the perineum, causing much discomfort. Jacobb describes a pouch of skin resembling a tail Avhich hung from the tip of the coccyx to the length of six inches. It Avas removed and Avas found to be thicker than the Fig. 128.—Caudal appendix observed in a , , . n „ ,. •. . . child in the clinic of m. Gosseiin. thumb, consisted ot distinctly jointed portions with synovial capsules. Gosseiin saw at his clinic a caudal appendix in an infant AA'hich measured about ten cm. (Fig. 128). Lissner says that in 1872 he assisted in the delivery of a young girl who had a tail consisting of a coccyx prolonged and covered Avith skin, and in 1884 he saAV the same girl, at this time the tail measuring nearly 13 cm. VirchoAV received for examination a tail three inches long amputated from a boy of eight weeks. Ornstein, chief physician of the Greek army, describes a Greek of twenty-six Avho had a hairless, conical tail, free only at the tip, two inches long and containing three vertebrae. He also remarks that other instances have been observed in recruits. Thirk of Broussa in 1820 de- scribed the tail of a Kurd of twenty-two which contained four vertebrae. Belinovskic gives an account of a hip-joint amputation and extirpation of a fatty caudal extremity, the only one he had ever observed. Before the Berlin Anthropological Society there Avere presented iavo adult male Papuans, in good health and spirits, Avho had been brought from NeAV a 476, 1885, ii., 452. b 31^ 1307. c 270, 1892. HUMAN TAILS. 279 Guinea ; their coccygeal bones projected \\ inches. Oliver AVendell Holmes in the Atlantic Monthly, June, 1890, says that he saAV in London a photo- graph of a boy Avith a considerable tail. The " Moi Boy" Avas a lad of tAvelve, Avho AA'as found in Cochin China, Avith a tail a foot long Avhich Avas simply a mass of flesh. Miller a tells of a AVest Point student avIio had an elongation of the coccyx, forming a protuberance Avhich bulged very visibly under the skin. Exercise at the riding school ahvays gave him great dis- tress, and the protuberance Avould often chafe until the skin Avas broken, the blood trickling into his boots. Bartelsb presents a very complete article in Avhich he describes 21 per- sons born Avith tails, most of the tails being merely fleshy protuberances. Danvin 289 speaks of a person Avith a fleshy tail and refers to a French arti- cle on human tails.0 Scienced contains a description of a negro child born near Louisville, eight Aveeks old, Avith a pedunculated tail "2\ inches long, Avith a base \\ inches in circumference. The tail resembled in shape a pig's tail and had groAvn \ inch since birth. It showed no signs of cartilage or bone, and had its origin from a point slightly to the left of the median line and about an inch above the end of the spinal column. Dickinson e recently reported the birth of a child Avith a tail (Fig. 129). It Avas a Avell-developed female between h\ and six pounds in Aveight. The coccyx Avas coA7ered Avith the skin on both the anterior and posterior surfaces. It thus formed a tail of the size of the nail of the little finger, Avith a length of nearly -^ inch on the inner surface and f inch on the rear surface. This little tip could be raised from the body and it sloAvly sank back. In addition to the familiar caudal projection of the human fetus, Dickin- son mentions a group of other vestigial remains of a former state of things. Briefly these are :— (1) The plica semilunaris as a vestige of the nictitating membrane of certain birds. (2) The pointed ear, or the turned-doAvn tip of the ears of many men. (3) The atrophied muscles, such as those that move the ear, that are well developed in certain people, or that shift the scalp, resembling the action of a horse in ridding itself of flies. (4) The supracondyloid foramen of the humerus. (o) The vermiform appendix. (6) The location and direction of the hair on the trunk and limbs. (7) The dAvindling Avisdom-teeth. (8) The feet of the fetus strongly deflected inAvard, as in the apes, and persisting in the early months of life, together Avith great mobility and a dis- tinct projection of the great toe at an angle from the side of the foot. a 545, 1881, 165. b 157, 1880. c 669, 1867-8, p. 625. d 727, June 6, 1884. e 227, viii., 568, 1894. 280 MINOR TERATA. (9) The remarkable grasping power of the hand at birth and for a few weeks thereafter, that permits young babies to suspend their whole weight on a cane for a period varying from half a minute to two minutes. Horrocks a ascribes to these anal tags a pathologic importance. He claims that they may be productive of fistula in ano, superficial ulcerations, fecal con- cretions, fissure in ano, and that they may hypertrophy and set up tenesmus and other troubles. The presence of human tails has given rise to discussion between friends and opponents of the Darwinian theory. By some it is Fig. 129.—Skin-covered coccyx forming a rudimentary tail in a female child at birth: C, coccyx; A, anus (Dickinson). considered a reversion to the lower species, while others deny this and claim it to be simply a pathologic appendix. Anomalies of the Spinal Canal and Contents.—AVhen there is a default in the spinal column, the vice of conformation is called spina bifida. This is of tAvo classes : first, a simple opening in the vertebral canal, and, second, a large cleft sufficient to allow the egress of spinal membranes and substance. Figure 130 represents a large congenital sacral tumor. Achard b speaks of partial duplication of the central canal of the spinal cord. De Cecco c reports a singular case of duplication of the lumbar seg- a Quar. Med. Jour., July, 1894. b 042, 1888, 922. c Morgagni, Napoli, 1857, i., 307. CURVATURES OF THE SPINE. 281 Fig. 130.-Sacral tu- mor (Mutter Mus., Col. of Phys.). ment of the spinal cord. AVagner speaks of duplication of a portion of the spinal cord. Foota records a case of amyelia, or absence of the spinal cord, in a fetus with hernia cerebri and complete fissure of the spinal column. Nicoll and Arnold b describe an anencephalous fetus Avith absence of spinal marrow ; and Smith also records the birth of an amyelitic fetus.c In some persons there are exaggerated curvatures of the spine. The first of these curvatures is called kyphosis, in Avhich the curvature is posterior ; second, lor- dosis, in Avhich the curvature is anterior; third, scoliosis, in Avhich it is lateral, to the right or left. Kyphosis is the most common of the deviations in man and is most often found in the dorsal region, although it may be in the lumbar region. Congenital kyphosis is very rare in man, is generally seen in monsters, and when it does exist is usually accompanied by lordosis or spina bifida. AVe sometimes observe a condition of anterior curvature of the lumbar and sacral regions, Avhich might be taken for a congenital lordosis, but this is really a deformity produced after birth by the physiologic Aveight of the body. Figure 131 represents a case of lordosis caused by paralysis of the spinal muscles. Analogous to this is Avhat the accoucheurs call spondy- lolisthesis. Scoliosis may be a cervicodorsal, dorso- lumbar, or lumbosacral curve, and the inclination of the vertebral column may be to the right or left (Figs. 132 and 133). The pathologists divide scoliosis into a myo- pathic variety, in Avhich the trouble is a physiologic an- tagonism of the muscles ; or osteopathic, ordinarily asso- ciated with rachitis, Avhich latter variety is generally accountable for congenital scoliosis. In some cases the diameter of the chest is shortened to an almost incredible degree, but may yet be compatible Avith life. Glover d speaks of an extraordinary deformity of the chest with lateral curvature of the spine, in Avhich the diameter from the pit of the stomach to the spinal integument Avas only 5| inches. Supernumerary ribs are not at all uncommon in man, nearly every medical museum having some examples. Cervical ribs are not rare. Gordon e describes a young man of seventeen Fig. 131.—Lordosis, —paralysis of spinal muscle (Hirst). a 536, Dublin, 1865, xi., 435. ; 1346_ TRANSPOSITION OF THE VISCERA. 291 besides that of the mesogastrium, are capable of forming splenic tissue. Jame- son a reports a case of double spleen and kidneys. Bainbrigge b mentions a case of supernumerary spleen causing death from the patient being placed in the supine position in consequence of fracture of the thigh. Peevor c men- tions an instance of second spleen. Beclard and Guy-Patin have seen the spleen congenitally misplaced on the right side and the liver on the left; Borellus and Bartholinus with others have observed misplacement of the spleen. The Pancreas.—Lieutaud has seen the pancreas missing and speaks of d a double pancreatic duct that he found in a man who died from starvation ; Bonet216 speaks of a case similar to this last. There are several cases of complete transposition of the viscera on record. This bizarre anomaly was probably observed first in 1650 by Riolanus, but the most celebrated case Avas that of Morand in 1660, and Mery described the instance later which was the subject of the following quatrain :— " La nature, peu sage et sans doute en debauche, Plaga le foie au cote gauche, Et de meme, vice versa, Le cceur a. le droite placa.'' Young e cites an example in a woman of eighty-five Avho died at Ham- mersmith, London. She Avas found dead in bed, and in a postmortem exami- nation, ordered to discover if possible the cause of death, there was seen complete transposition of the viscera. The heart lay with its base toAvard the left, its apex toward the right, reaching the loAver border of the 4th rib, under the right mamma. The vena cava was on the left side and passed into the pulmonary cavity of the heart, which AA'as also on the left side, the aorta and systemic ventricle being on the right. The left splenic vein Avas lying on the superior vena cava, the liver under the left ribs, and the spleen on the right side underneath the heart. The esophagus Avas on the right of the aorta, and the location of the two ends of the stomach was reversed; the sigmoid flexure Avas on the right side. Da\Tisf describes a similar in- stance in a man. Herrick g mentions transposition of viscera in a man of tAventy-five. Barbieux h cites a case of transposition of viscera in a man Avho was Avounded in a duel. The liver Avas to the left and the spleen and heart to the right, etc. Albers, Baron, Beclard, Boyer, Bull, Mackensie, Hutchinson, Hunt, Murray, Dareste, Curran, Duchesne, Musser, Sabatier, Shrady, A'ulpian, Wilson, and Wehn are among others reporting instances of transposition and inversion of the A'iscera. a 435, 1874, ix., 11. b 490, xxxviii., 1052. c 435, 1885, xx., 216. dHist. Anat. Med., i., 248. e 476, 1861, i., 630. f 476, 1879, i., 789. 8 538, July 28, 1894. b Ann. de la m6d. physiol., Par., xiii.,518. 292 MINOR TERATA. Congenital extroversion or eventration is the result of some congenital deficiency in the abdominal wall; instances are not uncommon, and some patients live as long as do cases of umbilical hernia proper. Ramsey a speaks of entire Avant of development of the abdominal parietes. Robertson, Rizzoli, Tait, Hamilton, Brodie, Denis, Dickie, Goyrand, and many others mention extroversion of viscera from parietal defects. The different forms of hernia will be considered in another chapter. There seem to be no authentic cases of complete absence of the kidney except in the loAvest grades of monstrosities. Becker, Blasius, Rhodius, Baillie, Portal, Sandifort, Meckel, Schenck, and Stoll are among the older Avriters Avho have observed the absence of one kidney. In a recent paper Ballowitz has collected 213 cases, from which the following extract has been made by the British Medical Journal:— "Ballowitz (Virchow's Archiv, August 5, 1895) has collected as far as possible all the recorded cases of congenital absence of one kidney. Exclud- ing cases of fused kidney and of partial atrophy of one kidney, he finds 213 cases of complete absence of one kidney, upon Avhich he bases the folloAving conclusions : Such deficiency occurs almost twice as often in males as in females, a fact, hoAve\Ter, which may be partly accounted for by the greater frequency of necropsies on males. As to age, 23 occurred in the fetus or newly born, most haA'ing some other congenital deformity, especially imperforate anus; the rest Avere about ewenly distributed up to seventy years of age, after Avhich only seven cases occurred. Taking all cases together, the deficiency is more common on the left than on the right side ; but Avhile in males the left kidney is far more commonly absent than the right, in females the tAvo sides sIioav the defect equally. The renal vessels were generally absent, as also the ureter, on the abnormal side (the latter in all except 15 cases); the suprarenal Avas missing in 31 cases. The solitary kidney AAas almost ahvavs normal in shape and position, but much enlarged. Microscopically the enlargement would seem to be due rather to hyperplasia than to hypertrophy. The bladder, except for absence of the opening of one ureter, Avas generally normal. In a large number of cases there Avere associated deformities of the organs of generation, especially of the female organs, and these Avere almost invariably on the side of the renal defect; they affected the conducting portion much more than the glandular portion—that is, uterus, vagina, and Fallopian tubes in the female, and vas deferens or vesiculse seminales in the male, rather than the ovaries or testicles. Finally, he points out the practical bearing of the subject—for example, the proba- bility of calculus causing sudden suppression of urine in such cases—and also the danger of surgical interference, and suggests the possibility of diagnosing the condition by ascertaining the absence of the opening of one ureter in the bladder by means of the cystoscope, and also the likelihood a Northwest Med. and Surg. Jour., Chicago, 1857, xiv., 450. ANOMALIES OF THE KIDNEYS. 293 of its occurring Avhere any abnormality of the genital organs is found, especially if this be unilateral." Greena reports the case of a female child in Avhich the right kidney and right Fallopian tube and ovary Avere absent Avithout any rudimentary struc- tures in their place. Guiteras and Riesman843 have noted the absence of the right kidney, right ureter, and right adrenal in an old Avoman who had died of chronic nephritis. The left kidney although cirrhotic was very much enlarged. Tompsettb describes a necropsy made on a coolie child of nearly twelve Fig. 141.—Renal symphysis and supernumerary kidney (Rayer). months, in Avhich it Avas seen that in the place of a kidney there Avere two left organs connected at the apices by a prolongation of the cortical substance of each; the child had died of neglected malarial feA^er. Sandifort0 speaks of a case of double kidneys and double ureters, and cases of supernume- rary kidney are not uncommon, generally being segmentation of one of the normal kidneys. Rayer has seen three kidneys united and formed like a horseshoe (Fig. 141). AVe are quite familiar Avith the ordinary " horse- shoe kidney," in Avhich tAvo normal kidneys are connected. a 224, Feb. 23, 1895. b 224, 1879, ii., 602. c 710, fasc. iii. 294 MINOR TERATA. There are seA'eral forms of displacement of the kidneys, the most com- mon being the " floating kidney," which is sometimes successfully re- moved or fixed ; Rayer has made an extensive study of this anomaly. The kidney may be displaced to the pelvis, and Guinard390 quotes an instance in Avhich the left kidney was situated in the pelvis, to the left of the rectum and back of the bladder. The ureter of the left side was very short. The left renal artery came from the bifurcation of the aorta and the primitive iliacs. The right kidney was situated normally, and received from the aorta two arteries, Avhose volume did not surpass the tAvo arteries supply- ing the left suprarenal capsule, which was in its ordinary place. Displace- ments of the kidney anteriorly are very rare. The ureters have been found multiple; Griffon a reports the history of a male subject in whom the ureter on the left side was double throughout its whole length; there Avere two A^esical orifices on the left side one above the other; and Morestin, in the same journal, mentions ureters double on both sides in a female subject. Molinetti572 speaks of six ureters in one person. Littre in 1705 described a case of coalition of the ureters. Allenb de- scribes an elongated kidney with two ureters. Coeyne c mentions duplica- tion of the ureters on both sides. Lediberderd reports a case in AA'hich the ureter had double origin. Tyson e cites an instance of four ureters in an infant. Penrosef mentions the absence of the upper two-thirds of the left ureter, Avith a small cystic kidney, and there are parallel cases on record. The ureters sometimes have anomalous terminations either in the rectum, vagina, or directly in the urethra. This latter disposition is realized nor- mally in a number of animals and causes the incessant Aoav of urine, result- ing in a serious inconvenience. Flajani speaks of the termination of the ureters in the pelvis ; Nebel g has seen them appear just beneath the umbil- icus ; and Lieutaud describes a man who died at thirty-five, from another cause, Avhose ureters, as large as intestines, terminated in the urethral canal, causing him to urinate frequently; the bladder Avas absent. In the early part of this century h there was a young girl examined in NeAV York Avhose ureters emptied into a reddish carnosity on the mons veneris. The urine dribbled continuously, and if the child cried or made any exertion it came in jets. The genital organs participated but little in the deformity, and Avith the exception that the umbilicus was low and the anus more anterior than natural, the child Avas Avell formed and its health good. Colzi1 reports a case in AA'hich the left ureter opened externally at the left side of the hymen a little below the normal meatus urinarius. There is a case described J of a man Avho evidently suffered from a patent urachus, as the urine passed in jets a 242, 1894. b 547, 1873-4, iv., 220. c 242, 1874, xliii., 55. d242, 1834-5, ix., 187. e 629, Lond., 1731, iii., 146. f 779, xl., 161. g Comment. Acad. Palat., vol. v., n. xii. b 302, iv., 159. i 747, May, 1895. j Mem. de l'Acad. de Chir., vol. xxx. ANOMALIES OF THE BLADDER. 295 Fig. 142.—Triple bladder (Scibelli). as if controlled by a sphincter from his umbilicus. Littre mentions a patent urachus in a boy of eighteen. Congenital dilatation of the ureters is occa- sionally seen in the ne\v-born. Shattuck a describes a male fetus showing reptilian characters in the sexual ducts. There Avas ectopia vesicas and pro- lapse of the intestine at the umbilicus ; the right kidney Avas elongated ; the right vas deferens opened into the ureter. There AAas persistence in a separate condition of the two Mullerian ducts which opened externally interior- ly, and there Avere two ducts near the openings Avhich represented anal pouches. Both testicles Avere in the abdomen. Ordb describes a man in Avhom one of the Mullerian ducts was persistent. Anomalies of the Bladder.—Blanchard, Blasius, Haller, Nebel, and Rhodius mention cases in which the bladder has been found absent and we have already mentioned some cases, but the instances in AA'hich the bladder has been duplex are much more frequent. Bourienne, Oberteuffer, Ruysch, Bartholinus, Morgagni, and Franck speak of vesical duplication. There is a description0 of a man Avho had tAvo blad- ders, each receiving a ureter. Bussierea de- scribes a triple bladder, and Scibelli of Naplese mentions an instance in a subject Avho died at fifty-seven Avith symptoms of re- tention of urine. In the illustration (Fig. 142), B represents the normal bladder, A and C the supplementary bladders, Avith D and E their respective points of entrance into B. As will be noticed, the ureters terminate in the supplementary bladders. Fantoni336 and Malgetti cite instances of quintuple blad- ders. The Ephemerides speaks of a case of coalition of the bladder Avith the os pubis and another case of coalition Avith the omentum. Prochaska652 men- tions vesical fusion with the uterus, and Ave have already described union Avith the rectum and intestine. Exstrophy of the bladder is not rare, and is often associated with hypo- Fig. 143.—Dilatation of the fetal bladder. a Jour, of Path, and Bacter., July, 1895. c Jour, de Trevoux, 1702. d629, n. 268. b491, 1880, 109. e 222, 1864, ii., 328. 296 MINOR TERATA. spadias, epispadias, and other malformations of the genitourinary tract. It consists of a deficiency of the abdominal Avail in the hypogastric region, in Avhich is seen the denuded bladder. It is remedied by many different and ingenious plastic operations. In an occasional instance in which there is occlusion at the umbilicus and arain at the neck of the bladder this organ becomes so distended as to produce a most curious deformity in the fetus. Figure 143 sIioavs such a case. The Heart.—Absence of the heart has never been recorded in human beings except in the case of monsters, as, for example, the omphalosites, although there Avas a case reported and firmly believed by the ancient authors, —a Roman soldier in whom Telasius said he could discover no vestige of a heart.a The absence of one ventricle has been recorded. Schenck b has seen the left ventricle deficient, and the Ephemerides, Behr, and Kerckringc speak of a single ventricle only in the heart. Riolan685 mentions a heart in Avhich both ventricles Avere absent. Jurgens reported in Berlin, February 1, 1882, an autopsy on a child avIio had lived some days after birth, in AA'hich the left A^entricle of the heart was found completely absent. Playfair d showed the heart of a child Avhich had lived nine months in which one ventricle Avas absent, In King's College Hospital in London there is a heart of a boy of thirteen in which the caA'ities consist of a single ventricle and a single auricle. Duplication of the heart, notwithstanding the number of cases reported, has been admitted Avith the greatest reserve by Geoffroy-Saint-Hilaire and by a number of authors. Among the celebrated anatomists Avho describe duplex heart are Littre, Meckel, Collomb, Panum, Behr, Paullini, Rhodius, AVinsloAV, and Zacutus Lusitanus. The Ephemerides e cites an instance of triple heart, and Johnstonf has seen a triple heart in a goose. The phenomenon of " blue-disease," or congenital cyanosis, is due to the patency of the foramen ovale, Avhich, instead of closing at birth, persists sometimes to adult life. Perhaps the most unique collection of congenital malformations of the heart from persons AA'ho haATe reached the age of puberty Avas to be seen in London in 1895.619 In this collection there Avas an adult heart in Avhich the foramen ovale remained open until the age of thirty-seven; there Avere but tAvo pulmonary valves ; there Avas another heart shoAving a large patent fora- men OA7ale from a man of forty-six ; and there Avas a septum ATentriculorum of an adult heart from a Avoman of sixty-three, Avho died of carcinoma of the breast, in Avhich the foramen ovale Avas still open and Avould admit the fore- a 302, xxxiv., 207. b 718, L. ii., obs. 184. o 473, ohs. 469. d 778, vol. xii., 169. e 104, dec. i., an. 9, obs. 108. f "Med. Bemerk. und Untersuch.," Band ii., 103. ANOMALIES OF THE BREASTS. 297 finger. This Avoman had shoAvn no symptoms of the malformation. There Avere also hearts in Avhich the interventricular septum was deficient, the ductus arteriosus patent, or some valvular malformation present. All these persons had reached puberty. Displacements of the heart are quite numerous. Deschamps of Laval made an autopsy on an old soldier which justified the expression, " He had a heart in his belly." This organ Avas found in the left lumbar region ; it had, Avith its vessels, traversed an anomalous opening in the diaphragm. Franck observed in the Hospital of Colmar a woman Avith the heart in the epigastric region. Ramela and Yetter speak of the heart under the diaphragm. Inversion of the heart is quite frequent, and Ave often find reports of cases of this anomaly. Fournierb describes a soldier of thirty years, of middle height, Avell proportioned and healthy, Avho Avas killed in a duel by receiving a Avound in the abdomen ; postmortem, the heart Avas found in the position of the right lung; the two lungs Avere joined and occupied the left chest. The anomalies of the vascular system are so numerous that avc shall dismiss them Avith a slight mention. Malacarne in Torino in 1784 de- scribed a double aorta, and Hommelius0 mentions an analogous case. The folioAving case is quite an interesting anatomic anomaly : A Avoman since infancy had difficulty in SAvalloAving, Avhich Avas augmented at the epoch of menstruation and after exercise; bleeding relieA^ed her momentarily, but the difficulty ahvavs returned. At last deglutition became impossible and the patient died of malnutrition. A necropsy revealed the presence of the sub- clavicular artery passing betAveen the tracheal artery and the esophagus, com- pressing this latter tube and opposing the passage of food. Anomalies of the Breasts.—The first of the anomalies of the generative apparatus to be discussed, although not distinctly belonging under this head, will be those of the mammae. Amazia, or complete absence of the breast, is seldom seen. Pilcher d de- scribes an indiATidual Avho passed for a female, but Avho Avas really a male, in whom the breasts Avere absolutely Avanting. Foerster, Froriep, and Ried cite instances associated Avith thoracic malformation. Greenhowe reports a case in Avhich the mammae Avere absent, although there Avere depressed rudimentary nipples and areolae. There Avere no OA'aries and the uterus Avas congenitally imperfect. There Avas a negress spoken of in 1842 in whom the right breast AA'as missing, and there are cases of but one breast, mentioned by King/ Paull, g and others.h Scanzoni has observed absence of the left mamma Avith ab- sence of the left ovary. a 462, tomexlix., p. 423. d 476, 1878, i., 915. g 476, 1862, i., 648. b 302, iv., 150. c 282, 1737. e 550, 1864, 195. f 548, 1858. h These de Paris, ann. x., No. 53, p. 15. 298 MINOR TERATA. Micromazia is not so rare, and is generally seen in females Avith associate genital troubles. Excessive development of the mammae, generally being a pathologic phenomenon, will be mentioned in another chapter. How- ever, among some of the indigenous negroes the female breasts are naturally very large and pendulous. This is well shown in Figure 144, which represents a woman of the Bushman tribe nursing an infant. The breasts are sufficiently pendulous and loose to be easily throAvn over the shoulder. Polymazia is of much more frequent occurrence than is supposed. Julia, the mother of Alexander Severus, was surnamed " Mammea" be- cause she had supernumerary breasts. Anne Boleyn, the unfortunate wife of Henry ArIII. of England, was reputed to have had six toes, six fingers, and three breasts. Lynoeus says that in his time there existed a Roman Avoman with four mammae, very beau- tiful in contour, arranged in two lines, regularly, one above the other, and all gi\dng milk in abundance. Rubens has pictured a Avoman with four breasts; the painting may be seen in the Louvre in Paris. There was a young and wealthy heiress Avho addressed herself to the ancient faculty at Tubingen, asking, as she displayed four mammae, whether, should she marry, she would have three or four children at a birth. This was a belief Avith Avhich some of her elder matron friends had inspired her, and which she held as a hindrance to mar- Fig. 144.—Bushwoman nursing her infant. ° Leichtenstern, who has collected 70 cases of polymazia in females and 22 in males, thinks that accessory breasts or nipples are due to atavism, and that our most remote interiorly organized ancestors had many breasts, but that by constantly bearing but one child, from being polymastia, females have gradually become bimastic. Some of the older philosophers contended that by the presence of two breasts woman Avas originally intended to bear two children. Hirst a says : " Supernumerary breasts and nipples are more common than is generally supposed. Bruce found 60 instances in 3956 persons examined (1.56 per cent.). Leichtenstern places the frequency at one in 500. Both observers declare that men present the anomaly about tAvice as fre- quently as Avomen. It is impossible to account for the accessory glands on a 792, May, 1896. POLYMAZIA. 299 the theory of reA^ersion, as they occur Avith no regularity in situation, but may develop at odd places on the body. The most frequent position is on the pectoral surface beloAv the true mammae and somewhat nearer the middle line, but an accessory gland has been obsen^ed on the left shoulder over the prominence of the deltoid, on the abdominal surface below the costal carti- lages, above the umbilicus, in the axilla, in the groin, on the dorsal sur- face, on the labium majus, and on the outer aspect of the left thigh. Ahlfeld explains the presence of mammae on odd parts of the body by the theory that portions of the embryonal material entering into the composition of the mammary gland are carried to and implanted upon any portion of the exterior of the body by means of the amnion." Possibly the greatest number of accessory mammae reported is that of Neugebauer in 1886, Avho found ten in one person. Peuch in 1876 collected 77 cases, and since then Hamy, Quinquaud, AYhiteford, Eng- strom, and Mitchell Bruce have collected cases. Polymazia must haA'e been knoAvn in the olden times, and Ave still haAre before us the old images of Diana, in which this goddess is portrayed with numerous breasts, indicating her ability to look after the grow- ing child. Figure 145 shoAvs an ancient Oriental statue of Artemisia or Diana iioav at Naples. Bartholinus a has observed a Danish woman with three mammae, tAvo ordinarily formed and a third form- ing a triangle Avith the others and resembling the breasts of a fat man. In the village of Phullendorf in Germany early in this century there was an old woman AA'ho sought alms from place to place, exhibit- ing to the curious four symmetrical breasts, arranged parallel. She Avas extremely ugly, and Avhen on all fours, with her breasts pendulous, she resembled a beast. The authors have seen a man Avith six distinct nipples, arranged as regularly as those of a bitch or soav. The two lower were quite small. This man's bodv was covered Avith heavy, long hair, making him a very conspicuous object when seen naked during bathing. The hair Avas absent for a space of nearly an inch about the nipples. Borellus speaks of a Avoman Avith three mammae, two as ordinarily, the third to the left side, Avhich gave milk, but not the same quantity as the others. Gardinerb describes a mulatto Avoman avIio had four mammae, two of AA'hich Avere near the axillae, about four inches in circumference, Avith proportionate sized nipples. She became a mother at fourteen, and save milk from all her breasts. In his " Dictionnaire Philo- sophique" Voltaire gives the history of a Avoman with four Avell-formed a 190, cent. iv. b 302, iv., 152. Fig. 145. —Statue of a polymas- tic Artemisia or Diana. 300 MINOR TERATA. and symmetrically arranged breasts ; she also exhibited an excrescence, coATered with a nap-like hair, looking like a coAV-tail. Percy thought the excrescence a prolongation of the coccyx, and said that similar instances Avere seen in saA'age men of Borneo. Percya says that among some prisoners taken in Austria Avas found a Avoman of Yalachia, near Roumania, exceedingly fatigued, and suffering intensely from the cold. It Avas January, and the ground Avas covered Avith three feet of snoAV. She had been exposed Avith her two infants, avIio had been born twenty days, to this freezing temperature, and died on the next day. An examination of her body reATealed five mammae, of AA'hich four projected as ordinarily, Avhile the fifth Avas about the size of that of a girl at puberty. Fig. 146.—AVoman with two axillary mammae (Charpentier). They all had an intense dark ring about them; the fifth was situated about five inches above the umbilicus. Percy injected the subject and dis- sected and described the mammary blood-supply. Hirstb mentions a negress of nineteen Avho had nine mammae, all told, and as many nipples. The two normal glands Avere very large. Tavo accessory glands and nipples beloAv them Avere small and did not excrete milk. All the other glands and nipples gave milk in large quantities. There Avere five nipples on the left and four on the right side. The patient's mother had an accessory mamma on the abdomen that secreted milk during the period of lactation. Charpentier has observed in his clinic a woman Avith two supplementary a 302, iv., 152. b 792, May, 1896. POLYMAZIA. 301 axillary mammae with nipples. They gave milk as the ordinary mammae (Fig. 146). Robert saw a Avoman Avho nourished an infant by a mamma on the thigh. Until the time of pregnancy this mamma Avas taken for an ordi- nary nevus, but Avith pregnancy it began to develop and acquired the size of a citron. Figure 147 is from an old Avood-cut shoAving a child suckling at a supernumerary mamma on its mother's thigh Avhile its brother is at the natural breast. Jenner speaks of a breast on the outer side of the thigh four inches below the great trochanter. Harea describes a woman of thirty- seven avIio secreted normal milk from her axillae. Lee b mentions a woman of thirty-five Avith four mammae and four nipples ; she suckled Avith the pectoral and not the axillary breasts. McGillicudy describes a pair of rudi- mentary abdominal mammae, and there is another similar case recorded.0 Har- tung'' mentions a woman of thirty avIio Avhile suckling had a mamma on the left labium majus. It was excised, and microscopic examina- tion shoAved its structure to be that of a rudimentary nipple and mam- mary gland. Leichtenstern cites a case of a mamma on the left shoulder nearly under the insertion of the deltoid, and Klob e speaks of an acromial accessory mamma situated on the shoulder over the greatest prominence of the deltoid. Hallf reports the case of a func- tionally active supernumerary mamma OATer the costal cartilage of the 8th rib. Jussieu s speaks of a Avoman avIio had three breasts, one of Avhich Avas situated on the groin and Avith Avhich she occasionally suckled ; her mother had three breasts, but they Avere all situated on the chest. Saunoish details an account of a female avIio had tAvo supernumerary breasts on the back. Bartholinus (quoted by Meckel) and Manget also mention mammae on the back, but Geolfrov-Saint-Hilaire questions their existence. Martin1 gives a very clear illustration of a Avoman Avith a supernumerary breast beloAv the natural organ (Fig. 148). Sneddon,j who has collected quite a number of cases of poly- mazia, quotes the case of a Avoman Avho had two SAvellings in each axilla in Fig. 147.—Functional supernumerary mamma on the thigh. a 476, 1860, ii., 405. d Iuaug. diss., Erlangen, 1872. f Quart. Med. Jour., April, 1894. i Archiv. f iir Klinische Chirurgie, b 550, xxi., 266. g 476, xii., 618. 1893. c 451, 1878, xiii., 425. e 833, 1858, i., 52. b These de Paris. j 381, 1879, p. 92. 302 MINOR TERA TA. which gland-structure was made out, but with no external openings, and which had no anatomic connection with the mammary glands proper. Shortly after birth they varied in size and proportion, as the breasts were full or empty, and in five Aveeks all traces of them Avere lost. Her only married sister had similar enlargements at her third confinement. Polymazia sometimes seems to be hereditary. Robert saAV a daughter Avhose mother Avas polymastic, and Woodmana saAV a mother and eldest daughter who each had three nipples. Lousier b mentions a woman wanting a mamma Avho transmitted this vice of conformation to her daughter. Handyside says he kneAV two brothers in both of whom breasts were wanting. Supernumerary nipples alone are also seen, as many as five having been found on the same breast. Neuge- bauer reports eight supernume- rary nipples in one case. Hollerus has seen a Avoman Avho had two nipples on the same breast Avhich gave milk with the same regu- larity and the same abundance as the single nipple. The Ephem- erides contains a description of a triple nipple. Barth c describes a " mamma erratica " on the face in front of the right ear which enlarged during menstruation. Cases of deficiency of the nipples have been reported by the Ephemerides, Lentilius, Se- verinus, and A\ erckardus. Cases of functional male mam- mae Avill be discussed in Chapter IX. Complete absence of the hymen is very rare, if Ave may accept the statements of Devilliers, Tardieu, and Brouardel, as they have never seen an example in the numerous young girls they have examined from a medico-legal point of A'ieAV. Duplication or biperforation of the hymen is also a very rare anomaly of this membrane. In this instance the hymen generally presents two lateral orifices, more or less irregular and separated by a membranous band, which gives the appearance of duplicity. Roze reported from Strasburg in 1866 a case of this kind, and Delensd has observed two examples of a 778, ix., 50. b "Dissert, sur la lactation," Paris, 1802. p. 15. c 161, 1888, 569. d " Annales d'hygiene publique et de medecine legale," 1877. Fig. 148.—Supernumerary breast (Martin). ABSENCE OF THE VAGINA. 303 biperforate hymen, Avhich shoAv very Avell that this disposition of the mem- brane is due to a vice of conformation. The first Avas in a girl of eleven in Avhich the membrane AAas of the usual size and thickness, but AAas dupli- cated on either side. In her sister of nine the hymen AA'as normally con- formed. The second case Avas in a girl under treatment by Cornil in 1876 for vaginitis. Her brother had accused a young man of eighteen of having violated her, and on examination the hymen shoAved a biperforate conforma- tion ; there Avere tAvo oval orifices, their greatest diameter being in the ver- tical plane; the openings Avere situated on each side of the median line, about Aa'c mm. apart; the dividing band did not appear to be cicatricial, but presented the same roseate coloration as the rest of the hymen. Since this report quite a number of cases haAre been recorded. The different A'arieties of the hymen will be left to the AA'orks on obstet- rics. As has already been observed, labor is frequently seriously complicated by a persistent and tough hymen. Deficient vulva may be caused by the persistence of a thick hymen, by congenital occlusion, or by absolute absence in vulvar structure. Bartholinus, Borellus, Ephemerides, Julius, Vallisneri, and Baux are among the older Avriters who mention this anomaly, but as it is generally associated Avith congenital occlusion, or complete absence of the vagina, the tAAro will be con- sidered together. Complete absence of the vagina is quite rare. Baux a reports a case of a girl of fourteen in whom " there AAas no trace of fundament or of genital organs." Oberteufferb speaks of a case of absent vagina. Vicq d'Azir c is accredited Avith having seen two females Avho, not having a vagina, copulated all through life by the urethra, and Fournier sagely remarks that the extra large urethra may have been a special dispensation of nature. Bosquetd describes a young girl of tAventy with a triple A'ice of conformation—an obliterated vulva, closure of the A-agina, and absence of the uterus. Men- strual hemorrhage took place from the gums. Clarke e has studied a similar case Avhich AA'as authenticated by an autopsy. O'Ferral of Dublin, Gooch, Davies, Boyd, Tyler Smith, Hancock, Coste, Kluyskens, Debrou, Braid, AVatson, and others are quoted by Churchill as having mentioned the absence of the vagina. Amussatf obserA'ed a Ger- man girl avIio did not have a trace of a vagina and Avho menstruated regularly. Griffiths describes a specimen in the Museum of St. BartholomeAv's Hospital, London, in Avhich the ovaries lay on the surface of the pelvic peritoneum and there AAas neither uterus nor A'agina ; the pelvis had some of the charac- teristics of the male type. MattheAVs Duncan has observed a someAvhat similar case, the A^agina not measuring more than an inch in length. Fer- guson h describes a prostitute of eighteen Avho had ne\Ter menstruated. The a 460, 1758, viii., 59. d778, xx vii., 123. 8 778, xxvii., 128. b 160, Band ii., 627. e 476, 1872, ii., 225. c 302, iv., 162. f 368, Dec. 12, 1865. b Planet, N. Y., 1883, 1. 304 MINOR TERATA. labia were found Avell developed, but there was no vagina, uterus, or ovaries. Coitus had been through the urethra, Avhich Avas considerably distended, though not causing incontinence of urine. Hulke reports a case of congeni- tal atresia of the vagina in a brunette of tAventy, menstruation occurring through the urethra. He also mentions the instance of congenital atresia of the vagina Avith hernia of both ovaries into the left groin in a servant of twenty, and the case of an imperforate vagina in a girl of nineteen Avith an undeveloped uterus. Brodhursta reports an instance of absence of the vagina and uterus in a girl of sixteen Avho at four years of age showed signs of approaching puberty. At this early age the mons Avas covered with hair, and at ten the clitoris was three inches long and two inches in circumference. The mammae Avere well developed. The labia descended laterally and expanded into folds, resembling the scrotum. Azema b reports an instance of complete absence of the vagina and im- permeability and probable absence of the col uterinus. The deficiencies Avere remedied by operation. Berard c mentions a similar deformity and operation in a girl of eighteen. Goodingd cites an instance of absent va- gina in a married Avoman, the uterus discharging the functions. Gosseiine re- ports a case in which a voluminous tumor Avas formed by the retained men- strual fluid in a Avoman Avithout a vagina. An artificial vagina was created, but the patient died from extravasation of blood into the peritoneal cavity. Carter, Polaillon, Martin, Curtis, Worthington, Hall, Hicks, Moliere, Patry, Dolbeau, Desormeaux, and Gratigny also record instances of absence of the A'agina. There are some cases reported in extramedical literature which might be cited. Bussy Rabutin in his Memoires in 1639 speaks of an instance. The celebrated Madame Recamier Avas called by the younger Dumas an involuntary virgin; and in this connection could be cited the malicious and piquant sonnet:— Chateaubriand et Madaaie Recamier. " Juliette et Rene s'aimaient d'amour si tendre Que Dieu, sans les punir, a pu leur pardonner : II n'avait pas voulu que l'une put donner Ce que 1'autre ne pouvait prendre." Duplex vagina has been observed by Bartholinus, Malacarne, Asch, Meckel, Osiander, Purcell, and other older Avriters. In more modern times reports of this anomaly are quite frequent. Hunterf reports a case of labor at the seventh month in a woman Avith a double vagina, and delivery through the rectum. Atthill and Watts speak of double vagina Avith single uterus. a 548, 1852, 187. b 140, 193. c 363, 1S41, iii., 377. d 476, 1879, i., 430. e 363, xl., 225. f 125, xi., 593. TRANSVERSE SEPTA OF THE VAGINA. 305 Robb a of Johns Hopkins Hospital reports a case of double vagina in a pa- tient of tAventy suffering from dyspareunia. The vaginal orifice Avas con- tracted ; the urethra Avas dilated and had evidently been used for coitus. A membrane divided the vagina into two canals, the cervix lying in the right half; the septum Avas also divided. Both the thumbs of the patient were so short that their tips could scarcely meet those of the little fingers. Double vagina is also reported by AiiAvay, Moulton, Freeman, Frazer, Haynes, Le- maistre, Boardman, Dickson, Dunoyer, and Rossignol. This anomaly is usually associated with bipartite or double uterus. Wilcoxb mentions a primipara, three months pregnant, Avith a double vagina and a bicornate uterus, who Avas safely delivered of several children. Haller and Borellus have seen double vagina, double uterus, and double ovarian supply; in the latter case there Avas also a double vulva. Sanger c speaks of a supernu- merary vagina connecting with the other vagina by a fistulous opening, and remarks that this Avas not a case of patent Gartner's duct. CullingAVorth d cites two cases in which there Avere transverse septa of the vagina. Stonee reports five cases of transverse septa of the vagina. Three of the patients were young Avomen who had never borne children or suffered injury. Pregnancy existed in each case. In the first the septum was about two inches from the introitus, and contained an opening about ^ inch in diameter which admitted the tip of the finger. The membrane was elastic and thin and shoAved no signs of inflammation. Menstruation had always been regular up to the time of pregnancy. The second Avas a duplicate of the first, excepting that a feAV bands extended from the cervix to the mem- branous septum. In the third the lumen of the vagina, about tAvo inches from the introitus, AA'as distinctly narroAved by a ridge of tissue. There Avas uterine displacement and some endocervicitis, but no history of injury or operation and no tendency to contraction. The two remaining cases occurred in patients seen by Dr. J. F. Scott. In one the septum was about If inches from the entrance to the vagina and contained an orifice large enough to admit a uterine probe. During labor the septum resisted the advance of the head for seA'eral hours, until it Avas slit in seATeral directions. In the other, menstruation had ahvavs been irregular, intermissions being folloAved by a profuse floAV of black and tarry blood, which lasted sometimes for fifteen days and Avas accompanied by seA'ere pain. The septum Avas 1J inches from the vaginal orifice and contained an opening AA'hich admitted a uterine sound. It Avas A'ery dense and tight and fully ^ inch in thickness. Mordief reported a case of congenital deficiency of the rectovaginal septum AArhich Avas successfully remedied by operation. Anomalous Openings of the Vagina.—The Aragina occasionally opens abnormally into the rectum, into the bladder, the urethra, or upon the a 446, April, 1895. b 647, 1877. c 261, Sept. 22, 1894. d476, 1889, i., 726. e 218, May 30, 1895. t 476, 1888, ii., 166. 20 306 MINOR TERATA. abdominal parietes. Rossi reports from a hospital in Turin the case of a Piedmontese girl in whom there AA'as an enormous tumor corresponding to the opening of the vaginal orifice; no traces of a A'agina could be found. The tumor AA'as incised and proved to be a liA'ing infant. The husband of the Avoman said that he had coitus Avithout difficulty by the rectum, and examination shoAved that the ATagina opened into the rectum, by AA'hich means impregnation had been accomplished. Bonnain a and Payne1' have observed analogous cases of this abnormality of the vaginal opening and subsequent accouchement by the anus. Payne's case AA'as of a woman of thirty-five, well formed, avIio had been in labor thirty-six hours, Avhen the physician examined and looked in vain for a vaginal opening; the finger, gliding along the perineum, came in contact Avith the distended anus, in AA'hich Avas recognized the head of the fetus. The woman from prolongation of labor Avas in a complete state of prostration, Avhich caused uterine inertia. Payne anes- thetized the patient, applied the forceps, and extracted the fetus Avithout further accident. The A'ulva of this Avoman five months afterward displayed all the characteristics of virginity, the vagina opened into the rectum, and menstruation had ahvavs been regular. This Avoman, as well as her husband, averred that they had no suspicion of the anomaly and that coitus (by the anus) had ahvavs been satisfactory. Opening of the vagina upon the parietes, of Avhich Le Fort has collected a number of cases, has never been observed in connection Avith a viable fetus. Absence of the labia majora has been observed, especially by Pozzi, to the exclusion of all other anomalies. It is the rule in exstrophy of the bladder. Absence of the nymphae has also been observed, particularly by Auvard and by Perchaux, and is generally associated with imperfect develop- ment of the clitoris. Constantinedesc reports absence of the external organs of generation, probably also of the uterus and its appendages, in a young lady. Van Haartman, LeFort, Magee, and Ogle cite cases of absence of the external female organs. Rioland in the early part of the seventeenth century reported a case of defective nymphae; Xeubauer in 1774 offers a contrast to this case in an instance of triple nymphae. The nymphae are sometimes enormously enlarged by hypertrophy, by varicocele, or by elephantiasis, of which latter type Rigal de Gaillac has observed a most curious case. There is also a variety of enlargement of the clitoris AA-hich seems to be constant in some races ; it may be a natural hyper- trophy, or perhaps produced by artificial manipulation. The peculiar conditions under Avhich the Chinese Avomen are obliged to live, particularly their mode of sitting, is said to have the effect of causing unusual development of the mons veneris and the labia majora. On the other hand, some of the loAver African races have been distinguished by a 789, Sept. 4, 1888. b 168, 1886, p. 854. c 250, 1870-1, iii., 77. d 685, L. ii., c. 35. PLATE 5. Hottentot apron, natural size (Billroth, " Fianeukraukheiten," vol. iii.). Left figure : Adult woman standing upright, the apron hanging between the thighs. Right figure : Adult woman lying on her back, the apron spread out to the sides. i. HOTTENTOT WOMEN. 307 the deficiency in deATelopment of the labia majora, mons veneris, and genital hair. In this respect they present an approximation to the genitals of the anthropoid apes, among whom the orang-outang alone sIioavs any tendency to formation of the labia majora. The labial appendages of the Hottentot female haAre been celebrated for many years. Blumenbach and others of the earlier traATelers found that the apron-like appearance of the genitals of the Hottentot Avomen Avas due to abnormal hypertrophy of the labia and nymphae (PI. 5). According to John Knott, the French traveler, Le Vaillant, said that the more coquettish among the Hottentot girls are excited by extreme vanity to practise artificial elongation of the nympha and labia. They are said to pull and rub these parts, and even to stretch them by hanging Aveights to them. Some of them are said to spend several hours a day at this process, which is considered one of the important parts of the toilet of the Hottentot belle, this malformation being an attrac- tion for the male members of the race. Merensky says that in Basuto- land the elder women begin to practise labial manipulation on their female children shortly after infancy, and Adams has found this custom to prevail in Dahomey ; he says that the King's seraglio includes 3000 members, the elect of his female subjects, all of whom have labia up to the standard of recognized length. Cameron found an analogous practice among the Avomen of the shores of Lake Tanganyika. The females of this nation manipulated the skin of the loAver part of the abdomens of the female children from infancy, and at puberty these women exhibit a cutaneous curtain over the genitals Avhich reaches half-Avay doAvn the thighs. A corresponding development of the preputian clitorides, attaining the length of 18 mm. or even more, has been observed among the females of Bechuanaland. The greatest elongation measured by Barrow Avas five inches, but it is quite probable that it Avas not possible for him to examine the longest, as the females so gifted generally occupied very high social positions. Morgagni describes a supernumerary left nympha, and Petit is accred- ited with seeing a case Avhich exhibited neither nymphae, clitoris, nor urinary meatus. Mauriceau performed nymphotomy on a Avoman Avhose nymphae Avere so long as to render coitus difficult. Morand575 quotes a case of congenital malformation of the nymphae, to Avhich he attributed impotency. There is sometimes coalition of the labia and nymphae, Avhich may be so firm and extensive as to obliterate the vulva. Debout3 has reported a case of absence of the vulva in a woman of twenty upon Avhom he operated, Avhich Avas the result of the fusion of the labia minora, and this with an en- larged clitoris gave the exteral appearance of an hermaphrodite. The absence of the clitoris coincides Avith epispadias in the male, and in atrophy of the vulva it is common to find the clitoris rudimentary ; but a more frequent anomaly is hypertrophy of the clitoris. a 235, 1864, 26, tome xlv. 308 MINOR TERATA. Among the older authorities quoting instances of enlarged clitorides are Bartholinus, Schenck, Helhvig, Rhodius, Riolanus, and Zacchias. Albu- casisU5 describes an operation for enlarged clitoris, Chabcrt ligated one, and Riedlin a gives an instance of an enlarged clitoris, in Avhich there appeared a tumor synchronous Avith the menstrual epoch. We learn from the classics that there Avere certain females inhabiting the borders of the JEgean Sea Avho had a sentimental attachment for one another Avhich Avas called " Lesbian love," and Avhich carried them to the highest degree of frenzy. The immortal effusions of Sappho contain refer- ences to this passion. The solution of this peculiar ardor is found in the fact that some of the females had enlarged clitorides, strong Aoices, robust figures, and imitated men. Their manner Avas imperative and authoritative to their sex, Avho Avorshiped them Avith perverted devotion. AVe find in Martialb mention of this perA'erted love, and in the time of the dissolute Greeks and Romans ridiculous jealousies for unfaithfulness betAveen these women prevailed. Aetius said that the Egyptians practised amputation of the clitoris, so that enlargement of this organ must have been a common A'ice of conformation along the Nile. It Avas also said that the Egyptian Avomen practised circumcision on their females at the age of seven or eight, the time chosen being Avhen the Nile Avas in flood. Bertherand c cites examples of enlarged clitorides in Arab AA'omen ; Bruce testifies to this circumstance in Abyssinia, and Mungo Park has observed it in the Mandingos and the Ibbos. Sonninid says that the AA'omen of Egypt had a natural excrescence, fleshy in consistency, quite thick and pendulous, coming from the skin of the mons veneris. Sonnini says that in a girl of eight he saw one of these caruncles Avhich Avas h inch long, and another on a woman of tAventy Avhich Avas four inches long, and remarks that they seem peculiar only to Avomen of distinct Egyptian origin. Duhouset e says that in circumcision the Egyptian Avomen not only remove a great part of the body of the clitoris Avith the prepuce, but also adjacent portions of the nymphae; Gallienif found a similar operation cus- tomary on the upper banks of the Niger. Otto at Breslau in 1824 reports seeing a negress Avith a clitoris 4^ inches long and 1^ inches in the transverse diameter ; it projected from the vulva and Avhen supine formed a complete covering for the vaginal orifice. The clitoris may at times become so large as to prevent coitus, and in France has constituted a legitimate cause for divorce. This organ is very sensitive, and it is said that in cases of supposed catalepsy a Avoman cannot bear titilla- tion of the clitoris Avithout some A'isible movement. Columbus cites an example of a clitoris as long as a little finger; Haller a 683. 1695, 295. b 509, L. i., epigram 91. c « Med. et Hygiene des Arabes," p. 190. <1 "Voyage dans la Haute et la Basse-Egypt.,." Paris, 1799. e 243, xii., 126. f Bull, de la Soc. de Geog., iv., 1883, 573. HYPERTROPHY OF THE CLITORIS. 309 mentions one Avhich measured seATen inches, and there is a record a of an enlarged clitoris Avhich resembled the neck of a goose and Avhich Avas 12 inches long. Bainbridgc b reports a case of enlarged clitoris in a Avoman of thirty-tAVO avIio Avas confined Avith her first child. This organ AA'as five inches in length and of about the diameter of a quiescent penis. Figure 149 sIioavs a Avell-niarked case of hypertrophy of the clitoris. Rogers c describes a. Avoman of twenty-five in a reduced state of health Avith an enormous clitoris and AAarts about the anus ; there Avere also manifestations of tuberculosis. On questioning her, it Avas found that she had formerly masturbated ; later she had sexual intercourse several times with a young man, but after his death she commenced self-abuse again, AA'hich brought on the present enlargement. The clitoris avus ligated and came aAvay Avithout leaving disfigurement. Cassano and Pedretti of Naples reported an instance of monstrous clitoris in 1860 before the Academy of Medicine. In some cases ossifica- tion of the clitoris is ob- served. Founder 302 speaks of a public woman in Venice who had an osseous clitoris ; it AA'as said that men having connection Avith her iiiA'ari- ably suffered great pain, fol- io Aved by inflammation of the penis. There are a feAV instances recorded of bifid clitoris, and Arnaudd cites the his- tory of a Avoman Avho had a double clitoris. which was in a permanent state of erection. Complete absence of the ovaries is seldom seen, but there are instances in Avhich one of the ovaries is missing. Hunter, Vidal, and Chaussier report in full cases of the absence of the oA'aries, and Thudicum has collected 21 cases of this nature. Morgagni, Pears,f and Cripps haATe published observations in Avhich both ovaries Avere said to have been absent. Cripps speaks of a young girl of eighteen Avho had an infantile uterus and no ovaries ; she neither menstruated nor had any signs of puberty. Lauth cites the case of a Avoman Avhose OA7aries and uterus were rudimentary, and avIio exhibited none of the principal physiologic characteristics of her sex; Fig. 149.—Hypertrophy of the clitoris. Secretain e speaks of a clitoris a 302. v., 374. b 548, I860, i., 45. 0 778, xii., 84. e Soc. d. sc. med. de Gannat., xxiii., 1868-9, 22. d " Mem. de Chirurg.," tome i. f 629, 1805, 225. 310 MINOR TERATA. on the other hand, Ruband describes a Avoman Avith only rudimentary ovaries avIio avus very passionate and quite feminine in her aspect. At one time the existence of genuine supernumerary ovaries Avas vigorously disputed, and the older records contain no instances, but since the researches of Boigel, Puech, Thudicum, Winckler, de Sinety, and Paladino the presence of multiple ovaries is an incontestable fact. It Avas originally thought that supernumerary OA'aries as Avell as supernumerary kidneys Avere simply segmentations of the normal organs and connected to them by por- tions of the proper substance ; now, hoAvever, by the recent reports avc are Avarranted in admitting these anomalous structures as distinct organs. It has even been suggested that it is the persistence of these OA'aries that causes the menstruation of Avhich Ave sometimes hear as taking place after ovariotomy. Sippel a records an instance of third ovary; Mangiagallib has found a supernumerary ovary in the body of a still-born child, situated to the inner side of the normal organ. AVinckel discovered a large supernumerary ovary connected to the uterus by its oavu ovarian ligament. Klebs found two ovaries on one side, both consisting of true ovarian tissue, and connected by a band ^ inch long. Doran dh'ides supernumerary ovaries into three classes :— (1) The ovarium succentauriatum of Beigel. (2) Those cases in Avhich two masses of ovarian tissue are separated by ligamentous bands. (3) Entirely separate organs, as in \Yinckel's case. Prolapsus or displacement of the ovaries into the culdesac of Douglas, the vaginal Avail, or into the rectum can be readily ascertained by the resulting sense of nausea, particularly in defecation or in coitus. Munde, Barnes, Lentz, Madden, and HeyAvood Smith report instances, and Cloquet describes an instance of inguinal hernia of the ovary in which the uterus as Avell as the Fallopian tube Avere found in the inguinal canal. Debierre0 mentions that Puech has gathered 88 instances of inguinal hernia of the ovary and 14 of the crural type, and also adds that Otted cites the only instance in Avhich crural ovarian hernia has been found on both sides. Such a condition Avith other associate malformations of the genitalia might easily be mistaken for an instance of hermaphroditic testicles. The Fallopian tubes are rarely absent on either side, although Bla- sius214 reports an instance of deficient oviducts. Blote reports a case of atro- phy, or rather rudimentary state of one of the ovaries, Avith absence of the tube on that side, in a Avoman of forty. Doranf has an instance of multiple Fallopian tubes, and Richard, in 1851, says several varieties are noticed. These tubes are often found fused a 261, 1889, No. 18. bi52) 1879, i., 149. c "Les vices de conformation des organs genitaux," etc. Par., 1892. d199, 1857, 345. e "Compt. rend. Soc. de biol.," iii., 176 Par., 1857. f 778, 1887. DOUBLE UTERUS. 311 or adherent to the ovary or to the uterus ; but Fabricius333 describes the symphysis of the Fallopian tube Avith the rectum. Absence of the uterus is frequently reported. Lieutaud and Richer- and302 are each said to have dissected female subjects in Avhom neither the uterus nor its annexed organs Avere found. Many authors are accredited Avith mentioning instances of defective or deficient uteri, among them Bosquet, a Boyer,b AValther,814 Le Fort, Calori, Pozzi, Mundc, and Strauch. Balade c has reported a curious absence of the uterus and vagina in a girl of eighteen. Azam, Bastien, Bibb, Bovel, AYarren, AVard, and many others report similar instances, and in several cases all the adnexa as Avell as the uterus and vagina Avere absent, and eATen the kidney and bladder malformed. Phillips d speaks of two sisters, both married, Avith congenital absence of the uterus. In his masterly article on " Heredity," e SedgAvick quotes an in- stance of total absence of the uterus in three out of five daughters of the same family ; two of the three Avere tAvice married. Double uterus is so frequently reported that an enumeration of the cases Avould occupy several pages. Bicorn, bipartite, duplex, and double uteruses are so called according to the extent of the duplication. The Ararieties range all the Avay from slight increase to tAvo distinct uteruses, with separate appendages and two A'aginae. Meckel, Boehmer, and Callisen are among the older writers Avho have observed double uterus Avith associate double vagina. Figure 150 represents a transverse section of a bipartite uterus Avith a double vagina. The so-called uterus didelphus is really a duplex uterus, or a A'eritable double uterus, each segment having the appearance of a complete unicorn uterus more or less joined to its neighbor (Fig. 151). Vallisnerif relates the history of a Avoman Avho was poisoned by cantharides Avho had tAvo uteruses, one open- ing into the A'agina, the other into the rectum. Morand, Bartholinus, Tiede- mann, Ollivier, Blundell, and many others relate instances of double uterus in which impregnation had occurred, the fetus being retained until the full term. Purcell of Dublin g says that in the summer of 1773 he opened the body of a Avoman Avho died in the ninth month of pregnancy. He found a uterus of ordinary size and form as is usual at this period of gestation, Avhich con- tained a full-groAvn fetus, but only one ovary attached to a single Fallopian tube. On the left side he found a second uterus, unimpregnated and of usual size, to Avhich another ovary and tube Avere attached. Both of these uteruses Avere distinct and almost entirely separate. Pregnancy with Double Uterus.—Hollander h describes the folloAving anomaly of the uterus AA'hich he encountered during the performance of a celiotomy :— '< There Avere found tAvo uteruses, the posterior one being a normal organ a 462, iv., 128. b 565, jjM 19. c Jour, de Medicine de Bordeaux, Oct. 4, 1891. d224, June 18, 1870. e 549, July, 1863, 457. f "Esperienze d'osservaz.," etc g 629, lxiv., 474. h 261, 1895, No. 4, p. 375. 312 MINOR TERATA. Fig. 150.—Bipartite uterus with double vagina. Fig. 151.—Didelphic uterus and divided vagina: a right segment; 6, left segment; c, d, right ovary and round ligament; /, e, left ovary and round ligament; g,j, left cervix and vagina; k, vaginal septum; h, %, right cervix and vagina. Fig. 152.—Complete prolapse of the uterus, with eversion of vagina (Keen and AVhite). HERNIA OF THE UTERUS. 313 with its adnexa; connected with this uterus Avas another one, anterior to it. The tAvo uteruses had a common cervix; the anterior of the two organs had no adnexa, though there Avere lateral peritoneal ligaments ; it had become pregnant." Hollander explains the anomaly by stating that probably the Mullerian ducts or one of them had groAvn excessively, leading to a folding off of a portion Avhich developed into the anterior uterus. Other cases of double uterus Avith pregnancy are mentioned on page 49. When there is simultaneous pregnancy in each portion of a double uterus a complication of circumstances arises. Debierre quotes an instance of a Avoman who bore one child on July 16, 1870, and another on October 31st of the same year, and both at full term. She had only had three menstrual periods betAveen the confinements. The question as to whether a case like this would be one of superfetation in a normal uterus, or Avhether the uterus Avas double, Avould immediately arise. There Avould also be the possibility that one of the children Avas of pro- tracted gestation or that the other Avas of premature birth. Article 312 of the Civil Code of France accords a minimum of one hundred and eighty and a maximum of three hundred days for the gestation of a viable child. (See Protracted Gestation.) Voighta is accredited with having seen a triple uterus, and there are several older parallels on record. TlliloAV mentions a UterUS AA'hich AVaS Fig-153.-Inguinal hernia containing a gravid womb (AVinckel). divided into three small portions. Of the different anomalous positions of the uterus, most of which are acquired, the only one that will be mentioned is that of complete prolapse of the uterus (Fig. 152). In this instance the organ may hang entirely out of the body and eAren forbid locomotion. Of 19 cases of hernia of the uterus quoted by Debierre 13 have been ob- served in the inguinal region (Fig. 153), five on the right and seven on the left side. In the case of Roux in 1891 the hernia existed on both sides. The uterus has been found twice only in crural hernia and three times in umbilical hernia. There is one case recorded, according to Debierre, in Avhich the uterus was one of the constituents of an obturator hernia. Sometimes its appendages are found Avith it. Doring, Ledesma, Rektorzick, and Scazoni haATe found the uterus in the sac of an inguinal hernia ; Leotaud, Murray, and Hagner in an umbilical hernia. The accompanying illustration (Fig. 154) represents a hernia of the gravid Avomb through the linea alba. a 503, iii., 175. 314 MINOR TERATA. Absence of the penis is an extremely rare anomaly, although it lias been noted by Schenck,a Borellus, Bouteiller, Xelaton, and others. Fortu- natus Fidelis b and Revolat describe a neAvly born child Avith absence of external genitals, Avith spina bifida and umbilical hernia. Xelaton( describes a child of tAvo entirely Avithout a penis, but both testicles Avere found in the scrotum; the boy urinated by the rectum. Ashby and Wrightd mention complete absence of the penis, the urethra opening at the margin of the anus outside the external sphincter ; the scrotum and testicles Avere Avell developed. Murphye gives the description of a Avell-formed infant apparently Avithout a penis ; the child passed urine through an opening in the loAver part of the abdomen just above the ordinary location of the penis; the scrotum was present. Incisions Avere made into a small SAvelling just below the urinary Fig. 154.—Hernia of the gravid womb through the linea alba. opening in the abdomen AA'hich brought into view the penis, the glans being normal but the body very small. The treatment consisted of pressing out the glans daily until the Avound healed ; the penis receded spontaneously. It is stated that the organ Avould doubtless be equal to any requirements de- manded of it. Demarquay quotes a someAvhat similar case in an infant, but it had no urinary opening until after operation. Among the older Avriters speaking of deficient or absent penis are Bar- tholinus,190 Bauhinus, Cattierus, the Ephemerides, Frank, Panaroli,617 A'an der AAiel, and others. Renauldinf describes a man Avith a small penis and enormous mammae. Goschler,g quoted by Jacobson, speaks of a Avell-de- veloped man of twenty-two, with abundant hair on his chin and suprapubic a 718, lib. iv., chap. 9. b pje relationibus medicorum, no. 357. c 363, 1854. d " Dis. of Children," p. 53. e 224, 1885, ii., 62. f 565, tome i., p. 294. 8 808, 1857. RUDIMENTARY DEVELOPMENT OF THE PENIS. 315 region and the scrotum apparently perfect, with median raphe; a careful search failed to sIioav any trace of a penis ; on the anterior Avail of the rectum four lines above the anus Avas an orifice Avhich gave vent to urine ; the right testicle and cord Ave re normal, but there Avas an acute orchitis in the left. Starting from just in front of the anal orifice Avas a fold of skin 1J inches long and f inch high continuous Avith the raphe, which seemed to be formed of erectile tissue and which sAvelled under excitement, the enlarge- ment lasting several minutes with usually an emission from the rectum. It Avas possible to pass a sound through the opening in the rectum to the blad- der through a urethra 1J inches Avide ; the patient had control of the bladder and urinated from every three to five hours. Many instances of rudimentary development of the penis have been recorded, most of them complicated Avith cryptorchism or other abnormality of the sexual organs. In other instances the organ is present, but the infantile type is present all through life ; sometimes the subjects are weak in intellect and in a condition similar to cretinism. Kaufmann quotes a case in a weakly boy of tAvelve Avhose penis was but f inch long, about as thick as a goose-quill, and feeling as limp as a mere tube of skin ; the corpora cavernosa Avere not entirely absent, but ran only from the ischium to the junction of the fixed portion of the penis, suddenly terminating at this point. Nothing indicative of a prostate could be found. The testicles Avere at the entrance of the inguinal canal and the glans was only slightly developed. Bineta speaks of a man of fifty-three Avhose external genitalia Avere of the size of those of a boy of nine. The penis Avas of about the size of the little finger, and contained on each side testicles not larger than a pea. There Avas no hair on the pubes or the face, giving the man the aspect of an old Avoman. The prostate Avas almost exterminated and the seminal vesicles Avere very primitive in conformation. AVilson Avas consulted by a gentleman of twenty-six as to his ability to perform the marital function. In size his penis and testicles hardly exceeded those of a boy of eight. He had never felt desire for sexual intercourse until he became acquainted Avith his intended wife, since Avhen he had erections and nocturnal emissions. The patient married and became the father of a family ; those parts Avhich at twenty-six Avere so much smaller than usual had increased at twenty-eight to normal adult size. There are three cases on record in the older literature of penises extremely primitive in development. They are quoted by the Ephemerides, Plater,635 Schenck,1' and Zacchias. The result in these cases Avas impotency. In the Army and Medical Museum at Washington are two injected speci- mens of the male organ divested of skin. From the meatus to the pubis they measure 6| and 5J inches; from the extremity to the termination of either cms 9f and 8f inches, and the circumferences are 4| and 4* inches. BetAveen these two Ave can strike an average of the size of the normal penis. a 242 1883. b 718> lib- iv-> obs- 12' 316 MINOR TERA TA. In some instances the penis is so large as to forbid coitus and even inconveni- ence its possessor, measuring as much as ten or even more inches in length. Extraordinary cases of large penis are reported by Albinus 114(\vho mentions it as a cause for sterility), Bartholinus,189 Fabricius Hildanus, Paullini, Pcyer, Plater, Schurig,a Sinibaldus,737 and Zacchias. Several cases of enormous penises in the neAV-born haA'e been observed by Wolffb and others.0 The penis palme, or suture de la verge of the French, is the name given to those examples of single cutaneous envelope for both the testicles and penis ; the penis is adherent to the scrotum by its inferior face ; the glans only is free and erection is impossible. Chretien cites an instance in a man of tAventy-five, and Schrumpf of Wesserling d describes an example of this rare anomaly. The penis and testes Avere inclosed in a common sac, a slight pro- jection not over £ inch long being seen from the upper part of this curious scrotum. When the child AA'as a year old a plastic operation Avas performed on this anomalous member Avith a A'ery satisfactory result. Petit describes an instance in Avhich the penis Avas slightly fused Avith the scrotum. There are many varieties of torsion of the penis. The glans itself may be inclined laterally, the curvature may be total, or there may be a veritable rotation, bringing the inferior face above and the superior face beloAv. Cay e describes a child Avith epispadias Avhose penis had undergone such torsion on its axis that its inferior surface looked upAvard to the left, and the child passed urine toAvard the left shoulder. Follinf mentions a similar instance in a boy of tAvelve Avith complete epispadias, and Verneuil and Guerlin also record cases, both complicated Avith associate maldevelopment. Caddy g mentions a youth of eighteen Avho had congenital torsion of the penis Avith- out hypospadias or epispadias. There was a complete half-turn to the left, so that the slit-like urinary meatus Avas reversed and the frenum Avas above. Among the older writers who describe incurvation or torsion of the penis are Arantius,h the Ephemerides, Haenel,401 Petit, * Schurig, Tulpius,J and Zacchias.830 Zacutus Lusitanus k speaks of torsion of the penis from freezing. Paul- lini l mentions a case the result of masturbation, and Hunterm speaks of torsion of the penis associated with arthritis. Ossification of the Penis.—MacClellan n speaks of a man of fifty-tAvo whose penis AAas curved and distorted in such a manner that urine could not be passed Avithout pain and coitus Avas impossible. A bony mass Avas dis- covered in the septum betAveen the corpora caATernosa ; this Avas dissected out Avith much hemorrhage and the upAvard curvature Avas remoATed, but there a "Spermatologia," p. 109. b " Lect. Memorab.," tome i., p. 31. c " Memoires concernant les Arts," 1672, 27. <* 369, 1882. e 779, xvi., 1*9. f 789, 1862. 8 476, Sept. 15, 1894. b 718, L. iv., no. 14. i 625, Supplement. j 842, L. iii., no. 39. k831, L. iii., obs. 118. 1 620, cent, iv., obs. 92. m" References on Venereal Diseases," etc. n NouA'eau Journal des Sciences Medicales, March, 1878. ANOMALIES OF THE URETHRA. 317 resulted a slight inclination in the opposite direction. The formation of bone and cartilage in the penis is quite rare. Yelpeau, Kauffmann, Lenhoseck, and Duploy are quoted by Jacobson as having seen this anomaly. There is an excellent preparation in Vienna figured by Demarquay, but no description is given. The Ephemerides and Paullinia describe osseous penises. The complete absence of the frenum and prepuce has been observed in animals but is very rare in man. The incomplete or irregular develop- ment is more frequent, but most common is excessive development of the pre- puce, constituting phimosis, when there is abnormal adherence with the glans. Instances of phimosis, being quite common, will be passed Avithout special mention. Deficient or absent prepuce has been observed by Blasius,214 Mar- cellus Donatus,306 and Gilibert. Partial deficiency is described by Petit, Severinus, and others. There may be imperforation or congenital occlusion of some portion of the urethra, causing enormous accumulation of urine in the bladder, but fortu- nately there is generally in such cases some anomalous opening of the ure- thra giving vent to the excretions. Tulpiusb mentions a case of deficient urethra. In the Ephemerides there is an account of a man who had a con- stant flow of semen from an abnormal opening in the abdomen. La Pey- roniac describes a case of impotence due to ejaculation of the spermatic ducts into the bladder instead of into the urethra, but remarks that there Avas a cicatrix of a Avound of the neighboring parts. There are a number of instances in which the urethra has terminated in the rectum. Congenital dilatation of the urethral canal is very rare, and generally accompanied by other malformation. Duplication of the urethra or the existence of two permeable canals is not accepted by all the authors, some of Avhom contend that one of the canals cither terminates in a culdesac or is not separate in itself. Verneuil has pub- lished an article clearly exposing a number of cases, shoAving that it is possi- ble for the urethra to have two or more canals Avhich are distinct and have separate functions. Fabricius Hildanus d speaks of a double aperture to the urethra ; Marcellus Donatus e describes duplicity of the urethra, one of the apertures being in the testicle ; and there is another case on recordf in Avhich there Avas a urethral aperture in the groin. A case of double urethra in a man of tAventy-fiA'e living in Styria g avIio Avas under treatment for gonorrhea is described, the supernumerary urethra opening aboA7e the natural one and receiving a sound to the depth of 17 cm. There aaus purulent gonorrhea in both urethrae. Vesalius h has an account of a double urethral aperture, one of Avhich AA'as supposed to giA^e spermatic fluid and the other urine. Borellus, Testa, and CriiA'cilhier have reported similar instances. Instances of double penis have been discussed under the head of diphallic terata, page 194. a 620, cent, i, obs. 72. <1334, cent, i., obs. 76. 8 536, 1887, vol. ii. b842, L. xliv., cap. 36. e 306, L. vi., c. ii., 619. c 563, i., 427. f 524, vol. ii., 440. b804, L. v., c. 18. 318 MINOR TERATA. Hypospadias and epispadias (Fig. 155) are names given to malforma- tions of the urethra in Avhich the Avail of the canal is deficient cither above or beloAv. These anomalies are particularly interesting, as they are nearly always found in male hermaphrodites, the fissure giving the appearance of a vulva, as the scrotum is sometimes included, and eA'en the perineum may be fissured in continuity Avith the other parts, thus exaggerating the deception. There seems to be an element of heredity in this malformation, and this allegation is exemplified by SedgAvick, Avho quotes a case from Heuremann in which a family of females had for generations giA^en birth to males Avith hypospadias. Belloca mentions a man Avhose urethra terminated at the base of the frenum Avho had four sons Avith the same deformity. Picardatb men- tions a father and son, both of Avhom had double urethral orifices, one above the other, from one of AA'hich issued urine and from the other semen— a fact that sIioavs the possibility of inheritance of this malformation. Patients in whom the urethra opens at the root of the penis, the meatus being imperforate, are not necessarily impotent; as, for instance, Fournier c knew of a man Avhose urethra opened posteriorly Avho Avas the father of four children. Fournier supposed that the semen ejaculated A'igorously and folloAved the fissure on the back of the penis to the uterus, the membrane of the ATagina supplanting the deficient Avail of the urethra. The penis Avas short, but about as thick as ordinary. Grayd mentions a curious case in a man afflicted Avith hypospadias Avho, suffering with delusions, Avas confined in the insane asylum at Utica. When he determined to get married, fully appreciating his physical defect, he re- solved to imitate nature, and being of a very ingenious turn of mind, he busied himself with the construction of an artificial penis. AAliile so en- gaged he had seized every opportunity to study the conformation of this organ, and finally prepared a body formed of cotton, six inches in length, and shaped like a penis, minus a prepuce. He sheathed it in pig's gut and gave it a slight vermilion hue. To the touch it felt elastic, and its shape was maintained by a piece of gutta-percha tubing, around which the cotton AAas firmly wound. It Avas fastened to the Avaist-band by means of straps, a cen- tral and an upper one being so arranged that the penis could be throAvn into a 302, xxiv. b These de Paris, 1858, No. 91. c 302, iv., 162. d 773, 1870 Fig. 155.—Complete epispadias. ABSENCE OF THE TESTICLES. 319 an erect position and s< > maintained. He had constructed a flesh-colored cov- ering Avhich completely concealed the straps. AATith this artificial member he Avas enabled to deceive his Avife for fifteen months, and Avas only discovered Avhen she undressed him Avhile he Avas in a state of intoxication. To further the deception he had told his Avife immediately after their marriage that it Avas quite indecent for a husband to undress in the presence of his Avife, and therefore she had ahvavs retired first and turned out the light. Partly from fear that his virile poAver Avould be questioned and partly from ignorance, the duration of actual coitus Avould approach an hour. AVhen the discoATery Avas made, his Avife hid the instrument with which he had perpetrated a most successful fraud upon her, and the patient subsequently attempted coitus by contact with unsuccessful results, although both parties had incomplete orgasms. Shortly afterAvard evidences of mental derangement appeared and the man became the subject of exalted delusions. His wife, at the time of report, had filed application for divorce. Haslam a reports a case in Avhich loss of the penis was compensated for by the use of an ivory succedaneum. Parallel instances of this kind have been recorded by Ammannb and Jonston.0 Entire absence of the male sexual apparatus is extremely rare, but Blondin and Velpeau have reported cases. Complete absence of the testicles, or anorchism, is a comparatively rare anomaly, and it is very difficult to distinguish betAveen anorchism and arrest of development, or simple atrophy, which is much more common. Fisher of Boston d describes the case of a man of forty-five, Avho died of pneumonia. From the age of puberty to tAventy-five, and even to the day of death, his voice had never changed and his manners Avere decidedly effeminate. He ahvavs sang soprano in concert with females. After the age of tAventy-fiATe, hoAvever, his A'oice became more graA'e and he could not accompany females Avith such ease. He had no beard, had never shaved, and had never exhibited amorous propensities or desire for female society. When about t\venty-one he became associated Avith a gay company of men and was addicted to the cup, but Avould never A'isit houses of ill-fame. On dissection no trace of testicles could be found ; the scrotum Avas soft and flabby. The cerebellum AA'as the exact size of that of a female child. Individuals Avith one testicle are called monorchids, and may be divided into three A'arieties :— (1) A solitary testicle divided in the middle by a deep fissure, the two lobes being each proA'ided Avith a spermatic cord on the same side as the lobe. (2) Testicles of the same origin, but Avith coalescence more general. (3) A single testicle and tAvo cords. Gruber of St. Petersburg e held a postmortem on a man in January, a 476, 1828, ii., 182. b " Irenicum Numse," p. 133. c 445, p. 406. d 124, Feb., 1839. e 553, Heft i., 1868. 320 MINOR TERATA. 18()7, in Avhom the right half of the scrotum, the right testicle, epididymis, and the scrotal and inguinal parts of the right vas deferens Avere absent. Gruber examined the literature for thirty years up to the time of his report, and found 30 recorded postmortem examinations in Avhich there Avas absence of the testicle, and in eight of these both testicles avc re missing. As a rule, natural eunuchs have feeble bodies, are mentally dull, and live only a short time. The penis is ordinarily defective and there is sometimes another associate mal- formation. They are not ahvays disinclined toAvard the opposite sex. Polyorchids are persons Avho have more than two testicles. For a long time the abnormality Avas not belieA'ed to exist, and some of the observers denied the proof by postmortem examination of any of the cases so diagnosed ; but there is at present no doubt of the fact,—three, four, and five testicles having been found at autopsies. Russell, one of the older writers on the testicle, mentions a monk Avho Avas a triorchid, and was so salacious that his indomitable passion prevented him from keeping his atoavs of chastity. The amorous propensities and generative faculties of polyorchids have ahvavs been supposed greater than ordinary. Russell reports another case of a man Avith a similar peculiarity, Avho Avas prescribed a concubine as a reasonable allow- ance to a man thus endowed. Morgagni and Meckel say that they never discovered a third testicle in dissections of reputed triorchids, and though Haller a has collected records of a great number of triorchids, he has never been able to verify the presence of the third testicle on dissection. Some authors, including Haller, have demonstrated heredity in examples of polyorchism. There is an old instance b in Avhich two testicles, one above the other, were found on the right side and one on the left. Macann0 describes a recruit of tAventy, Avhose scrotum seemed to be much larger on the right than on the left side, although it Avas not pendulous. On dissection a right and left testicle were found in their normal positions, but situated on the right side between the groin and the normal testicle Avas a supernumerary organ, not in contact, and having a separate and short cord. Prankard d also describes a man Avith three testicles. Three cases of triorchidism Avere found in recruits in the British Army.e Lanef reports a supernumerary testis found in the right half of the scrotum of a boy of fifteen. In a necropsy held on a man killed in battle, Hohlberg « discovered three fully developed testicles, two on the right side placed one above the other. The London Medical Record of 1884 quotes Jdanoff of St. Petersburg in men- tioning a soldier of tAventy-one Avho had a supernumerary testicle erroneously diagnosed as inguinal hernia. Quoted by the same reference, Bulatoff men- tions a soldier Avho had a third testicle, which diagnosis was confirmed by several of his confreres. They recommended dismissal of the man from the service, as the third testicle, usually resting in some portion of the inguinal canal, caused extra exposure to traumatic influence. a 400, L. xxvii., 412. b 504, xviii., 362. c 656, 1842. d 654, 1842. e 476, 1865, ii., 501. f 224, Dec. 1, 1894. 8 812, 1882, 38, 642. CRYPTORCHIDS. 321 Vencttca gives an instance of four testicles, and Scharff, in the Ephe- merides, mentions five; Bursitis214 mentions more than three testicles, and, Avithout citing proof, Buffon admits the possibility of such occurrence and adds that such men are generally more A'igorous. Russellb mentions four, five, and even six testicles in one individual; all Avere not verified on dissection. He cites an instance of six testicles, four of Avhich Avere of usual size and two smaller than ordinary. Baillie, the Ephemerides, and Schurig mention fusion of the testicles, or synorcliidism, someAvhat after the manner of the normal disposition of the batrachians and also the kangaroos, in the former of AA'hich the fusion is ab- dominal and in the latter scrotal. Kerckringc has a description of an indi- vidual in Avhom the scrotum Avas absent. In those cases in Avhich the testicles are still in the abdominal cavity the individuals are termed cryptorchids. Johnsond has collected the re- sults of postmortem examinations of 89 supposed cryptorchids. In eight of this number no testicles Avere found postmortem, the number found in the abdomen Avas uncertain, but in 18 instances both testicles Avere found in the inguinal canal, and in eight only one Avas found in the inguinal canal, the other not appearing. The number in which the semen Avas examined microscopically AA'as 16, and in three spermatozoa were found in the semen; one case Avas dubious, spermatozoa being found tAvo weeks afterAvard on a boy's shirt. The number having children Avas ten. In one case a monorchid generated a cryptorchid child. Some of the cryptorchids were effeminate, although others Avere manly Avith good evidences of a beard. The morbid, hypochon- driac, the voluptuous, and the imbecile all found a place in Johnson's statis- tics ; and although there are evidences of the possession of the generative function, still, Ave are compelled to say that the chances are against fecundity of human cryptorchids. In this connection might be quoted the curious case mentioned by Geoffroy-Saint-Hilaire, of a soldier Avho was hung for rape. It Avas alleged that no traces of testicles Avere found externally or internally, yet semen containing spermatozoa Avas found in the seminal A'esicles. Sper- matozoa luue been found days and Aveeks after castration, and the indh'iduals during this period Avere capable of impregnation, but in these cases the reser- voirs Avere not empty, although the spring had ceased to Aoav. Beigel, in A^irchoAv's Archh'es, mentions a cryptorchid of twenty-tAvo Avho had noctur- nal emissions containing spermatozoa and Avho indulged in sexual congress. Partridge e describes a man of tAventy-four avIio, notAArithstanding his condi- tion, gave evidences of virile seminal Aoav. In some cases there is anomalous position of the testicle. Houghf mentions an instance in Avhich, from the great pain and sudden appearance, a small tumor lying against the right pubic bone AAras supposed to be a strangu- a 215, an. ii., 38. b " Obs. on Testicles," Edinburgh, 1833. c 473, obs. xii. d775, 1884. e 476, 1860, i., 66. f 545, 1884. 21 322 MINOR TERATA. lated hernia. There Avere two Avell-developed testicles in the scrotum, and the hernia proved to be a third. McElmail a describes a soldier of twenty-nine, who tAvo or three months before examination felt a pricking and slight burn- ing pain near the internal aperture of the internal inguinal canal, succeeded by a SAvelling until the tumor passed into the scrotum. It AA'as found in the upper part of the scrotum above the original testicle, but not in contact, and AAas about half the size of the normal testicle ; its cord and epididymis could be distinctly felt and caused the same sensation as pressure on the other testicle did. Marshallb mentions a boy of sixteen in whom the right half of the scrotum Avas empty, although the left Avas of normal size and contained a testicle. On close examination another testicle Avas found in the perineum ; the boy said that Avhile running he fell doAvn, four years before, and on get- ting up suffered great pain in the groin and this pain recurred after exertion. This testicle Avas removed successfully to the scrotum. Horsley collected 20 instances of operators avIio made a similar attempt, Annandale being the first one ; his success Avas likely due to antisepsis, as previously the testicles had ahvavs sloughed. There is a record of a dog remarkable for its salacity who had two testicles in the scrotum and one in the abdomen ; some of the older authors often indulged in playful humor on this subject. BroAvnc describes a child Avith a SAvelling in the perineum both painful and elastic to the touch. The child cried if pressure Avas applied to the tumor and there Avas eA'ery eA'idence that the tumor Avas a testicle. Hutche- son, quoted by Russell,d has given a curious case in an English seaman Avho, as AA'as the custom at that time, Avas impressed into service by H. M. S. Druid in 1807 from a trading ship off the coast of Africa. The man said he had been examined by dozens of ship-surgeons, but was invariably re- jected on account of rupture in both groins. The scrotum Avas found to be an empty bag, and close examination showed that the testicles occupied the seats of the supposed rupture. As soon as the discovery Avas made the man became unnerved and agitated, and on re-examining the parts the testicles were found in the scrotum. AAhen he found that there was no chance for escape he acknoAvledged that he Avas an impostor and gave an exhibition in which, with incredible facility, he pulled both testes up from the bottom of the scrotum to the external abdominal ring. At the word of command he could pull up one testicle, then another, and let them drop simultaneously ; he performed other like feats so rapidly that the movements could not be dis- tinguished. In this connection Russell speaks of a man whose testicle was elevated eATery time the east wind bleAv, Avhich caused him a sense of languor and re- a 523, 1856, ix., 91. b 543, 1383. c 436, 1891, ii., 546. d "Obs. on Testicles." Edinb., 1833. INVERSION OF THE TESTICLE. 323 laxation ; the same author describes a man Avhose testicles ascended into the inguinal canal every time he was in the company of women. Inversion of the testicle is of several varieties and quite rare; it has been recognized by Sir Astley Cooper, Boyer, Maisonneuve, Royet, and other writers. The anomalies of the vas deferens and seminal vesicles are of little in- terest and will be passed with mention of the case of Weber,a who found the seminal vesicles double; a similar conformation has been seen in hermaphrodites. a 559, May, 1811, 88. CHAPTER VII. ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT. Giants.—The fables of mythology contain accounts of horrible monsters, terrible in ferocity, Avhose mission was the destruction of the life of the in- dividuals unfortunate enough to come into their domains. The ogres known as the Cyclops, and the fierce anthropophages, called Lestrygons, of Sicily, who were neighbors of the Cyclops, are pictured in detail in the "Odyssey" of Homer. Nearly all the nations of the earth have their fairy tales or super- stitions of monstrous beings inhabiting some forest, mountain, or cave ; and pages have been Avritten in the heroic poems of all languages describing battles between these monsters and men Avith superhuman courage, in Avhich the giant finally succumbs. The Avord giant is derived indirectly from the old English word " geant," which in its turn came from the French of the conquering Normans. It is of Greek derivation, " r£ra""—or the Latin, " gigas." The Hebrew parallel is " nophel," or plural, " nephilim." Ancient Giants.—We are told in the Bible a that the bedstead of Og, King of Basham, was 9 cubits long, which in English measure is 16^ feet. Goliath of Gath, Avho Avas slain by DaA'id, stood 6 cubits and a span tall— about 11 feet. The body of Orestes, according to the Greeks, was 11J feet long. The mythical Titans, 45 in number, Avere a race of Giants who warred against the Gods, and their descendants Avere the Gigantes. The height attributed to these creatures Avas fabulous, and they Avere supposed to heap up mountains to scale the sky and to help them to wage their battles. Hercules, a man of incredible strength, but AA'ho is said to haA'e been not over 7 feet high, AAras dispatched against the Gigantes. Pliny describes Gabbaras, who AA'as brought to Rome by Claudius Caesar from Arabia and Avas betAveen 9 and 10 feet in height, and adds that the re- mains of Posio and Secundilla, found in the reign of Augustus Caesar in the Sallustian Gardens, of Avhich they Avere supposed to be the guardians, meas- ured 10 feet 3 inches each. In common Avith Augustine, Pliny believed that the stature of man has degenerated, but from the remains of the ancients so far discovered it would appear that the modern stature is about the same as a Deuteronomy iii., 11. 324 DISCOVERIES OF " GIANTS' BONES." 325 the ancient. The beautiful alabaster sarcophagus discovered near Thebes in 1817 and now in Sir John Soane's Museum in Lincoln's Inn Fields in London measures 9 feet 4 inches long. This unique example, the finest extant, is well Avorth inspection by \Tisitors in London. Herodotus says the shoes of Perseus measured an equivalent of about 3 feet, English standard. Josephus tells of Eleazar, a Jew, among the hostages sent by the King of Persia to Rome, avIio Avas nearly 11 feet high. Saxo, the grammarian, mentions a giant 13 J feet high and says he had 12 companions Avho Avere double his height. Ferragus, the monster supposed to have been slain by Roland, the nephew of Charlemagne, Avas said to have been nearly 11 feet high. It was said that there was a giant liA'ing in the twelfth century under the rule of King Eugene II. of Scotland Avho Avas 11| feet high. There are fabulous stories told of the Emperor Maximilian. Some accounts say that he was between 8 J and 9 feet high, and used his wife's bracelet for a finger-ring, and that he ate 40 pounds of flesh a day and drank six gallons of Avine. He was also accredited with being a great runner, and in his earlier days was said to have conquered single-handed eight soldiers. The Emperors Charlemagne and Jovianus Avere also accredited with great height and strength. In the olden times there were extraordinary stories of the giants who lived in Patagonia. Some say that Magellan gave the name to this country because its inhabitants measured 5 cubits. The naturalist Turner says that on the river Plata near the Brazilian coast he saAV naked savages 12 feet high ; and in his description of America, Thevenot confirms this by saying that on the coast of Africa he saw on a boat the skeleton of an American giant Avho had died in 1559, and avIio Avas 11 feet 5 inches in height. He claims to have measured the bones himself. He says that the bones of the leg measured 3 feet 4 inches, and the skull was 3 feet and 1 inch, just about the size of the skull of Borghini, who, however, Avas only of ordinary height. In his account of a voyage to the Straits of Magellan, Jacob Lemaire says that on December 17, 1615, he found at Port Desire seATeral graves covered with stones, and beneath the stones Avere skeletons of men which measured between 10 and 11 feet. The ancient idea of the Spaniards was that the men of Patagonia Avere so tall that the Spanish soldiers could pass under their arms held out straight; yet we know that the Patagonians exhibit no exaggeration of height—in fact, some of the inhabitants about Terra del Fuego are rather diminutive. This superstition of the voyagers was not limited to America; there were accounts of men in the neighborhood of the Peak of Teneriffe Avho had 80 teeth in their head and bodies 15 feet in height. Discoveries of "Giants' Bones."—Riolan,685 the celebrated anatomist, says that there Avas to be seen at one time in the suburbs of Saint Germain the tomb of the giant Isoret, who was reputed to be 20 feet tall; and that in 326 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT. 1509, in digging ditches at Rouen, near the Dominicans, they found a stone tomb containing a monstrous skeleton, the skull of Avhich Avould hold a bushel of corn ; the shin-bone measured about 4 feet, Avhich, taken as a guide, would make his height over 17 feet. On the tomb was a copper plate which said that the tomb contained the remains of " the noble and puissant lord, the Chevalier Ricon de Vallemont." Plater,635 the famous physician, declares that he saAV at Lucerne the true human bones of a subject that must have been at least 19 feet high. Valence in Dauphine boasted of possessing the bones of the giant Bucart, the tyrant of the Vivarias, Avho Avas slain by his vassal, Count de Cabillon. The Dominicans had the shin-bone and part of the knee-articulation, Avhich, substantiated by the frescoes and inscriptions in their possession, shoAved him to be 221 feet high. They claimed to have an os frontis in the medical school of Leyden measuring 9.1 X 12.2 X .5 inches, Avhich they deduce must have belonged to a man 11 or 12 feet high. It is said that Avhile digging in France in 1613 there was disinterred the body of a giant bearing the title " Theutobochus Rex," and that the skeleton measured 25 feet long, 10 feet across the shoulders, and 5 feet from breast to back. The shin-bone Avas about 4 feet long, and the teeth as large as those of oxen. This is likely another version of the finding of the remains of Bucart. Near Mezarino in Sicily in 1516 there Avas found the skeleton of a giant Avhose height was at least 30 feet; his head was the size of a hogshead, and each tooth Aveighed 5 ounces; and in 1548 and in 1550 there were others found of the height of 30 feet. The Athenians found near their city skele- tons measuring 34 and 36 feet in height. In Bohemia in 758 it is recorded that there was found a human skeleton 26 feet tall, and the leg-bones are still kept in a medieval castle in that country. In September, 1691, there Avas the skull of a giant found in Macedonia AA'hich held 210 pounds of corn. General Opinions.—All the accounts of giants originating in the finding of monstrous bones must of course be discredited, as the remains Avere likely those of some animal. Comparative anatomy has only lately obtained a hold in the public mind, and in the Middle Ages little Avas knoAvn of it. The pre- tended giants' remains have been those of mastodons, elephants, and other animals. From Suetonius we learn that Augustus Ciesar pleased himself by adorning his palaces Avith so-called giants' bones of incredible size, prefer- ring these to pictures or images. From their enormous size Ave must be- lieve they Avere mastodon bones, as no contemporary animals shoAv such measurements. Bartholinus a describes a large tooth for many years exhib- ited as the canine of a giant Avhich proved to be nothing but a tooth of a spermaceti Avhale (Cetus dentatus), quite a common fish. Hand b described an alleged giant's skeleton shoAvn in London early in the eighteenth century, a 190, cent, i., hist, 98. b 629, No. 168. GENERAL OPINIONS. 327 and Avhich Avas composed of the bones of the fore-fin of a small whale or of a porpoise. The celebrated Sir Hans Sloane, Avho treated this subject very learnedly, arrived at the conclusion that Avhile in most instances the bones found Avere those of mastodons, elephants, Avhales, etc., in some instances accounts Avere giAren by connoisseurs who could not readily be deceived. HoAvever, modern scientists Avill be loath to believe that any men ever existed Avho measured over 9 feet; in fact, such cases with authentic references are extremely rare. Quetelet considers that the tallest man whose stature is authentically recorded was the " Scottish Giant" of Frederick the Great's regiment of giants. This person Avas not quite 8 feet 3 inches tall. Buffon, ordinarily a reliable au- thority, comes to a loose conclusion that there is no doubt that men have lived who were 10, 12, and eATen 15 feet tall; but modern statisticians can- not accept this deduction from the references offered. From the original estimation of the height of Adam (Henrion once calcu- lated that Adam's height Avas 123 feet and that of Eve 118) Ave gradually come to 10 feet, which seemed to be about the favorite height for giants in the Middle Ages. Approaching this century,Ave still have stories of men from 9 to 10 feet high, but no authentic cases. It Avas only in the latter part of the last century that we began to have absolutely authentic heights of giants, and to-day the men shoAving through the country as measuring 8 feet generally exaggerate their height several inches, and exact measurement Avould shoAV that but few men commonly called giants are over T\ feet or Aveigh over 350 pounds. Danaa says that the number of giants figuring as public characters since 1700 is not more than 100, and of these about 20 Avere advertised to be over 8 feet. If we confine ourselves to those ac- curately and scientifically measured the list is surprisingly small. Topinard measured the tallest man in the Austrian army and found that he was 8 feet 4i inches. The giant AYinckelmeyer measured 8 feet 6 inches in height. lianke measured Marianne AVehde, avIio was born in Germany in the present century, and found that she measured 8 feet 44; inches when only sixteen and a half years old. In giants, as a rule, the great stature is due to excessive groAvth of the loAver extremities, the size of the head and that of the trunk being nearly the same as those of a man or boy of the same age. On the other hand, in a natural dAvarf the proportions are fairly uniform, the head, hoAvever, being . ahvays larger in proportion to the body, just as we find in infants. Indeed, the proportions of " General Tom Thumb " were those of an ordinary infant of from thirteen to fifteen months old. Figure 156 shoAvs a portrait of tAvo Avcll-knoAvn exhibitionists of about the same age, and illustrates the possible extremes of anomalies in stature. Recently, the association of acromegaly with gigantism has been a 723, Feb., 1895. 328 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT noticed, and in these instances there seems to be an acquired uniform enlarge- ment of all the bones of the body. Brissaud and Meigea describe the case of a male of forty-seven Avho presented nothing unusual before the age of sixteen, Avhen he began to groAV larger, until, having reached his majority, he measured 7 feet 2 inches in height and Aveighed about 340 pounds. He remained Avell and very strong until the age of thirty-seven, Avhen he OA^erlifted, and following this he deA^eloped an extreme deformity of the spine and trunk, the latter " tele- scoping into itself" until the nipples Avere on a level Avith the anterior superior spines of the ilium. For two years he suffered Avith debility, fatigue, bron- chitis, night-sAveats, head- ache, and great thirst. Mentally he Avas dull; the bones of the face and extremities shoAved the hypertrophies character- istic of acromegaly, the soft parts not being in- A'oh'ed. The circumfer- ence of the trunk at the nipples was 62 inches, and OATer the most promi- nent portion of the ky- phosis and pigeon-breast, 74 inches. The authors agree Avith Dana and others that there is an intimate relation between acromegaly and gigan- tism, but they go further and compare both to the groAvthof the body. They call attention to the strik- ing resemblance to acromegaly of the disproportionate groAvth of the boy at adolescence, which corresponds so well to Marie's terse description of this disease : " The disease manifests itself by preference in the bones of the extremities and in the extremities of the bones," and conclude Avith this rather striking and aphoristic proposition : " Acromegaly is gigantism of the adult; gigantism is acromegaly of adolescence." The many theories of the cause of gigantism Avill not be discussed here, the reader being referred to volumes exclusively devoted to this subject. Celebrated Giants.—Mention of some of the most famous giants will be made, together with any associate points of interest. a Jour, de Med. et de Chir. prat., Jan. 25, 1895. Fig. 156.—Giantess and dwarf of the same age. CELEBRATED GIANTS. 329 Becanus, physician to Charles V., says that he saAV a youth 9 feet high and a man and a Avoman almost 10 feet. AinsAvorth says that in 1553 the To Aver of London Avas guarded by three brothers claiming direct descent from Henry VIII., and surnamed Og, Gog, and Magog, all of Avhom Avere over 8 feet in height. In his " Chronicles of Holland" in 1557 Hadrianus Barlandus said that in the time of John, Earl of Holland, the giant Nicho- las was so large that men could stand under his arms, and his shoe held 3 ordinary feet. Among the yeoman of the guard of John Frederick, Duke of Hanover, there Avas one Christopher Munster, 8J feet high, avIio died in 1676 in his forty-fifth year. The giant porter of the Duke of AYurtemberg was 7\ feet high. " Big Sam," the porter at Carleton Palace, Avhen George IN. Avas Prince of AVales, Avas 8 feet high. The porter of Queen Elizabeth, of whom there is a picture in Hampton Court, painted by Zucchero, Avas 7| feet high -, and AValter Parson, porter to James L, AAas about the same height. William Evans, Avho served Charles L, was nearly 8 feet; he carried a dwarf in his pocket. In the seventeenth century, in order to gratify the Empress of Austria, Guy- Patin made a congress of all the giants and dAvarfs in the Germanic Empire. A peculiarity of this congress Avas that the giants complained to the authorities that the dAvarfs teased them in such a manner as to make their lh^es miserable. Plater speaks of a girl in Basle, SAvitzerland, five years old, Avhose body Avas as large as that of a full-groAvn Avoman and Avho Aveighed Avhen a year old as much as a bushel of Avheat. He also mentions a man living in 1613, 9 feet high, Avhose hand Avas 1 foot 6 inches long. Peter van den Broecke speaks of a Congo negro in 1640 Avho was 8 feet high. Daniel, the porter of CromAvell, AAras 7 feet 6 inches high ; he became a lunatic. Frazier speaks of Chilian giants 9 feet tall. There is a chronicle Avhich says one of the Kings of Nonvay was 8 feet high. Morula says that in 1538 he saAV in France a Flemish man over 9 feet. Keysler mentions see- ing Hans Bran in Tyrol in 1550, and says that he Avas nearly 12 feet high. Jonston447 mentions a lad in Holland Avho AA'as 8 feet tall. Pasumota mentions a giant of 8 feet. Edmund Mallone Avas said to have measured 7 feet 7 inches. AVierski, a Polander, presented to Maximilian II., Avas 8 feet high. At the age of thirtA'-tAvo there died in 1798 a clerk of the Bank of England Avho Avas said to have been nearly 7\ feet high. The Daily Advertiser for February 23, 174.1, says that there Avas a young colossus exhibited opposite the Man- sion House in London Avho aaus 7 feet high, although but fifteen years old. In the same paper on January 31, 1753, is an account of MacGrath, whose skeleton is still preserved in Dublin. In the reign of George I., during the time of the Bartholomew Fair at Smithfield, there was exhibited an English- man seventeen years old Avho Avas 8 feet tall. a '' Voyages physiques dans les Pyrenees.'' 330 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT. Nicephorus tells of Antonius of Syria, in the reign of Theodosius, avIio died at the age of tAventy-fiA'e Avith a height of 7 feet 7 inches. Artacsecas, in c 2$2, lxvi. GENERAL REMARKS ON OBESLTY. 355 who weighed 82 pounds, and Benzenberg noted a child of the same age who Aveighed 137. Hildman, quoted by Picat, speaks of an infant three years and ten months old avIio had a girth of 30 inches. Hillairet a knew of a child of five Avhich weighed 125 pounds. Bottab cites several instances of preternaturally stout children. One child died at the age of three Aveighing 90 pounds, another at the age of five Aveighed 100 pounds, and a third at the age of two Aveighed 75 pounds. Figure 170 represents Miss "Millie Josephine" of Chicago, a recent ex- Fig. 170.—Age thirteen, weight 422 pounds. hibitionist, who at the reputed age of thirteen was 5 feet 6 inches tall and weighed 422 pounds. General Remarks.—It has been chiefly in Great Britain and in Hol- land that the most remarkable instances of obesity have been seen, especially in the former country colossal Aveights have been recorded. In some coun- tries corpulency has been considered an adornment of the female sex. Hesse- Wartegg c refers to the JeAvesses of Tunis, who when scarcely ten years old are subjected to systematic treatment by confinement in narrow, dark rooms, where they are fed on farinaceous foods and the flesh of young puppies until a 233, 1881. b Cincin. Med. News, 1877, 321. c Tunis, Vienna, 1881. 356 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT. they are almost a shapeless mass of fat. According to Lbstein, the Moorish Avomen reach Avith astonishing rapidity the desired embonpoint on a diet of dates and a peculiar kind of meal. In some nations and families obesity is hereditary, and generations come and go Avithout a change in the ordinary conformation of the representa- tives. In other people slenderncss is equally persistent, and efforts to over- come this peculiarity of nature are Avithout aA'ail. Treatment of Obesity.—Many persons, the most famous of Avhom Avas Banting, have adA'anced theories to reduce corpulency and to impro\*e slen- derncss ; but they have been uniformly unreliable, and the Avhole subject of stature-development presents an almost unexplored field for investigation. Recently, Leichtenstein,a obserAdng in a case of myxedema treated Avith the thyroid gland that the subcutaneous fat disappeared with the continuance of the treatment, Avas led to adopt this treatment for obesity itself and reports striking results. The diet of the patient remained the same, and as the appetite Avas not diminished by the treatment the loss of weight Avas evidently due to other causes than altered alimentation. He holds that the observations in myxedema, in obesity, and psoriasis warrant the belief that the thyroid gland eliminates a material ha\7ing a regulating influence upon the consti- tution of the panniculus adiposus and upon the nutrition of the skin in general. There Avere 2o patients in all; in 22 the effect Avas entirely satisfactory, the loss of Aveight amounting to as much as 9.5 kilos (21 pounds). Of the three cases in which the result Avas not satisfactory, one had nephritis Avith severe Graves' disease, and the third psoriasis. Charrin b has used the injections of thyroid extract Avith decided benefit. So soon as the administration of the remedy Avas stopped the loss of Aveight ceased, but Avith the reneAval of the remedy the loss of weight again ensued to a certain point, beyond Avhich the extract seemed poAverless to act. EAvald also reports good results from this treatment of obesity. Remarkable Instances of Obesity.—From time immemorial fat men and Avomen have been the object of curiosity and the number avIio have exhibited themselves is incalculable. Nearly every circus and dime museum has its example, and some of the most famous have in this Avay been able to accumulate fortunes. Athenseus c has Avritten quite a long discourse on persons of note Avho in the olden times were distinguished for their obesity. He quotes a description of Denys, the tyrant of Heraclea, Avho Avas so enormous that he Avas in con- stant danger of suffocation ; most of the time he was in a stupor or asleep, a peculiarity of very fat people. His doctors had needles put in the back of his chairs to keep him from falling asleep when sitting up and thus incur- ring the danger of suffocation. In the same work A thenarsd speaks of a 300, No. 50, 1894. b Conipt. rend, de la Soc. de Biol., Dec. 29, 1894. c " Banquet des savants," edition of Lefebvre, etc. d l. xii., chap. 12. REMARKABLE INSTANCES OF OBESITY. 357 several soA^ereigns noted for their obesity ; among others he says that Ptol- emy VII., son of Alexander, was so fat that, according to Posidonius, Avhen he Avalked he had to be supported on both sides. Xe\Tertheless, Avhen he was excited at a repast, he would mount the highest couch and execute with agility his accustomed dance. According to old chronicles the cavaliers at Rome who grew fat Avere condemned to lose their horses and Avere placed in retirement. During the Middle Ages, according to Guillaume in his "Vie de Suger," obesity Avas considered a grace of God. Among the prominent people in the olden time noted for their embonpoint Avere Agesilas, the orator C. Licinius Calvus, Avho several times opposed Cicero, the actor Lucius, and others. Among men of more modern times Ave can mention William the Conqueror; Charles le Gros ; Louis leGros; Humbert II., Count of Maurienne ; Henry I., King of Navarre; Henry III., Count of Champagne ; Conan III., Duke of Brittany ; Sancho L, King of Leon; Alphonse II., King of Portugal ; the Italian poet Bruni, avIio died in 1635 ; Vivonne, a general under Louis XIV.; the celebrated German botanist Dil- lenius ; Haller ; Frederick I., King of Wi'irtemberg, and Louis XVIII. Probably the most famous of all the fat men was Daniel Lambert, born March 13, 1770, in the parish of Saint Margaret, Leicester. He did not differ from other youths until fourteen. He started to learn the trade of a die-sinker and engraver in Birmingham. At about nineteen he began to believe he Avould be A'ery heavy and developed great strength. He could lift 500 pounds Avith ease and could kick seven feet high Avhile standing on one leg. In 1793 he Aveighed 448 pounds; at this time he became sensitive as to his appearance. In June, 1809, he Aveighed 52 stone 11 pounds (739 pounds), and measured oA'er 3 yards around the body and OATer 1 yard around the leg. He had many A'isitors, and it is said that once, when the dwarf BorAvilaski came to see him, he asked the little man hoAv much cloth he needed for a suit. AVhen told about f of a yard, he replied that one of his sleeves Avould be ample. Another famous fat man Avas Edward Bright, sometimes called "the fat man of Essex." He Aveighed 616 pounds.a In the same journal that records Bright's Aveight is an account of a man ex- hibited in Holland who Aveighed 503 pounds. Wadd, a physician, himself an enormous man, Avrote a treatise on obesity and used his oavii portrait for a frontispiece. He speaks of Doctor Beddoes, who Avas so uncomfortably fat that a lady of Clifton called him a " Avalking feather bed." He mentions Doctor Stafford, Avho was so enormous that this epitaph Avas ascribed to him :— " Take heed, O good traveler ! and do not tread hard, For here lies Dr. Stafford, in all this churchyard." Wadd has gathered some instances, a feAV of which will be cited. At a 476, 1827, 361. 358 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT Staunton, January 2, 1816, there died Samuel Sugars, Gent., Avho Aveighed with a single Avood coffin 50 stone (700 pounds). Jacob PoAvell died in 175 4, weighing 560 pounds. It took 16 men to carry him to his grave.* Mr. Baker of Worcester, supposed to be larger than Bright, Avas interred in a coffin that AA'as larger than an ordinary hearse. In 1797 there Avas buried Philip Hayes, a professor of music, avIio Avas as heavy as Bright (616 pounds). Mr. Spooner, an eminent farmer of WarAvickshire, avIio died in 1775, aged fifty-seven, Aveighed 569 pounds and measured over 4 feet across the shoulders. The tAvo brothers Stoneclift of Halifax, Yorkshire, together Aveighed 980 pounds.b Keysler in his travels speaks of a corpulent Englishman Avho in passing through Savoy had to use 12 chairmen ; he says that the man Aveighed 550 pounds. It is recorded on the tombstone of James Parsons, a fat man of Ted- dington, Avho died March 7, 1743, that he had often eaten a whole shoulder of mutton and a peck of hasty pudding. Keysler mentions a young English- man living in Lincoln AA'ho AA'as accustomed to eat 18 pounds of meat daily. He died in 1724 at the age of tAventy-eight, weighing 530 pounds. In 1815 there died in TrenaAV, in Cornwall, a person known as " Giant Chillcot." He measured at the breast 6 feet 9 inches and weighed 460 pounds. One of his stockings held 6 gallons of Avheat. In 1822 there Avas reported to be a Cambridge student who could not go out in the daytime Avithout exciting as- tonishment. The fat of his legs overhung his shoes like the fat in the legs of Lambert and Bright. Dr. Short mentions a lady who died of corpulency in her twenty-fifth year Aveighing over 50 stone (700 pounds). Catesby speaks of a man who Aveighed 500 pounds,c and Coe mentions another avIio weighed 584 pounds.d Fabricius and Godart speak of obesity so excessive as to cause death. There is a case reported from the French of a person who weighed 800 pounds.e Smetiusf speaks of George Fredericus, an office-holder in Brandenburgh, who Aveighed 427 pounds. Dupuytren g gives the history of Marie Francoise-Clay, who attained such celebrity for her obesity. She Avas born in poverty, reached puberty at thir- teen, and married at tAventy-five, at AA'hich age she Avas already the stoutest woman of her neighborhood notAvithstanding her infirmity. She folloAved her husband, avIio Avas an old-clothes dealer, afoot from toAvn to toAvn. She bore six children, in AA'hom nothing extraordinary Avas noticed. The last one was born Avhen she Avas thirty-five years old. Xeither the births, her travels, nor her poverty, AA'hich sometimes forced her to beg at church doors, arrested the progress of the obesity. At the age of forty she Avas 5 feet 1 inch high and one inch greater about the Avaist. Her head Avas small and her neck was entirely obliterated. Her breasts were over a yard in circumference and a 374, vol. xxiv., 483. b 629, vol. xliv., 100. c 629, No. 479. d629, vol. xlvii., 75. e 462, vol. xiii., 65. f 730, 579. 8 302, vol. iv. REMARKABLE INSTANCES OF OBESITY. 359 hung as Ioav as the umbilicus. Her arms Avere elevated and kept from her body by the fat in her axillae. Her belly Avas enormous and Avas augmented by six pregnancies. Her thighs and haunches Avere in proportion to her general contour. At forty she ceased to menstruate and soon became af- flicted Avith organic heart disease. Fournier a quotes an instance of a Avoman in Paris Avho at tAventy-four, the time of her death, Aveighed 486 pounds. Not being able to mount any conveyance or carriage in the city, she walked from place to place, finding difficulty not in progression, but in keeping her equilibrium. Roger Byrne, Avho lived in Rosenalis, Queen's County, Ireland, died of excessive fatness at the age of fifty-four, weighing 52 stone. Percy and Laurent speak of a young German of tAventy who Aveighed 450 pounds. At birth he weighed 13 pounds, at six months 42, and at four years 150 pounds. He was 5 feet 5 inches tall and the same in circumference. William Campbell, the landlord of the Duke of Wellington in XeAvcastle-on-Tyne, AAas 6 feet 4 inches tall and Aveighed 728 pounds. He measured 96 inches around the shoulders, 85 inches around the Avaist, and 35 inches around the calf. He avus born at GlasgoAV in 1856, and Avas not quite twenty-tvvo when last meas- ured. To illustrate the rate of augmentation, he Aveighed 4 stone at nine months and at ten years 18 stone. He AAas one of a family of seven children. His appetite Avas not more than the aA'erage, and he Avas moderate as regards the use of liquors, but a great smoker. Notwithstanding his corpulency, he Avas intelligent and affable.b Miss Conley, a member of an American traA'eling circus, Avho weighed 479 pounds,0 Avas smothered in bed by rolling over on her face; she was unable to turn on her back Avithout assistance. There was a girl Avho died at Plaisance near Paris in 1890 who weighed 470 pounds or more. In 1889 an impresario undertook to exhibit her; but eight men could not move her from her room, and as she could not pass through the door the idea Avas abandoned.11 There Avas a colored Avoman aa4io died near Baltimoree avIio Aveighed 850 pounds, exceeding the great Daniel Lambert by 120 pounds. The journal reporting this case quotes the Medical Record as saying that there was a man in North Carolina, AA'ho Avas born in 1798, AA'ho was 7 feet 8 inches tall and Aveighed over 1000 pounds, probably the largest man that eATer hved. Hutchi- son f says that he saAV in the Infirmary at Kensington, under Porter's care, a remarkable example of obesity. The Avoman Avas only just able to walk about and presented a close resemblance to Daniel Lambert. Obesity forced her to leave her occupation. The accumulation of fat on the abdomen, back, and thighs Avas enormous. According to a recent number of La Liberte, a young woman of Penn- a 302, iv., 196. b 476, 1878, i 297. c 224, 1883, ii., 284. d 536, 1890, ii., 112. e 536, 1888, ii., 587. f 166, vol. iv., 358. 360 ANOMALIES OF STATURE, SIZE, AND DEVELOPMENT. sylvania, although only sixteen years old, Aveighs 4o(> pounds. Her Avaist measures 61 inches in circumference and her neck 22 inches. The same paper says that on one of the quays of Paris may be seen a Avinc-shop keeper with whom this Pennsylvania girl could not compare. It is said that this curiosity of the Notre-Damc quarter uses three large chairs Avhile sitting behind her specially constructed bar. There is another Paris report of a man living in SAvitzerland who Aveighs more than 40 stone (560 pounds) and cats five times as much as an ordinary person. When traveling he finds the greatest difficulty in entering an ordinary railway carriage, and as a rule contents himself in the luggage Aran. Figure 171 repre- sents an extremely fat Avoman Avith a Avell-developed beard. To end this list of obese individuals, avc mention an old gentleman living in San Francisco who, haA'ing pre- viously been thin, gained 14 pounds in his seventieth year and 14 pounds each of seven succeeding years. Simulation of Obesity.— General dropsy, elephantiasis, lipo- mata, myxedema, and various other affections in Avhich there is a hy- pertrophic change of the connec- tive tissues may be mistaken for general obesity ; on the other hand, a fatty, pendulous abdomen may simulate the appearances of preg- nancy or even of ovarian cyst (Fig. 172)! Dercum of Philadelphia3 has described a variety of obesity Avhich he has called "adiposis dolorosa,'' in which there is an enormous growth of fat, sometimes limited, sometimes spread all over the body, this condition differing from that of general lipomatosis in its rarity, in the mental symptoms, in the headache, and the generally painful condition com- plained of. In some of the cases examined by Dercum he found that the thyroid was indurated and infiltrated by calcareous deposits. The disease is not myxe- dema because there is no peculiar physiognomy, no spade-like hands nor infil- trated skin, no alteration of the speech, etc. Dercum considers it a connective- tissue dystrophy—a fatty metamorphosis of various stages, possibly a neuritis. The first of Dercum's cases (Fig. 173) Avas a widow of Irish birth, who died a 124, Nov., ls 302, iv., 176. <= o2o; 1867; nf 470. 380 LONGEVITY. served under three Kings, Frederick I., Frederick AVilliam I., and Frederick II., and did active service in the Seven Years' War, in Avhich his horse was shot under him and he was taken prisoner by the Russians. In his sixty- eight years of army service he participated in 17 general engagements, braved numerous dangers, and Avas Avounded many times. After his turbulent life he married, and at last in 1790, in his one hundred and tenth year, he took a third Avife. Until shortly before his death he Avalked every month to the pension office, a distance of two miles from his house.184 Longevity in Physicians.—It may be of interest to the members of our profession to learn of some instances of longevity among confreres. Dr, R. Baynes of Rockland, Maine, has been mentioned in the list of " grand old men" in medicine; folloAving in the footsteps of Hippocrates and Galen, he Avas practising at ninety-nine. He lives on Graham's diet, AA'hich is a form of vegetarianism ; he does not eat potatoes, but does eat fruit. His drink is almost entirely Avater, milk, and chocolate, and he condemns the use of tea, coffee, liquors, and tobacco. He has almost a perfect set of natural teeth and his sight is excellent. Like most men Avho live to a great age, Dr. Baynes has a " fad," to Avhich he attributes a chief part in prolonging his life. This is the avoidance of beds, and except AA'hen away from home he has not slept on a bed or even on a mattress for over fifty years. He has an iron reclin- ing chair, over AA'hich he spreads a few blankets and rugs. The British Medical Journal speaks of Dr. Boisy of Havre, who is one hundred and three. It is said he goes his rounds e\rery day, his practice being chiefly among the poor. At one time he practised in India. He has taken alcoholic bevTerages and smoked tobacco since his youth, although in moderation. His father, it is added, died at the age of one hundred and eight. Mr. AVilliam R. Salmon, living near Coaa4)ridge, Glamorganshire, recently celebrated his one hundred and sixth birthday. Mr. Salmon Avas born at AVickham Market in 1790, and became a member of the Royal Col- lege of Surgeons in 1809, the year in Avhich Gladstone Avas born. He died April 11, 1896. In reference to this wonderful old physician the Journal of the American Medical Association, 1896, page 995, says :— " AVilliam Reynold Salmon, M.R.C.S., of Penllyn Court, CoAvbridge, Glamorganshire, South AVales, completed his one hundred and sixth year on March 16th, and died on the 11th of the present month—at the time of his death the oldest knoAvn individual of indisputably authenticated age, the oldest physician, the oldest member of the Royal College of Surgeons, England, and the oldest Freemason in the Avorld. His age does not rest upon tradition or repute. He Avas the son of a successful and esteemed practising physician of Market AVickham, Suffolk, England, and there is in the possession of his two surviving relathTes, Avho cared for his household for many years, his mother's diary, in Avhich is inscribed in the handwriting of a lady of the eighteenth century, under the date, Tuesday, March 16, 1790, a prayer of LONGEVITY IN PHYSICIANS. 381 thankfulness to God that she had passed her ' tryall,' and that a son was born, Avho she hoped ' Avould prosper, be a support to his parents, and make virtue his chief pursuit.' The Royal College of Surgeons verified this record many years ago, and it Avas subsequently again authenticated by the authori- ties of the Freemasons, who thereupon enshrined his portrait in their gallery as the oldest living Freemason. The Salmon family moved to CoAvbridge in 1796, so that the doctor had lived exactly a century in the lovely and poetic Vale of Glamorgan, in the very heart of which Penllyn Court is situ- ated. Here on his one hundred and sixth birthday—a man of over middle height, Avith still long, flowing hair, Druidical beard and mustache, and bushy eyebroAvs—Dr. Salmon was visited by one who writes :— "' Seen a feAV days ago, the Patriarch of Penllyn Court was hale and hearty. He eats Avell and sleeps well and was feeling better than he had felt for the last five years. On that day he rose at noon, dined at six, and retired at nine. Drank tAvo glasses of port Avith his dinner, but did not smoke. He abandoned his favorite Aveed at the age of ninety, and had to discontinue his drives over his beautiful estate in his one hundredth year.' One day is much the same as another, for he gives his two relatives little trouble in attending upon his Avants. Dr. Salmon has not discovered the elixir of life, for the shadoAvs of life's evening are stealing sloAvly over him. He cannot move about, his hearing is dulled, and the light is almost shut out from the " AvindoAvs of his soul." Let us think of this remarkable man Avaiting for death uncomplainingly in his old-fashioned mansion, surrounded by the beau- tiful foliage and the broad expanse of green fields that he loved so much to roam Avhen a younger man, in that sylvan Sleepy Hollow in the Vale of Glamorgan.' " Eight Aveeks later he, Avho in youth had been ' the youngest surgeon in the army,' died, the oldest physician in the Avorld." Dr. AVilliam Hotchkiss,a said to have reached the age of one hundred and forty years, died in St. Louis April 1, 1895. He Avent to St. Louis forty years ago, and has ahvays been knoAvn as the " color doctor." In his peculiar practice of medicine he termed his patients members of his " circles," and claimed to treat them by a magnetic process. Dr. A. J. Buck says that his Masonic record has been traced back one hundred years, shoAving conclu- sively that he Avas one hundred and twenty-one years old. A letter received from his old home in Virginia, over a year ago, says that he Avas born there in 1755. It is comforting to the members of our profession, in Avhich the average of life is usually so Ioav, to be able to point out exceptions. It has been aptly said of physicians in general: " Aliis inserviendo consumuntur; aliis medendo moriuntur," or " In serving others they are consumed ; in healing others they are destroyed." a Nat. Pop. Review, Aug., 1895. 382 LONGEVITY. Recent Instances of Longevity.—There was a man who died in Spain at the advanced age of one hundred and fifty-one,a which is the most extra- ordinary instance from that country. It is reported that quite recently a Chinese centenarian passed the examination for the highest place in the Academy of Mandarins. Chevreul, born in 1786, at Angers, has only re- cently died after an active life in chemical investigation. Sir Moses Monte- fiore is a recent example of an active centenarian. In the New York Herald of April 21, 1895, is a description and a portrait of Noah Raby of the Piscataway Poor Farm of NeAV Jersey, to whom was ascribed one hundred and tAventy-three years. He was discharged from active duty on the " Brandywine," U. S. N., eighty-three years ago. He relates having heard George Washington speak at Washington and at Ports- mouth while his ship was in those places. The same journal also says that at Wichita, Kansas, there appeared at a municipal election an old negress named Mrs. Harriet McMurray, who gave her age as one hundred and fifteen. She had been a slave, and asserted that once on a A'isit to Alexandria with her master she had seen General AVashington. From the Indian Medical Record we learn that Lieutenant Nicholas Lavin of the Grand Armee died several years ago at the age of one hundred and twenty-five, leaving a daughter of seventy-eight. He Avas born in Paris in 1768, served as a hussar in several campaigns, and Avas taken a prisoner during the retreat from Moscow. After his liberation he married and made his residence in Saratoff. a Siglo Med., Madrid, 1851. CHAPTER IX. PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. In considering the anomalies of the secretions, it must be remembered that the ingestion of certain kinds of food and the administration of peculiar drugs in medicine have a marked influence in coloring secretions. Probably the most interesting of all these anomalies is the class in which, by a compensatory process, metastasis of the secretions is noticed. Colored Saliva.—Among the older writers the Ephemerides contains an account of blue saliva; Huxhama speaks of green saliva; Marcellus Don- atus b of yellow, and Peterman c relates the history of a case of yellow salh'a. Dickinsonddescribes a Avoman of sixty whose saliva was blue; besides this nothing was definitely the matter with her. It seemed, however, that the color Avas due to some chemic-pencil poisoning rather than to a pathologic process. A piece of this aniline pencil Avas caught in the false teeth. Paget cites an instance of blue saliva due to staining the tongue in the same manner. Most cases of anomalous coloring of this kind can be subsequently traced to artificial substances unconsciously introduced. Crocker mentions a woman who on Avashing her hands constantly found that the water Avas stained blue, but this was subsequently traced to the accidental introduction of an orchid leaf. In another instance there Avas a woman whose linen was at eA'erv change stained brown ; this, however, was found to be due to a hair-wash that she Avas in the habit of using. Among the older writers who have mentioned abnormal modes of exit of the urine is Baux,e who mentions urine from the nipples ; Paullinif and the Ephemerides describe instances of urination from the eyes. Blancard, the Ephemerides, Sorbalt, and Vallisneri s speak of urination by the mouth. Arnold relates the history of a case of dysuria in which urine was discharged from the nose, breasts, ears, and umbilicus;h the woman Avas tAventy-seven years old, and the dysuria Avas caused by a prolapsed uterus. There was an instance of anomalous discharge of urine from the body reported in Philadel- phia many years ago AA'hich led to animated discussion.1 A case of dysuria in which the patient discharged urine from the stomach was reported early in a 428, iii., 12 and 14. b 306, L. i., cap. 9. c "Diss, de Ictero." Lipsse, 1696. d779, 1884. e 462, T. viii., 59. f 620, cent, i., obs. 79. 8 796, iii., 338. h Jour. Universal des Sciences, 1829. * 768, i. 383 384 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. this century from Germany.* The patient could feel the accumulation of urine by burning pain in the epigastrium. Suddenly the pain Avould move to the soles of the feet, she Avould become nauseated, and large quantities of urine would soon be vomited. There avus reported the case of an hysterical female Avho had convulsions and mania, alternating Avith anuria of a peculiar nature and lasting seven days. There was not a drop of urine passed during this time, but there were discharges through the mouth of alkaline Avaters Avith a strong ammoniacal odor.b Senter c reports in a young Avoman a singular case of ischuria which con- tinued for more than three years ; during this time if her urine Avas not drawn off with the catheter she frequently voided it by vomiting ; for the last twenty months she passed much gravel by the catheter; when the use of the instru- ment avus omitted or unsuccessfully applied the vomitus contained gravel. Carlisle d mentions a case in Avhich there was vomiting of a fluid containing urea and having the sensible properties of urine. Curious to relate, a cure was effected after ligature of the superior thyroid arteries and sloughing of the thyroid gland. \Tomiting of urine is also mentioned by Coley, Domine, Liron, Malago, Zeviani, and Yeats. Marsdene reports a case in which, following secondary papular syphilis and profuse spontaneous ptyalism, there was vicari- ous secretion of the urinary constituents from the skin. Instances of the anomalous exit of urine caused by congenital malforma- tion or fistulous connections are mentioned in another chapter. Black urine is generally caused by the ingestion of pigmented food or drugs, such as car- bolic acid and the anilines. Amatus Lusitanus, Bartholinus, and the Ephe- merides speak of black urine after eating grapes or damson plums. The Ephemerides speaks of black urine being a precursor of death, but Piso, Rho- dius, and Schenck say it is anomalous and seldom a sign of death. White urine, commonly knoAvn as chyluria, is frequently seen, and sometimes results from purulent cystitis. Though containing sediment, the urine looks as if full of milk. A case of this kind Avas seen in 1895 at the Jefferson Medical Col- lege Hospital, Philadelphia, in which the chyluria Avas due to a communication between the bladder and the thoracic duct. Ackerman has spoken of metastasis of the tears, and Dixonf gives an instance in which crying was not attended by the visible shedding of tears. Salomon^ reports a case of congenital deficiency of tears. Blood-stained tears Avere frequently mentioned by the older writers. Recently Cross h has Avritten an article on this subject, and its analogy is seen in the next chapter under hemorrhages from the eyes through the lacrimal duct. The Semen.—The older Avriters spoke of metastasis of the seminal Aoav, the issue being by the skin (perspiration) and other routes. This was espe- a Allgem. Medic. Annal., Jan., 1815. b 222, 1860, i., 27. c 768, 1793, i., 96. d 476, 1832-1833, ii., 704. e 476, 1857. ii., 519. f 548, 1860, ii., 80. g 175, 1854. h 476, 1891, i., 21. CHROMIDROSIS. 385 cially supposed to be the ease in satyriasis, in which the preternatural exit Avas due to superabundance of semen, AA'hich could be recognized by its odor. There is no doubt that some people have a distinct seminal odor, a fact that will be considered in the section on "Human Odors." The Ephemerides, Schurig,a and Hoffman report instances of Avhat they call fetid semen (possibly a complication of urethral disease). PaaAv speaks of black semen in a negro, and the Ephemerides and Schurig mention instances of dark semen. Blancardb records an instance of preternatural exit of semen by the boAvel. Heers 409 mentions a similar case caused by urethral fistula. Inghamc mentions the escape of semen through the testicle by means of a fistula. Demarquay d is the authority on bloody semen. Andouard e mentions an instance of blue bile in a woman, blue flakes being found in her vomit. There Avas no trace of copper to be found in this case. Andouard says that the older physicians frequently spoke of this occurrence. Rhodiusf speaks of the sweat being sweet after eating honey ; the Eph- emerides and Paullini also mention it. Chromidrosis, or colored sAveat, is an interesting anomaly exemplified in numerous reports. Black sweat has been mentioned by Bartholinus,g who remarked that the secretion resembled ink ; in other cases Galeazzih and Zacutus Lusitanus* said the perspiration resembled sooty Avater. Phosphorescent SAveat has been recorded.J' Paul- lini k and the Ephemerides mention perspiration which was of a leek-green color, and Borellus1 has observed deep green perspiration. Marcard men- tions green perspiration of the feet, possibly due to stains from colored foot- gear. The Ephemerides and Paullinim speak of violet perspiration, and Bartholinus n has described perspiration Avhich in taste resembled wine. Sir Benjamin Brodie ° has communicated the history of a case of a young girl of fifteen on whose face was a black secretion. On attempting to remove it by Avashing, much pain Avas caused. The quantity removed by soap and Avater at one time Avas sufficient to make four basins of water as black as if Avith India ink. It seemed to be physiologically analogous to melanosis. The cessation of the secretion on the forehead was folloAved by the ejection of a similar substance from the bowel, stomach, and kidney. The secretion Avas more abundant during the night, and at one time in its course an erysipelas- eruption made its appearance. A complete cure ultimately followed. Purdon p describes an Irish married Avoman of forty, the subject of rheu- matic feA'er, avIio occasionally had a blue serous discharge or perspiration that literally floAved from her legs and body, and accompanied by a miliary erup- tion. It Avas on the posterior portions, and twelve hours previous was usually a " Spermatologia," 22. b "Op. Med. et Chirurg," T. ii. c Med. Obs. and Inquiries, ii., No. 22. d 363, xxxviii., 217 ; 374. e 349, quoted in 476, i., 1878, 248. f 680, cent, iii., obs. 68. 8 110, i., obs. 70. b "Comment. Bouon.," vi., 60. * 831, L. iii., obs. 73. J 105, x., obs. 95. k 620, cent, i., obs. 38. 1 841, cent, ii., obs. 54. ™ 620, cent, i., obs. 21. n 190, cent, iv., 62. ° 550, 1845, 611. P Jour. Cutan. Med., London, 1868, ii., 247. 25 386 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. preceded by a moldy smell and a prickly sensation. On the abdomen and the back of the neck there Avas a yelloAvish secretion. In place of eatamenia there Avas a discharge reddish-green in color. The patient denied having taken any coloring matter or chemicals to influence the color of her perspira- tion, and no remedy relieved her cardiac or rheumatic symptoms. The first English case of chromidrosis, or colored SAveat, Avas published by Yonge of Plymouth in 1709. In this affection the colored sAveating appears symmetrically in various parts of the body, the parts commonly affected being the cheeks, forehead, side of the nose, Avhole face, chest, abdomen, backs of the hands, finger-tips, and the flexors, flexures at the axillae, groins, and pop- liteal spaces. Although the color is generally black, nearly every color has been recorded. Colcott Foxa reported a genuine case, and Crocker speaks of a case at ShadAvell in a Avoman of forty-seven of naturally dark complexion. The boAvels were habitually sluggish, going three or four days at least Avith- out action, and latterly the Avoman had suffered from articular pains. The discolored SAveat came out gradually, beginning at the sides of the face, then spreading to the cheeks and forehead. When seen, the upper half of the forehead, the temporal regions, and the skin betAveen the ear and malar emi- nence Avere of a blackish-broAvn color, Avith slight hyperemia of the adjacent parts ; the Avoman said the color had been almost black, but she had cleaned her face some. There Avas evidently much fat in the secretion ; there Avas also seborrhea of the scalp. AV ashing Avith soap and Avater had A'cry little effect upon it; but it Avas remoATed Avith ether, the skin still looking darker and redder than normal. After a Aveek's treatment Avith saline purgatives the discoloration Avas much less, but the patient still had articular pains, for which alkalies Avere prescribed; she did not again attend. Crocker also quotes the case of a girl of tAventy, originally under Mackay of Brighton. Her affection had lasted a year and Avas limited to the left cheek and eyebroAV. Six months before the patch appeared she had a superficial burn which did not leaA'e a distinct scar, but the surface avus slightly granular. The deposit avus distinctly fatty, eATidently seborrheic and of a sepia-tint. The girl suf- fered from obstinate constipation, the bowels acting only once a Aveek. The left side flushed more than the right. In connection Avith this case may be mentioned one by AVhite of Harvard, a case of unilateral yelloAV chromi- drosis in a man.b Demons gh'es the history of a case of yellow sAveat in a patient Avith three intestinal calculi. Wilson says that cases of green, yelloAV, and blue perspiration have been seen, and Hebra, Rayer, and Fuchs mention instances. Conradi records a case of blue perspiration on one-half the scrotum. ChojnoAvskic records a case in Avhich the perspiration resembled milk. Hyperidrosis occurs as a symptom in many nerAfous diseases, organic and functional, and its presence is often difficult of explanation. The folloAving a 767, lxvi. b 455, ii.; Nov. 10, 1884. c 657, 1863, ii., 387. HYPERIDROSIS. 387 are recent examples:843 Kustermann reports a case of acute myelitis in which there Avas profuse perspiration above the level of the girdle-sensation and none at all beloAv. Sharkey reports a case of tumor of the pons varolii and left cms cerebri, in Avhich for months there Avas excessive generalized perspiration ; it finally disappeared Avithout treatment. Hutchinson describes the case of a woman of sixty-four avIio for four years had been troubled by excessive sweating on the right side of the face and scalp. At times she Avas also troubled by an excessive flow of saliva, but she could not say if it Avas unilateral. There Avas great irritation of the right side of the tongue, and for tAvo years taste Avas totally abolished. It Avas normal at the time of examina- tion. The author offered no explanation of this case, but the patient gaA'e a decidedly neurotic history, and the symptoms seem to point Avith some degree of probability to hysteria. Pope reports a peculiar case in AA'hich there Avere daily attacks of neuralgia preceded by SAveating confined to a bald spot on the head. RockAvell reports a case of unilateral hyperidrosis in a feeble old man Avhich he thought due to organic affection of the cervical sympathetic. Duponta has published an account of a curious case of chronic general hyperidrosis or profuse sweating Avhich lasted upAvard of six years. The Avoman thus affected became pregnant during this time and Avas happily delhr- ered of an infant, Avhich she nursed herself. According to Dupont, this hyperi- drosis was independent of any other affection, and after having been combated fruitlessly by various remedies, yielded at last to fluid extract of aconitin. Myrtle b relates the case of a man of seventy-seven, Avho, after some flying pains and fever, began to SAveat profusely and continued to do so until he died from exhaustion at the end of three months from the onset of the SAveating. Richardsonc records another case of the same kind. Crocker quotes the case of a tailor of sixty-five inAvhom hyperidrosis had existed for thirty-fiVe years. It Avas usually confined to the hands and feet, but Avhen Avorst affected the whole body. It Avas absent as long as he preserved the horizontal posture, but came on directly Avhen he rose ; it Avas ahvays increased in the summer months. At the height of the attack the man lost appetite and spirit, had a pricking sensation, and sometimes minute red papules appeared all oATer the hand. He had tried almost every variety of treatment, but sulphur did the most good, as it had kept the disease under for twelve months. Latterly, eA^en that failed. Bachman d reports the history of a case of hyperidrosis cured by hypnotism. Unilateral and localized sweating accompanies some forms of nervous disturbance. Mickleehas discussed unilateral SAveating in the general paral- ysis of the insane. Ramskillf reports a case of SAveating on one side of the face in a patient Avho was subject to epileptic convulsions. Tablesg describes a a 458, 1807, T. xxx., 33. b 536, Feb. 25, 1885. c 173, 1885, 191. d Soc. de Biolog., Jan., 1894. e 465, xxiii., 196 ; xxix., 396. f 548, 1866, i., 367. 8 614, xxiv., 1141. 388 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. case of unilateral SAveating Avith proportionate nervous prostration. Bartho- Ioav and Bryan report unilateral SAveating of the head. Cason speaks of uni- lateral sAveating of the head, face, and neck. Elliotson a mentions sAveat from the left half of the body and the left extremities only. Lewis b reports a case of unilateral perspiration Avith an excess of temperature of 3.5° F. in the axilla of the perspiring side. Mills, AVhite, Doav, and Duncan also cite instances of unilateral perspiration. Boquisc describes a case of unilateral perspiration of the skin of the head and face, and instances of complete unilateral perspiration have been frequently recorded by the older Avriters,— Tebure, Marcellus Donatus, Paullini, and Hartmann d discussing it. Hyperi- drosis confined to the hands and feet is quite common. Instances of bloody sweat and " stigmata " have been known through the ages and are most interesting anomalies. In the olden times there were people Avho represented that in their OAvn persons they realized at certain periods the agonies of Gethscmane, as portrayed in medieA'al art, e. g., by pictures of Christ wearing the croAvn of thorns in Pilate's judgment hall. Some of these instances were, perhaps, of the nature of compensatory hemor- rhage, substituting the menses or periodic hemorrhoids, hemoptysis, epis- taxis, etc., or possibly purpura. Extreme religious frenzy or deep emotions might have been the indirect cause of a number of these bleeding zealots. There are instances on record in AA'hich fear and other similar emotions have caused a sweating of blood, the expression " sweating blood" being not uncommon. Among the older writers, Ballonius,e Marcolini, and Riedlin mention bloody SAveat. The Ephemerides speaks of it in front of the hypochondrium. Paullini observed a sailor of thirty, who, falling speechless and faint during a storm on the deck of his ship, sweated a red perspiration from his entire body and Avhich stained his clothes. He also mentions bloody sweat folloAving coitus. Aristotle speaks of bloody sweat, and Pellison describes a scar which periodi- cally opened and sAveated blood. There Avere many cases like this, the scars being usually in the location of Christ's wounds. De Thou mentions an Italian officer Avho in 1552, during the Avar betAveen Henry II. of France and Emperor Charles V., Avas threatened with public execution ; he became so agitated that he sweated blood from every portion of the body. A young Florentine about to be put to death by an order of Pope Sixtus X. was so overcome Avith grief that he shed bloody tears and sAveated blood. The Ephemerides contains many instances of bloody tears and sweat occasioned by extreme fear, more especially fear of death. Mezeray f men- tions that the detestable Charles IX. of France, being under constant agitation and emotion, sank under a disorder Avhich was accompanied by an exudation a 548, 1857, 291. c 462, T. lxxiii., 49. e "Paradigmata," 193. b 809, 1878-79, 284. d "Diss, sudore unius lateris." Hal., 1751. f "Histoire de France," iii., 306. INSTANCES OF BLOODY SWEAT AND "STIGMATA." 389 of blood from every pore of his body. This Avas taken as an attempt of na- ture to cure by bleeding according to the theory of the Arenesectionists. Fabri- cius Hildanus334 mentions a child who, as a rule, never drank anything but Avater, but once, contrary to her habit, drank freely of Avhite wine, and this Avas soon followed by hemorrhage from the gums, nose, and skin. There is a case also related of a woman of forty-fiA'e who had lost her only son. One day she fancied she beheld him beseeching her to release his soul from purgatory by prayers and fasting every Friday. The following Friday, which Avas in the month of August, and for five succeeding Fridays she had a profuse bloody perspiration, the disorder disappearing on Friday, March 8th, of the following year. Pooleya says that Maldonato, in his " Commentaries of Four Gospels," mentions a healthy and robust man who on hearing of his sentence of death SAveated blood, and Zacchias noted a similar phenomenon in a young man condemned to the flames. Allusion may also be made to St. Luke, who said of Christ that in agony He prayed more earnestly, " and His sweat was, as it were, great drops of blood falling down to the ground." b Pooley quotes the case of a young woman of indolent habit who in a relig- ious fanatical trance SAveated blood. The stigmatists were often impostors who artificially opened their scars, and set the example for the really peculiar cases of bloody sweat, which among ignorant people was considered evidence of sympathy Avith the agony of the Cross. Probably the best studied case on record is that of Louise Lateau of Bois d'Haine, which, according to Gray, occurred in 1869 in a village of Belgium when the girl avus at the age of twenty-three; her previous life had offered nothing remarkable. The account is as follows : " One Friday Louise Lateau noticed that blood was flowing from one side of her chest, and this recurred every Friday. On each Thursday morning an o\ral surface about one inch in length on the back of each hand became pink in color and smooth, whilst a similar oval surface on the palm of each hand became of the same hue, and on the upper surface of each foot a pinkish-Avhite square appeared. Exam- ined under a magnifying glass, the epidermis appeared at first Avithout solution of continuity and delicate. About noon on Thursday a vesicle formed on the pink surfaces containing clear serum. In the night between Thursday and Friday, usually betAveen midnight and one o'clock, the flow of blood began, the vesicle first rupturing. The amount of blood lost during the so-called stigmata varied, and some obserA^ers estimated it at about one and three-quarter pints. The blood itself Avas of a reddish color, inclining to violet, about the hue, therefore, of capillary blood, coagulating in the usual way, and the Avhite and red corpuscles being normal in character and relative proportion. The Aoav ceased on Saturdays. During the Aoav of the blood the patient Avas in a rapt, ecstatic condition. The facial expression Avas one of absorption and far-off a 638, 1854, 357 et seq. b St. Luke, xxii., 44. 390 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. contemplation, changing often to melancholy, terror, to an attitude of prayer or contrition. The patient herself stated that at the beginning of the ecstasy she imagined herself surrounded by a brilliant light; figures then passed be- fore her, and the successive scenes of the crucifixion Avere panoramically pro- gressive. She saAV Christ in person—His clothing, His Avounds, His croAvn of thorns, His cross—as well as the Apostles, the holy Avomen, and the assembled Jcavs. During the ecstasy the circulation of the skin and heart Avas regular, although at times a sudden flash or pallor overspread the face, according Avith the play of the expression. From midday of Thursdays, Avhen she took a frugal meal, until eight o'clock on Saturday mornings the girl took no nourish- ment, not eA'en Avater, because it Avas said that she did not feel the Avant of it and could not retain anything upon her stomach. During this time the ordi- nary secretions were suspended." Fournier a mentions a statesman of forty-five Avho, folloAving great Cabinet labors during several years and after some Avorriment, found that the day after indulging in sexual indiscretions he Avould be in a febrile condition, Avith pains in the thighs, groins, legs, and penis. The veins of these parts became en- gorged, and subsequently blood oozed from them, the Aoav lasting several days. The penis Avas the part most affected. He was under observation for tAventy months and presented the same phenomena periodically, except that during the last few months they Avere diminished in every respect. Fournier also mentions a curious case of diapedesis in a woman injured by a coav. The animal struck her in the epigastric region, she fell unconscious, and soon after vomited great quantities of blood, and continued with convulsive efforts of expulsion to eject blood periodically from every eight to fifteen days, losing possibly a pound at each paroxysm. There was no alteration of her menses. A physician ga\re her astringents, Avhich partly suppressed the vomiting, but the hemorrhage changed to the skin, and every day she sweated blood from the chest, back of the thighs, feet, and the extremities of the fingers. AVhen the blood ceased to Aoav from her skin she lost her appetite, became oppressed, and Avas confined to her bed for some days. Itching always preceded the ap- pearance of a new Aoav. There Avas no dermal change that could be noticed. Fullerton b mentions a girl of thirteen Avho had occasional oozing of blood from her broAV, face, and the skin under the eyes. Sometimes a pound of clots AAas found about her face and pilloAV. The blood first appeared in a single clot, and, strange to say, lumps of fieshy substance and minute pieces of bone Avere discharged all day. This latter discharge became more infre- quent, the bone being replaced by cartilaginous substance. There Avas no pain, discoloration, SAvelling, or soreness, and after this strange anomaly dis- appeared menstruation regularly commenced. Van SAvietenc mentions a young lady Avho from her twelfth year at her menstrual periods had hem- orrhages from pustules in the skin, the pustules disappearing in the interval. a 302, iv., 189. b Philadelphia Jour, of Med. and Physical Sciences, 1825. c 755; xii., 86. ANOMALIES IN LACTATION. 391 Schmidt's Jahrbueher for 1836 gives an account of a woman Avho had dis- eased ovaries and a rectovesicovaginal fistula, and though sometimes eata- menia appeared at the proper place it Avas generally arrested and hemorrhage appeared on the face. Chambers a mentions a Avoman of twenty-seven Avho suffered from bloody sAveat after the manner of the stigmatists, and Petrone b mentions a young man of healthy antecedents, the sAA'eat from Avhose axillae and pubes Avas red and ATery pungent. Petrone belieATes it Avas due to a chromogcnic micrococcus, and relieved the patient by the use of a five per cent, solution of caustic potash. Chloroform, ether, and phenol had been tried Avithout success. Hebra 407 mentions a young man in Avhom the blood spurted from the hand in a spiral jet corresponding to the direction of the duct of the SAveat-gland. Wilson826 refers to five cases of bloody sAveat. There is a recordc of a patient Avho once or twice a day Avas attacked Avith SAvelling of the scrotum, AA'hich at length acquired a deep red color and a stony hardness, at Avhich time the blood Avould spring from a hundred points and floAv in the finest streams until the scrotum Avas again empty. Hilld describes a boy of four Avho during the SAveating stage of malaria sAveated blood from the head and neck. Tavo months later the skin-hem- orrhages ceased and the boy died, A'omiting blood and Avith bloody stools. Postmortem sweating is described in the Ephemerides and reported by Ilaseneste and Schneider. Bartholinusf speaks of bloody SAveat in a cadaver. In considering the anomalies of lactation Ave shall first discuss those of color and then the extraordinary places of secretion. Black milk is spoken of by the Ephemerides and Paullini. Red milk has been observed by Cramer and Viger.s Green milk has been observed by Lanzonius, Riverius,687 and Paullini.620 The Ephemerides also contains an account of green milk. Yellow milk has been mentioned in the Ephemerides and its cause ascribed to eating rhubarb. It is a Avell-knoAvn fact that some cathartics administered to nursing mothers are taken from the breast by their infants, Avho, notAvithstanding its indirect mode of administration, exhibit the effects of the original drug. The same is the case Avith some poisons, and instances of lead-poisoning and arsenic-poisoning luwe been seen in children Avho have obtained the toxic sub- stance in the mother's milk. There is one singular case on record in which a child has been poisoned from the milk of its mother after she had been bitten by a serpent.h Paullini and the Ephemerides give instances of milk appearing in the per- spiration, and there are numerous varieties of milk-metastasis recorded. Doheus and Xuck * mention the appearance of milk in the saliAra. Auten- reith mentions metastasis of milk through an abdominal abscess to the thigh, « 476, 1S61. b 747. Xov., 1884. c 504, xviii. d SO!), 1S79-S0. e 406, iii., 44. f 189, Epis. i., 718. 8 462, T. xxxii., 222, and T. xxv., 62. b 463, xii., 455. * "Sialographia," 49. 392 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. and Balthazaar also mentions excretion of milk from the thigh. Bourdon 4T0 mentions milk from the thigh, labia, and vulva. Kleina speaks of the metastasis of the milk to the lochia. Gardane367 speaks of metastasis to the lungs, and there is another case on record in which this phenomenon caused asphyxia. Schenck b describes excretion of milk from the bladder and uterus. Jaeger in 1770 at Tubingen describes the metastasis of milk to the umbili- cus, Haen395to the back, and Schurig 724 to a Avound in the foot. Knack- stedt has seen an abscess of the thigh Avhich contained eight pounds of milk. Hauserc gives the history of a case in Avhich the kidneys secreted milk vicari- ously. There is the history of a AA'oman who suffered from metastasis of milk to the stomach, and Avho, with convulsive action of the chest and abdomen, vomited it daily.d A peculiar instance of milk in a tumor is that of a Mrs. Reed, Avho, Avhen pregnant with twins, developed an abdominal tumor from which 25 pounds of milk Avas drawn off.e There is a French reportf of secretion of milk in the scrotum of a man of tAventy-one. The scrotum Avas tumefied, and to the touch gave the sensa- tion of a human breast, and the parts were pigmented similar to an engorged breast. Analysis showed the secretion to have been true human milk. Cases of lactation in the new-born are not infrequent. Bartholinus, Baricelli, Muraltus, Deusingius, Rhodius, Schenck, and Schurig mention instances of it. Cardanus describes an infant of one month whose breasts were swollen and gave milk copiously. Battersbyg cites a description of a male child three Aveeks old whose breasts Avere full of a fiuid, analysis proving it to have been human milk ; Darby, in the same journal, mentions a child of eight days whose breasts were so engorged that the nurse had to milk it. Fayeh gives an interesting paper in which he has collected many instances of milk in the breasts of the new-born. Jonstoni details a description of lacta- tion in an infant. Variotj mentions milk-secretion in the new-born and says that it generally takes place from the eighth to the fifteenth day and not in the first Aveek. He also adds that probably mammary abscesses in the neAV-born could be avoided if the milk were squeezed out of the breasts in the first days. Variot says that out of 32 children of both sexes, aged from six to nine months, all but six shoAved the presence of milk in the breasts. Gibb k mentions copious milk-secretion in an infant, and Sworder! and Menardm haA'e seen young babes Avith abundant milk-secretion. Precocious Lactation.—Bochutn says that he saw a child whose breasts were large and completely developed, offering a striking contrast to the slight development of the thorax. They were as large as a stout man's fist, pear- a 490, L. v., 202. b 718, L. ii., No. 285. c Oglethorpe, Med. and Surg. Jour., Savannah, Ga., 1859-60, ii., 408. d Allgem. Medic. Annal., Jan., 1815. e 218, 1833, vii., 13. f 368, 1835. g 312, 1850. b602, 1876, viii., 1-10. i 447, 461. J 237, July 25, 1890. M76, 1859. 1 536, 1877, 348. m233, 1839, iv., 77. n 363, 1878. LACTATION IN THE AGED. 393 shaped, Avith a rosy areola, in the center of which Avas a nipple. These pre- cocious breasts increased in size at the beginning of the menstrual epoch (which Avas also present) and remained enlarged while the menses lasted. The vulva AAas covered Avith thick hair and the external genitalia were well developed. The child was reticent, and with a doll was inclined to play the role of mother. Baudelocque mentions a girl of eight who suckled her brother with her extraordinarily developed breasts. In 1783 this child milked her breasts in the presence of the Royal Academy at Paris. Belloc spoke of a similar case. There is another of a young negress who was able to nourish an infant ;a and among the older writers we read accounts of young virgins who induced lacta- tion by applying infants to their breasts. Bartholinus, Benedictus, Hippocrates, Lentilius, Salmuth, and Schenck mention lactation in virgins. De la Coide describes a case in which lactation was present, though menstruation had always been deficient. Dix, at the Derby Infirmary,b has obserA'ed tAvo females in Avhom there was continued lactation, although they had never been pregnant. The first was a chaste female of twenty-five, avIio for tAvo years had abundant and spontaneous discharge of milk that Averted the linen ; and the other was in a prostitute of tAventy, who had never been preg- nant, but Avho had, nevertheless, for several months an abundant secretion of healthy milk. Zoologists knoAV that a nonpregnant bitch may secrete milk in abundance. Delafond and de Sinnety have cited instances. Lactation in the aged has been frequently noticed. Amatus Lusi- tanus119 and Schenck have observed lactation in old women ; in recent years Dunglison has collected some instances. Semple c relates the history of an elderly Avoman Avho took charge of an infant the mother of which had died of puerperal infection. As a means of soothing the child she allowed it to take the nipple, and, strange to say, in thirty-six hours milk appeared in her breasts, and soon she had a Aow as copious as she had ever had in her early married life. The child thrived on this production of a sympathetic and spontaneous lactation. Sir Hans Sloane mentions a lady of sixty-eight Avho, though not having borne a child for tAventy years, nursed her grandchildren, one after another. Montegre367 describes a Avoman in the Department of Charente who bore Iavo male children in 1810. Not having enough milk for both, and being too poor to secure the assistance of a michvife, in her desperation she sought an old Avoman named Laverge, a widoAV of sixty-five, Avhose husband had been dead twenty- nine years. This old Avoman gave the breast to one of the children, and in a Icav days an abundant Aow of milk Avas present. For twenty-tAvo months she nursed the infant, and it thrived as well as its brother, who was nursed by their common mother—in fact, it was even the stronger of the two. Dargan d tells of a case of remarkable rejuvenated lactation in a Avoman of a 302, xxx., 386. b 548, 1856, i., 89. c 629, ix., 1674. <* 264, 1874. 394 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. sixty, Avho, in play, placed the child to her breast, and to her surprise after three Aveeks' nursing of this kind there appeared an abundant supply of milk, even exceeding in amount that of the young mother. Blanchard a mentions milk in the breasts of a Avoman of sixty, and Krane b cites a similar instance. In the Philosophical Transactions c there is an in- stance of a Avoman of sixty-eight having abundant lactation. AVarren, Boring, Buzzi, Stack, Durston, Egan, Scalzi, Fitzpatrick, and Gillespie mention rejiwenation and reneAved lactation in aged Avomen. Ford'1 has collected several cases in AA'hich lactation Avas artificially induced by Avomen avIio, though for some time not haA'ing been pregnant theiiiseh'es, nursed for others. Prolonged lactation and galactorrhea may extend through several pregnancies. Greene reports the case of a Avoman of forty-seven, the mother of four children, Avho after each Aveaning had so much milk constantly in her breasts that it had to be drawn until the next birth. At the time of report the milk Avas still secreting in abundance. A similar and oft-quoted case Avas that of Gomez Pamo,f Avho described a woman in Avhom lactation seemed in- definitely prolonged ; she married at sixteen, tAvo years after the establishment of menstruation. She became pregnant shortly after marriage, and after de- livery had continued lactation for a year Avithout any sign of returning men- struation. Again becoming pregnant, she Aveaned her first child and nursed the other without delay or complication. This occurrence took place fourteen times. She nursed all 14 of her children up to the time that she found her- self pregnant again, and during the pregnancies after the first the flow of milk never entirely ceased ; ahvays after the birth of an infant she was able to nurse it. The milk was of good quality and always abundant, and during the period between her first pregnancy to seA'en years after the birth of her last child the menses had never reappeared. She weaned her last child five years before the time of report, and since then the milk had still persisted in spite of all treatment. It Avas sometimes so abundant as to necessitate draw- ing it from the breast to relieve painful tension. Kennedy « describes a Avoman of eighty-one Avho persistently menstruated through lactation, and for forty-seA'en years had uninterruptedly nursed manv children, some of which were not her own. Three years of this time she Avas a AvidoAV. At the last reports she had a moderate but regular secretion of milk in her eighty-first year. In regard to profuse lacteal flow, Remy is quoted b as having seen a young Avoman in Japan from Avhom Avas taken 12^ pints of milk each day, Avhich is possibly one of the most extreme instance of continued galactorrhea on record. Galen refers to gynecomastia or gynecomazia; Aristotle says he has a 213, cent, ii., No. 83. b 452, L. v., 243. c 629, No. 453. d 579, 1869, 39. e 594, 1844, 188. t Quoted 494, Aug. 4, 1883. g 549, 1832. b 548, 1883 ii., 581. GYNECOMAZIA. 395 seen men Avith mammas a Avhich Avere as Avell deA7eloped as those of a Avoman, and Paulus iEgineta recognized the fact in the ancient Greeks. Subsequently Albucasis discusses it in his Avritings. Bartholinus, Behr, Benedictus, Borel- lus, Bonet, the Ephemerides, Marcellus Donatus, Schenck, Vcsalius, Schacher, Alartineau, and Buffon all discuss the anomalous presence of milk in the male breast. Puech says that this condition is found in one out of 13,000 con- scripts. To Bedor, a marine surgeon,1' Ave owe the first scientific exposition of this subject, and a little later Villeneuve published his article in the French dic- tionary.302 Since then many observations have been made on this subject, and quite recently Laurent479 has published a most exhaustive treatise upon it. Robert c describes an old man avIio suckled a child, and Meyer discusses the case of a castrated man Avho was said to suckle chil- dren. It is said that a Bishop of Cork, Avho gave one-half croAvn to an old Frenchman of seventy, AA'as reAvarded by an exhibition of his breasts, Avhich were larger than the Bishop had ever seen in a Avoman. Petrequin speaks of a male breast 18 inches long AA'hich he amputated, and Laurent gives the photograph of a man Avhose breasts measured 30 cm. in cir- cumference at the base, and hung like those of a nursing Avoman (Fig. 178). In some instances Avhole families Avith supernumerary breasts are seen. Handyside gives tAvo instances of quadruple breasts in brothers. Blanchard d speaks of a father Avho had a supernumerary nipple on each breast and his seven sons had the same deformities ; it Avas not noticed in the daughters. The youngest son transmitted this anomaly to his four sons. Petrequine describes a man with three mamma;, tAvo on the left side, the third being beneath the others. He had three sons Avith accessory mamma? on the right side and two daughters Avith the same anomaly on the left side. Savitzkyf reports a case of gynecomazia in a peasant of twenty-one Avhose father, elder brother, and a cousin Avere similarly endoAved. The patient's breasts Avere 33 cm. in circum- a 169, " Hist, animal.," lib. iii., chap. xx. b 461, Oct., 1812. c 629, No. 461. d 243, 1886, 485. e 368, 1837, 195. f 703, Feb., 1894. Fig. 178.—Alan with fully-developed mammse (Laurent). 396 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. ference and 15 cm. from the nipple to the base of the gland ; they resembled normal female mammae in all respects. The penis and the other genitalia Avere normal, but the man had a female A'oicc and absence of facial hair. There was an abundance of subcutaneous fat and a rather broad pelvis. AViltshire a said that he kneAV a gynoeomast in the person of a distinguished naturalist av ho since the age of puberty obseiwed activity in his breasts, accom- panied Avith secretion of milky fluid which lasted for a period of six Aveeks and occurred every spring. This authority also mentions that the French call husbands AA'ho have well-deA'eloped mammse "la couvade;" the Germans call male supernumerary breasts " bauchwarze," or ventral nipples. Hutchinson b describes seA'eral cases of gynecomazia, in Avhich the external genital organs decreased in propor- tion to the size of the breast and the manners became effeminate. Cameron, quoted by Sned- don, speaks of a felloAv-student Avho had a super- numerary nipple, and also says he saw a case in a little boy who had an extra pair of nipples much Avider than the ordinary ones. Ansiaux, surgeon of Liege, saAV a conscript of thirteen whose left mamma Avas well developed like that of a woman, and whose nipple was surrounded by a large are- ola. He said that this breast had always been larger than the other, but since puberty had grown greatly; the genital organs were well formed. Morgan c examined a seaman of tAventy- one, admitted to the Royal Naval Hospital at Hong Kong, whose right mamma, in size and conformation, had the appearance of the well- developed breast of a full-groAvn Avoman. It Avas lobulated and had a large, brown-colored areola; the nipple, however, Avas of the same size as that on the left breast (Fig. 179). The man stated that he first ob- served the breast to enlarge at sixteen and a half years ; since that time it had steadily increased, but there Avas no milk at any time from the nipple ; the external genital organs Avere well and fully developed. He complained of no pain or uneasiness except when in drilling aloft his breast came in contact Avith the ropes. Gruger of St. Petersburg d divides gynecomazia into three classes :— (1) That in Avhich the male generative organs are normal; (2) In AA'hich they are deformed ; (3) In Avhich the anomaly is spurious, the breast being a mass of fat or a neAV growth. a 224,1884, i., 654. b ]66, iii., 326. o 476,1875, ii., 767. d Quoted 224, 1886, ii., 172. Fig. 179.—Abnormal development of right breast in a young man (Morgan). MEN SUCKLING INFANTS. 397 The same journal quotes an instance (possibly Morgan's case) in a young man of tAventy-one Avith a deep voice, excellent health, and genitals well developed, and Avho cohabited with his Avife regularly. AVhen sixteen his right breast be- gan to enlarge, a fact that he attributed to the pressure of a rope. Glandular substance could be distinctly felt, but there was no milk-secretion. The left breast Avas normal. Schuchardt has collected 272 cases of gynecomazia. Instances of Men Suckling Infants.—These instances of gynecomazia are particularly interesting when the individuals display ability to suckle in- fants. Hunter refers to a man of fifty who shared equally with his wife the suckling of their children. There is an instance of a sailor avIio, having lost his wife, took his son to his oavii breast to quiet him, and after three or four days was able to nourish him.a Humboldt describes a South American peasant of thirty-tAvo who, Avhen his wife fell sick immediately after delivery, sustained the child with his own milk, which came soon after the application to the breast; for five months the child took no other nourishment. In Franklin's " Voyages to the Polar Seas " he quotes the instance of an old Chippewa who, on losing his wife in childbirth, had put his infant to his breast and earnestly prayed that milk might Aoav ; he Avas fortunate enough to eventually produce enough milk to rear the child. The left breast, with which he nursed, afterward retained its unusual size. According to Mehliss some missionaries in Brazil in the six- teenth century asserted that there Avas a whole Indian nation Avhose Avomen had small and withered breasts, and Avhose children owed their nourishment entirely to the males. Hall exhibited to his class in Baltimore a negro of fifty-five who had suckled all his mistress' family. Dunglison reports this case in 1837, and says that the mammae projected seven inches from the chest, and that the external genital organs Avere well developed. Paullini and Schenck cite cases of men suckling infants, and Blumenbach has described a male-goat Avhich, on account of the engorgement of the mammae, it Avas neces- sary to milk every other day of the year. Fordb mentions the case of a captain Avho in order to soothe a child's cries put it to his breast, and avIio subsequently developed a full supply of milk. He also quotes an instance of a man suckling his own children, and mentions a negro boy of fourteen Avho secreted milk in one breast. Hornor and Pulido y Fernandez c also mention similar instances of gynecomazia. Human Odors.—Curious as it may seem, each individual as well as each species is in life emreloped Avith an odor peculiarly its own, due to its exhaled breath, its excretions, and principally to its insensible perspiration. The fac- ulty of recognizing an odor in different individuals, although more developed in savage tribes, is by no means unknown in civilized society. Fournier quotes the instance of a young man who, like a dog, could smell the enemy by scent, and Avho by smell alone recognized his own Avife from other persons. d a 302, xxx., 384. b 579, 169, 39. c Iudepend. raed., Barcel., xi., 274, 297, 309. d302, iv. 398 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Fournier alsoa mentions a French Avoman, an inhabitant of Naples, avIio had an extreme supersensitiveness of smell. The slightest odor was to her intoler- able ; sometimes she could not tolerate the presence of certain individuals. She could tell in a numerous circle Avhich Avomen Avere menstruating. This Avoman could not sleep in a bed Avhich any one else had made, and for this reason discharged her maid, preparing her OAvn toilet and her sleeping apart- ments. Cadet de Gassicourt Avitnessed this peculiar instance, and in con- sultation with several of the physicians of Paris attributed this excessive sensitiveness to the climate. There is a tale told of a Hungarian monk4,!;) who affirmed that he Avas able to decide the chastity of females by the sense of smell alone. It is avcII known that some savage tribes Avith their large, open nostrils not only recognize their enemies but also track game the same as hounds. Individual Odors.—Many individuals are said to have exhaled particu- larly strong odors, and history is full of such instances. AVe are told by Plutarch that Alexander the Great exhaled an odor similar to that of A'iolet floAvers, and his undergarments always smelled of this natural perfume. It is said that Cujas offered a particular analogy to this. On the contrary, there are certain persons spoken of Avho exhaled a sulphurous odor. Martial509 said that Thais was an example of the class of people Avhose odor Avas insupportable. Schmidt has inserted in the Ephemerides an account of a journeyman sad- dler, tAventy-three years of age, of rather robust constitution, AA'hose hands exhaled a smell of sulphur so powerful and penetrating as to rapidly fill any room in Avhich he happened to be. Rayer was once consulted by a valet-de- chambre who could never keep a place in consequence of the odor he left behind him in the rooms in Avhich he worked. Hammond b is quoted with saying that AAdien the blessed Venturni of Ber- gamons officiated at the altar people struggled to come near him in order to enjoy the odor he exhaled. It was said that St. Francis de Paul, after he had subjected himself to frequent disciplinary inflictions, including a fast of thirty- eight to forty days, exhaled a most sensible and delicious odor. Hammond attributes the peculiar odors of the saints of earlier days to neglect of Avashing and, in a measure, to affections of the nervous system. It may be added that these odors were augmented by aromatics, incense, etc., artifically applied. In more modern times Malherbe and Haller were said to diffuse from their bodies the agreeable odor of musk. These " human floAvers," to use Goethe's expres- sion, are more highly perfumed in Southern latitudes. Modifying Causes.—According to Brieude, sex, age, climate, habits, ail- ments, the passions, the emotions, and the occupations modify the difference in the humors exhaled, resulting in necessarily different odors. Xursing infants have a peculiar sourish smell, caused by the butyric acid of the milk, Avhile bottle- fed children smell like strong butter. After being weaned the odors of the a 302, iv., 96. b 491 f 1878, 279. HUMAN ODORS. 399 babies become less decided. Boys when they reach puberty exhibit peculiar odors which are similar to those of animals when in heat. These odors are leading symptoms of Avhat Borden calls " seminal fever" and are more strongly marked in those of a voluptuous nature. They are said to be caused by the absorption of spermatic fluid into* the circulation and its subsequent elimination by the skin. This peculiar circumstance, however, is not seen in girls, in Avhom menstruation is sometimes to be distinguished by an odor someAvhat similar to that of leather. Old age produces an odor similar to that of dry leaves, and there haA'e been persons who declared that they could tell approximately the age of indh'iduals by the sense of smell. Certain tribes and races of people have characteristic odors. Ne- groes have a rank ammoniacal odor, unmitigated by cleanliness; according to Pruner-Bey it is due to a volatile oil set free by the sebaceous follicles. The Esquimaux and Greenlanders have the odors of their greasy and oily foods, and it is said that the Cossacks, avIio live much Avith their horses, and Avho are principally vegetarians, will leave the atmosphere charged with odors several hours after their passage in numbers through a neighborhood. The lower race of Chinamen are distinguished by a peculiar musty odor, Avhich may be noticed in the laundry shops of this country. Some people, such as the low grade of Indians, have odors, not distinctive, and solely due to the filth of their persons. Food and drink, as haA7e been mentioned, markedly influence the odor of an individual, and those perpetually addicted to a special diet or drink have a particular odor. Odor after Coitus.—Preismann in 1877 makes the statement that for six hours after coitus there is a peculiar odor noticeable in the breath, owing to a peculiar secretion of the buccal glands. He says that this odor is most perceptible in men of about thirty-five, and can be discerned at a distance of from four to six feet. He also adds that this fact would be of great medico- legal value in the early arrest of those charged with rape. In this connection the analogy of the breath immediately after coitus to the odor of chloroform has been mentioned.a The same article states that after coitus naturally foul breath becomes sAveet. The emotions are said to have a decided influence on the odor of an individual. Gambrini, quoted by Monin,b mentions a young man, unfortunate in love and violently jealous, whose Avhole body exhaled a sickening, pernicious, and fetid odor. Orteschi met a young lady Avho, Avithout any possibility of fraud, exhaled the strong odor of vanilla from the commissures of her fingers. Rayer speaks of a woman under his care at the Hopital de la Charite affected Avith chronic peritonitis, Avho some time before her death exhaled a very decided odor of musk. The smell had been noticed several days, but was thought to be due to a bag of musk put purposely into the bed to overpower other bad smells. The woman, however, gave full assurance that she had no a 536, 1883, i., 374. b "Sur les Odeurs du Corps Humain." Paris, 1885. 400 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. kind of perfume about her and that her clothes had been frequently changed. The odor of musk in this case Avas A'ery perceptible on the arms and other portions of the body, but did not become more poAverful by friction. Alter continuing for about eight days it greAV fainter and nearly A'anished before the patient's death. Speranzaa relates a similar case. Complexion.—Pare618 states that persons of red hair and freckled com- plexion have a noxious exhalation; the odor of prussic acid is said to come from dark individuals, while blondes exhale a secretion resembling musk. Fat persons frequently have an oleaginous smell. The disorders of the nervous system are said to be associated with peculiar odors. Fevre says the odor of the sweat of lunatics resembles that of yelloAV deer or mice, and Knight remarks that the absence of this symptom Avould enable him to tell Avhether insanity was feigned or not. Bur- toavs declares that in the absence of further evidence he Avould not hesitate to pronounce a person insane if he could perceive certain associate odors. Sir William Gull and others arc credited with asserting that they could detect syphilis by smell. Weir Mitchell has observed that in lesions of nerves the corresponding cutaneous area exhaled the odor of stagnant water. Hammond refers to three cases under his notice in which specific odors Avere the results of affections of the nervous system. One of these cases Avas a young Avoman of hysterical tendencies who exhaled the odor of violets, which peiwaded her apartments. This odor Avas given off the left half of the chest only ami could be obtained concentrated by collecting the perspiration on a handker- chief, heating it Avith four ounces of spirit, and distilling the remaining mixture. The administration of the salicylate of soda modified in degree this violaceous odor. Hammond also speaks of a young lady subject to chorea Avhose insensible perspiration had an odor of pineapples; a hypochondriac gentleman under his care smelled of violets. In this connection he mentions a young Avoman avIio, when suffering from intense sick headache, exhaled an odor resembling that of Limburger cheese. Barbier met a case of disordered innervation in a captain of infantry, the upper half of Avhose body was subject to such offensive perspiration that despite all treatment he had to finally resign his commission. In lethargy and catalepsy the perspiration \^ery often has a cadaverous odor, Avhich has probably occasionally led to a mistaken diagnosis of death. Schaper and de Meara517 speak of persons having a cadaveric odor during their entire life. Various ingesta readily give evidence of themselves by their influence upon the breath. It has been remarked that the breath of individuals Avho have recently performed a prolonged necropsy smells for some hours of the odor of the cadaver. Such things as copaiba, cubebs, sandalwood, alcohol, coffee, etc., have their recognizable fragrance. There is an instance of a a 162, T. xxx., 399. ODORS OF DISEASES. 401 young woman taking Fowler's solution who had periodic offensive axillary sAveats that ceased Avhen the medicine Avas discontinued. Henry of Navarre Avas a victim of bromidrosis; proximity to him Avas insufferable to his courtiers and mistresses, Avho said that his odor was like that of carrion. Tallemant says that when his wife, Marie de Medicis, approached the bridal night Avith him she perfumed her apartments and her person Avith the essences of the floAvers of her country in order that she might be spared the disgusting odor of her spouse. Some persons are afflicted Avith an excessive perspiration of the feet which often takes a disgusting odor. The inguinoscrotal and inguinovulvar perspirations have an aromatic odor like that of the genitals of either sex. During menstruation, hyperidrosis of the axillae diffuses an aromatic odor similar to that of acids or chloroform, and in suppression of menses, according to the Ephemerides, the odor is as of hops. Odors of Disease.—The various diseases have their own peculiar odors. The " hospital odor," so well known, is essentially variable in character and chiefly due to an aggregation of cutaneous exhalations. The wards containing women and children are perfumed Avith butyric acid, while those containing men are influenced by the presence of alkalies like ammonia. Gout, icterus, and even cholera (Drasch and Porker) have their own odors. Older observers, confirmed by Doppner, say that all the plague-patients at Vetlianka diffused an odor of honey. In diabetes there is a marked odor of apples. The SAveat in dysentery unmistakably bears the odor of the dejecta. Behier calls the odor of typhoid that of the blood, and Berard says that it attracts flies even before death. Typhus has a mouse-like odor, and the fol- loAving diseases have at different times been described as having peculiar odors,—measles, the smell of freshly plucked feathers; scarlatina, of bread hot from the o\'en; eczema and impetigo, the smell of mold ; and rupia, a decidedly offensh'e odor. The hair has peculiar odors, differing in individuals. The hair of the Chinese is knoAvn to have the odor of musk, which cannot be washed away by the strongest of chemicals. Often the distinctive odor of a female is really due to the odor of great masses of hair. It is said that wig-makers simply by the sense of smell can tell Avhether hair has been cut from the living head or from combings, as hair loses its odor Avhen it falls out. In the paroxysms of hysteroepilepsy the hair sometimes has a specific odor of ozone. Taenia favosa gives to the scalp an odor resembling that of cat's urine. Sexual Influence of Odors.—In this connection it may be mentioned that there is a peculiar form of sexual perversion, called by Binet " fetich- ism," in Avhich the subject displays a perverted taste for the odors of hand- kerchiefs, shoes, underclothing, and other articles of raiment Avorn by the opposite sex. Binet maintains that these articles play the part of the " fetich " in early theology. It is said that the favors given by the ladies to the knights 26 402 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. in the Middle Ages Avere not only tokens of remembrance and appreciation, but sexual excitants as avcII. In his remarkable " Osphresiologie," Cloquet calls attention to the sexual pleasure excited by the odors of floAvers, and tells hoAV Richelieu excited his sexual functions by living in an atmosphere loaded Avith these perfumes. In the Orient the harems are perfumed with intense extracts and floAvers, in accordance with the strong belief in the aphrodisiac effect of odors. Krafft-Ebinga quotes several interesting cases in Avhich the connection betAveen the olfactory and sexual functions is strikingly verified. " The case of Henry III. sIioavs that contact Avith a person's perspiration may be the exciting cause of passionate love. At the betrothal feast of the King of Navarre and Margaret of Valois he accidentally dried his face with a garment of Maria of Cleves AA'hich Avas moist Avith her perspiration. Although she Avas the bride of the Prince of Conde, Henry immediately con- ceived such a passion for her that he could not resist it, and, as history sIioavs, made her very unhappy. An analogous instance is related of Henry IV., Avhose passion for the beautiful Gabrielle is said to have originated at the instant when, at a ball, he Aviped his brow Avith her handkerchief." Krafft-Ebing also says that " one learns from reading the work of Ploss (' Das AVeib ') that attempts to attract a person of the opposite sex by means of the perspiration may be discerned in many forms in popular psychology. In reference to this a custom is remarkable which holds among the natives of the Philippine Islands when they become engaged. AVhen it becomes neces- sary for the engaged pair to separate they exchange articles of Avearing apparel, bv means of which each becomes assured of faithfulness. These objects are carefully preserved, covered Avith kisses, and smelled." The love of perfumes by libertines and prostitutes, as well as sensual women of the higher classes, is quite marked. Heschl reported a case of a man of forty-fiA^e in Avhom absence of the olfactory sense Avas associated Avith imperfect deArelopment of the genitals ; it is also well knoAvn that olfactory hallucinations are frequently associated Avith psychoses of an erotic type. Gamier b has recently collected a number of obseiwations of fetichism, in which he mentions individuals Avho have taken sexual satisfaction from the odors of shoes, night-dresses, bonnets, draAvers, menstrual napkins, and other objects of the female toilet. He also mentions creatures who have gloated over the odors of the blood and excretions from the bodies of Avomen, and gives instances of fetichism of persons Avho have been arrested in the streets of Paris for clipping the long hair from young girls. There are also on record instances of homosexual fetichism, a type of disgusting inversion of the sexual instinct, AA'hich, hoAveA'er, it is not in the proA'ince of this Avork to discuss. Among animals the influence of the olfactory perceptions on the sexual sense is unmistakable. According to Krafft-Ebing, Althaus sIioavs that ani- a "Psychopathia Sexualis." b 'Les Fetichistes," etc. Paris, 1896. BULIMIA. 403 mals of opposite sexes are draAvn to each other by means of olfactory percep- tions, and that almost all animals at the time of rutting emit a A'ery strong odor from their genitals. It is said that the dog is attracted in this Avay to the bitch seA'eral miles aAvay. An experiment by Schiff is confirmatory. He extir- pated the olfactory nerA'cs of puppies, and found that as they greAV the male Avas unable to distinguish the female. Certain animals, such as the musk-ox, civet-cat, and beaver, possess glands on their sexual organs that secrete mate- rials having a very strong odor. Musk, a substance possessing the most pene- trating odor and used in therapeutics, is obtained from the preputial follicles of the musk-deer of Thibet; and castor, a substance less penetrating, is ob- tained from the preputial sacs of the beaver. Virgin moths (Bombyx) carried in boxes in the pockets of entomologists will on Avide commons cause the appearance of males of the same species. Bulimia is excessive morbid hunger, also called canine appetite. AVhile sometimes present in healthy people, it is most often seen in idiots and the insane, and is a symptom of diabetes mellitus. Mortimer a mentions a boy of twelve Avho, while laboring under this affliction, in six days devoured food to the extent of 384 pounds and tAvo ounces. He constantly A'omited, but his craving for food Avas so insatiable that if not satisfied he would devour the flesh off his OAvn bones. Martyn,b Professor of Botany at Cambridge in the early part of the last century, tells of a boy ten years old Avhose appetite Avas enormous. He consumed in one week 373 pounds of food and drink. His urine and stools Avere \roided in normal quantities, the excess being A'omited. A pig avus fed on Avhat he Aromited, and Avas sold in the market. The boy continued in this condition for a year, and at last reports AA'as fast failing. Burroughs c mentions a laborer at Stanton, near Bury, AA'ho ate an ordinary leg of A'eal at a meal, and fed at this extraATagant rate for many days together. He Avould eat thistles and other similar herbs greedily. At times he Avould A'oid Avorms as large as the shank of a clay-pipe, and then for a short period the bulimia Avould disappear. Johnstond mentions a case of bulimia in a man Avho ckwoured large quantities of raAV flesh. There is an instance on recorde of a case of canine appetite in Avhich nearly 400 pounds of solid and fluid elements Avere taken into the body in six days and again ejected. A recoA'ery Avas effected by gh'ing A'ery concentrated food, frequently repeated in small quantities. Masonf mentions a Avoman in St. BartholomeAv's Hospital in London in the early part of this century Avho Avas Avretched unless she Avas ahvays eating. Each day she consumed three quartern-loaves, three pounds of beef-steak, in addition to large quantities of A'egetables, meal, etc., and Avater. Smith « describes a boy of fourteen avIio ate continuously fifteen hours out of the tAventy-four, and who had eight boAvel movements each day. One year preA'ious his weight a 629, 1743. 1066. b 629, 1743. c 629, No. 598. d 535, 1800, iii., 209. e 564. iii., 501. f 476, 1870, i., 701. 8 545, 1880, xiii., 385. 404 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES AA'as 105 pounds, but Avhen last seen he Aveighed 284 pounds and Avas increas- ing a half pound daily. Despite his continuous eating, this boy constantly complained of hunger. Polydipsia is an abnormal thirst; it may be seen in persons otherAvise normal, or it may be associated Avith diseases—such as diabetes mellitus or diabetes insipidus. Mackenziea quotes a case from Trousseau, in Avhich an indhddual afflicted with diabetes insipidus passed 32 liters of urine daily and drank enormous quantities of Avater. This patient subjected himself to severe regimen for eight months,—although one day, in his agonies, he seized the chamber-pot and drank its contents at once. Mackenzie also mentions an infant of three Avho had polydipsia from birth and drank daily nearly two pailfuls of Avater. At the age of tAventy-tAvo she married a cobbler, unaAvare of her propensity, Avho found that his earnings did not suffice to keep her in Avater alone, and he Avas compelled to melt ice and suoav for her. She drank four pailfuls a day, the price being 12 sous; water in the community was scarce and had to be bought. This Avoman bore 11 children. At the age of forty she appeared before a scientific commission and drank in their presence 14 quarts of Avater in ten hours and passed ten quarts of almost colorless urine. Dickinson mentions that he has had patients in his OAvn practice who drank their OAvn urine. Mackenzie also quotes Trousseau's history of a man Avho drank a liter of strong French brandy in two hours, and habitually drank the same quantity daily. He stated that he Avas free from the effects of alcohol; on several occasions on a Avager he took 20 liters of wine, gaining his wager AA'ithout A'isibly affecting his nervous system. There is an instance of a man of fifty-eightb who could not live through the night Avithout a pail of Avater, although his health Avas otherAvise good. Atkinson in 1856 reported a young man who in childhood was a dirt- eater, though at that time complaining of nothing but excessive thirst. He Avas active, industrious, enjoyed good health, and was not addicted to alcoholics. His daily ration of Avater was from eight to twelve gallons. He ahvays placed a tub of Avater by his bed at night, but this sometimes proved insufficient. He had frequently driven hogs from mudholes to slake his thirst AA-ith the Avater. He married in 1829 and moved into "Western Ten- nessee, and in 1854 he Avas still drinking the accustomed amount; and at this time he had grown-up children. AVarec mentions a young man of tAventy Avho drank six gallons of Avater daily. He Avas tormented Avith thirst, and if he abstained he became Aveak, sick, and dizzy. Throughout a long life he continued his habit, sometimes drinking a gallon at one draught; he never used spirits. There are three cases of polydipsia reported from London in 1792.d Fielde describes a boy Avith bilious remittent fever who Avould drink until a 548, 1*78, ii., 268. b 218, 1856. c 589, 1815. d528, 1792. e Western Jour. Med., 1869, iv., 714. PERVERTED APPETITES. 405 his stomach Avas completely distended and then call for more. Emesis Avas folloAved by cries for more Avater. Becoming frantic, he Avould jump from his bed and struggle for the Avater bucket; failing in this, he ran to the kitchen and drank soapsuds, dish-water, and any other liquid he could find. He had sAvalloAved a mass of mackerel which he had not properly masticated, a fact proved later by ejection of the Avhole mass. There is a case on record a in Avhich there Avas intolerable thirst after retiring, lasting for a year. There was apparently no polydipsia during the daytime. The amount of Avater drunk by glass-blowers in a day is almost incredi- ble. McElroy b has made observations in the glass-factories in his neighbor- hood, and estimates that in the nine Avorking hours of each day a glass-blower drinks from 50 to 60 pints of Avater. In addition to this many are addicted to the use of beer and spirits after Avorking hours and at lunch-time. The excreta and urine never seem to be perceptibly increased. AVhen not Avorking these men do not drink more than three or four pints of Avater. Occasionally a man becomes Avhat is termed " blown-up Avith Avater;" that is, the perspira- tion ceases, the man becomes utterly helpless, has to be carried out, and is disabled until the sAveating process is restored by vigorously applied friction. There is little deleterious change noticed in these men ; in fact, they are rarely invalids. Hydroadipsia is a lack of thirst or absence of the normal desire for water. In some of these cases there is a central lesion which accounts for the symp- toms. McElroy, among other cases, speaks of one in a patient Avho was con- tinually dull and listless, eating little, and complaining of much pain after the least food. This, too, will be mentioned under abstinence. Perverted appetites are of great A'ariety and present many interesting as well as disgusting examples of anomalies. In some cases the tastes of people differ so that an article considered by one race as disgusting Avould be held as a delicacy by another class. The ancients used asafetida as a seasoning; and Avhat avc have called " stercus diaboli," the Asiatics have named the "food of the gods." The inhabitants of Greenland drink the oil of the whale with as much avidity as we Avould a delicate Avine, and they eat blubber the mere smell of which nauseates an European. In some nations of the lower grade, insects, worms, serpents, etc., are considered edible. The inhabitants of the interior of Africa arc said to relish the flesh of serpents and eat grubs and Avorms. The very earliest accounts of the Indians of Florida and Texas show that "for food, they dug roots, and that they ate spiders, ants' eggs, AA'orms, lizards, sala- manders, snakes, earth, Avood, the dung of deer, and many other things." c Gomara, in his " Historia de les Indias," says this loathsome diet Avas particu- lar to one tribe, the Yaguaces of Florida. It is said that a Russian peasant prefers a rotten egg to a fresh one ; and there are persons who prefer game partly spoiled. a 476, 1869, i., 285, etc. b 272, 1877, 9 et seq. c "De Vaca in Ternaux," vii., 144. 406 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Bourkea recalls that the drinking of human urine has often been a re- ligious rite, and describes the urine-dance of the Zunis of Xcav Mexico, in Avhich the participants drink freely of their urine ; he dnnvs an analogy to the Feast of the Fools, a religious custom of Pagan origin Avhich did not disap- pear in Europe until the time of the Reformation. It is still a practice in some parts of the United States to giATe children fresh urine for certain dis- eases. It is said that the ordure of the Grand Lama of Thibet Avas at one time so venerated that it Avas collected and Avorn as amulets. The disgusting habit of eating human excrement is mentioned by Schurig,b Avho gives numerous examples in epileptics, maniacs, chlorotic young Avomen, pregnant Avomen, children AA'ho haA'e soiled their beds and, dreading detection, have SAvalloAved their ejecta, and finally among men and Avomen Avith abnormal appetites. The Indians of North America consider a broth made from the dung of the hare and caribou a dainty dish, and according to Abbe Dome- nech, as a means of imparting a flavor, the bands near Lake Superior mix their rice Avith the excrement of rabbits. De Bry mentions that the negroes of Guinea ate filthy, stinking elephant-meat and buffalo-flesh infested Avith thou- sands of maggots, and says that they ravenously devoured dogs' guts raAV. Spencer, in his " DescriptiA'e Sociology," describes a "Snake savage" of Aus- tralia Avho dcA'oured the contents of entrails of an animal. Some authors have said that Avithin the last century the Hottentots devoured the flesh and the entrails of wild beasts, uncleansed of their filth and excrement, and Avhether sound or rotten. In a personal letter to Captain Bourke, the Rev- erend J. OAven Dorsey reports that Avhile among the Ponkas he saw a woman and child devour the entrails of a beef Avith their contents. Bourke also cites instances in Avhich human ordure Avas eaten by East Indian fanatics. Nu- merous authorities are quoted by Bourke to prove the alleged use of ordure in food by the ancient Israelites. Pages of such reference are to be found in the Avorks on Scatology, and for further reference the reader is referred to books on this subject, of Avhich prominent in English literature is that of Bourke.0 Probably the most revolting of all the perverted tastes is that for human flesh. This is called anthropophagy or cannibalism, and is a time-hon- ored custom among some of the tribes of Africa. This custom is often prac- tised more in the spirit of vengeance than of real desire for food. Prisoners of Avar Avere killed and eaten, sometimes cooked, and among some tribes raAV. In their religious frenzy the Aztecs ate the remains of the human beings Avho Avere sacrificed to their idols. At other times cannibalism has been a neces- sity. In a famine in Egypt, as pictured by the Arab Abdallatif, the putrefy- ing debris of animals, as well as their excrement, Avas used as food, and finally the human dead Avere used ; then infants Avere killed and devoured, so great Avas the distress. In many sieges, shipAvrecks, etc., cannibalism has been a "Scatologic Eites of All Nations." b " Chylologia." Dresden, 1725. « "Scatologic Rites of All Nations." ANTHROPOPHAGY OR CANNIBALISM. 407 practised as a last resort for sustaining life. AVhen supplies have given out several Arctic explorers have had to resort to eating the bodies of their com- rades. In the famous AViertz Museum in Brussels is a painting by this ec- centric artist in Avhich he has graphically portrayed a Avoman driven to insanity by hunger, avIio has actually destroyed her child with a vieAv to cannibalism. At the siege of Rochelle it is related that, urged by starvation, a father and mother dug up the scarcely cold body of their daughter and ate it. At the siege of Paris by Henry IV. the cemeteries furnished food for the starving. One mother in imitation of what occurred at the siege of Jerusalem roasted the limbs of her dead child and died of grief under this revolting nourishment. St. Jerome states that he saAV Scotchmen in the Roman armies in Gaul Avhose regular diet Avas human flesh, and Avho had " double teeth all around." Cannibalism, according to a prominent New York journal, has been recently made a special study by the Bureau of Ethnology at AVashington, I). C. Data on the subject have been gathered from all parts of the Avorld, Avhich are particularly interesting in view of discoveries pointing to the con- elusion that this horrible practice is far more Avidespread than Avas imagined. Stanley claims that 30,000,000 cannibals dAvell in the basin of the Congo to-day—people who relish human flesh above all other meat. Perah, the most peculiar form of cannibalism, is found in certain mountainous districts of northeast Burmah, Avhere there are tribes that folloAV a life in all important respects like that of Avild beasts. These people eat the congealed blood of their enemies. The blood is poured into bamboo reeds, and in the course of time, being corked up, it hardens. The filled reeds are hung under the roofs of the huts, and Avhen a person desires to treat his friends very hospitably the reeds are broken and the contents deAroured. " The black natives of Australia are all professed cannibals. Dr. Carl Lum- holtz, a Nonvegian scientist, spent many months in studying them in the Avilds of the interior. He Avas alone among these saA'ages, Avho are extremely treach- erous. AVearing no clothing Avhatever, and living in nearly every respect as monkeys do, they knoAV no such thing as gratitude, and have no feeling that can be properly termed human. Only fear of the traveler's Aveapons pre- vented them from slaving him, and more than once he had a narroAv escape. One of the first of them Avhom he employed looked more like a brute than a man. ' AVhen he talked,' says the doctor, ' he rubbed his belly Avith com- placency, as if the sight of me made his mouth Avater.' This individual was regarded Avith much respect by his felloAVS because of his success in procuring human flesh to eat. These aborigines say that the white man's flesh is salt and occasions nausea. A Chinaman they consider as good for eating as a black man, his food being chiefly vegetable. "The most horrible development of cannibalism among the Australian blacks is the eating of defunct relatives. AVhen a person dies there folloAvs an elaborate ceremony, Avhich terminates Avith the lowering of the corpse into the 408 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. graA'e. In the grave is a man not related to the deceased, avIio proceeds to cut off the fat adhering to the muscles of the face, thighs, arms, and stomach, and passes it around to be sAvalloAved by some of the near relatives. All those Avho have eaten of the cadaver haA'e a black ring of charcoal powder and fat draAvn around the mouth. The order in Avhich the mourners partake of their dead relatives is duly prescribed. The mother eats of her children and the children of their mother. A man eats of his sister's husband and of his brother's Avife. Mothers' brothers, mothers' sisters, sisters' children, mothers' parents, and daughters' children are also eaten by those to whom the deceased person stands in such relation. But the father does not eat of his children, nor the children of their sire. " The Nca\- Zealanders, up to very recent times, Avere probably the most anthropophagous race that ever existed. As many as 1000 prisoners have been slaughtered by them at one time after a successful battle, the bodies being baked in ovens underground. If the individual consumed had been a redoubt- able enemy they dried his head as a trophy and made flutes of his thigh bones. "Among the Monbuttos of Africa human fat is commonly employed for a variety of purposes. The explorer ScliAveinfurth speaks of writing out in the evenings his memoranda respecting these people by the light of a little oil-lamp contrived by himself, Avhich was supplied with some questionable-looking grease furnished by the nath'es. The smell of this grease, he says, could not fail to arouse one's worst suspicions against the negroes. According to his account the Monbuttos are the most confirmed cannibals in Africa. Sur- rounded as they are by a number of peoples who are blacker than themselves, and avIio, being inferior to them in culture, are held in contempt, they carry on expeditions of Avar and plunder Avhich result in the acquisition of a booty especially coveted by them—namely, human flesh. The bodies of all foes Avho fall in battle are distributed on the field among the A'ictors, and are prepared by drying for transportation. The sa\Tages drive their prisoners before them, and these are reserved for killing at a later time. During Schweinfurth's residence at the Court of Munza it Avas generally understood that nearly every day a little child was sacrificed to supply a meal for the ogre potentate. For centuries past the slave trade in the Congo Basin has been conducted largely for the purpose of furnishing human flesh to consumers. Slaves are sold and bought in great numbers for market, and are fattened for slaughter. " The Mundurucus of the Upper Amazon, Avho are exceedingly ferocious, have been accused of cannibalism. It is they Avho preserve human heads in such a remarkable Avay. AVhen one of their Avarriors has killed an enemy he cuts off the head Avith his bamboo knife, removes the brain, soaks the head in a vegetable oil, takes out bones of the skull, and dries the remaining parts by putting hot pebbles inside of it. At the same time care is taken to preserve all the features and the hair intact. By repeating the process with the hot pebbles many times the head finally becomes shrunken to that of a small doll, ANCIENT CUSTOMS. 409 though still retaining its human aspect, so that the effect produced is very weird and uncanny. Lastly, the head is decorated Avith brilliant feathers, and the lips are fastened together Avith a string, by which the head is suspended from the rafters of the council-house." Ancient Customs.—According to Herodotus the ancient Lydians and Medcs, and according to Plato the islanders in the Atlantic, cemented friend- ship by drinking human blood. Tacitus speaks of Asian princes swearing allegiance Avith their oavii blood, which they drank. Juvenal says that the Scythians drank the blood of their enemies to quench their thirst. Occasionally a religious ceremony has gh'en sanction to cannibalism. It is said that in the Island of Chios there Avas a rite by Avay of sacrifice to Dionysius in which a man Avas torn limb from limb, and Faber tells us that the Cretans had an annual festival in which they tore a lh'ing bull Avith their teeth. Spencer quotes that among the Bacchic orgies of many of the tribes of North America, at the inauguration of one of the Clallum chiefs on the north- west coast of British America, the chief seized a small dog and began to deArour it alive, and also bit the shoulders of bystanders. In speaking of these cere- monies, Boas, quoted by Bourke, says that members of the tribes practising Hamatsa ceremonies shoAv remarkable scars produced by biting, and at cer- tain festivals ritualistic cannibalism is practised, it being the duty of the Ha- matsa to bite portions of flesh out of the arms, legs, or breast of a man. Another cause of cannibalism, and the one AAdiich deserves discussion, here, is genuine perversion or depravity of the appetite for human flesh among civil- ized persons,—the desire sometimes being so strong as to lead to actual murder. Several examples of this anomaly are on record. Gruner of Jena speaks of a man by the name of Goldschmidt, in the environs of Weimar, Avho developed a depraved appetite for human flesh. He Avas married at tAventy-seven, and for twenty-eight years exercised his calling as a coAv-herd. Nothing extraordinary Avas noticed in him, except his rudeness of manner and his chol- eric and gross disposition. In 1771, at the age of fifty-five, he met a young traveler in the Avoods, and accused him of frightening his coavs ; a discussion arose, and subsequently a quarrel, in Avhich Goldschmidt killed his antagonist by a blow Avith a stick which he used. To avoid detection he dragged the body to the bushes, cut it up, and took it home in sections. He then Avashed, boiled, and ate each piece. Subsequently, he developed a further taste for human flesh, and Avas finally detected in eating a child Avhich he had enticed into his house and killed. He acknoAvledged his appetite before his trial. Hector Boetius says that a Scotch brigand and his Avife and children were condemned to death on proof that they killed and ate their prisoners. The extreme youth of one of the girls excused her from capital punishment; but at twelve years she was found guilty of the same crime as her father and suffered capital punishment. This child had been brought up in good surroundings, yet her inherited appetite developed. Gall tells of an individual who, instigated 410 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. by an irresistible desire to eat human flesh, assassinated many persons ; and his daughter, though educated away from him, yielded to the same craving. At Bicetrea there Avas an individual AA'ho had a horribly depraved appetite for decaying human flesh. He Avould haunt the graveyards and cat the putre- fying remains of the recently buried, preferring the intestines. HaA'ing re- galed himself in a midnight proAvl, he Avould fill his pockets for future use. AVhen interrogated on the subject of his depravity he said it had existed since childhood. He acknoAvledged the greatest desire to devour children he Avould meet playing; but he did not possess the courage to kill them. Prochaska quotes the case of a Avoman of Milan Avho attracted children to her home in order that she might slay, salt, and eat them. About 1600, there is the record of a boy named Jean Granier, who had repeatedly killed and devoured several young children before he was discoA'ered. Rodcricus a Cas- tro257 tells of a pregnant Avoman Avho so strongly desired to eat the shoulder of a baker that she killed him, salted his body, and devoured it at intervals. There is a record of a woman Avho in July, 1817, Avas discovered in cooking an amputated leg of her little child. Gorget in 1827 reported the celebrated case of Leger the vine dresser, who at the age of tAventy-four wandered about a forest for eight days during an attack of depression. Coming across a girl of twelve, he violated her, and then mutilated her genitals, and tore out her heart, eating of it, and drinking the blood. He finally confessed his crime Avith calm indifference. After Leger's execution Esquirol found morbid adhe- sions between the brain and the cerebral membranes. Mascha relates a simi- lar instance in a man of fifty-five Avho violated and killed a young girl, eating of her genitals and mammae. At the trial he begged for execution, saying that the inner impulse that led him to his crime constantly persecuted him. A modern example of lust-murder and anthropophagy is that of Menes- clou, who Avas examined by Brouardel, Motet, and others, and declared to be mentally sound ; he Avas convicted. This miscreant was arrested with the fore- arm of a missing child in his pocket, and in his stove Avere found the head and entrails in a half-burnt condition. Parts of the body were found in the water- closet, but the genitals were missing; he was executed, although he made no confession, saying the deed was an accident. Morbid changes were found in his brain. Krafft-Ebing cites the case of Alton, a clerk in England, who lured a child into a thicket, and after a time returned to his office, Avhere he made an entry in his note-book : " Killed to-day a young girl; it Avas fine and hot." The child Avas missed, searched for, and found cut into pieces. Many parts, and among them the genitals, could not be found. Alton did not shoAv the slightest trace of emotion, and gave no explanation of the motive or circumstances of his horrible deed ; he Avas executed. D'Amadorb tells of persons Avho went into slaughter-houses and Avaste- places to dispute Avith wolves for the most revolting carrion. It is also men- a 162, March, 1825. b " La Vie du Sang," note 7. FURTHER EXAMPLES OF DEPRAVED APPETITES. 411 tioned that patients in hospitals have been detected in drinking the blood of patients after venesections, and in other instances frequenting dead-houses and sucking the blood of the recently deceased. Du Saullea quotes the case of a chlorotic girl of fourteen Avho eagerly drank human blood. She preferred that floAving fresh from a recent Avound. Further Examples of Depraved Appetites.—Bijoux b speaks of a por- ter or garcon at the Jardin des Plantes in Paris Avho Avas a prodigious glutton. He had eaten the body of a lion that had died of disease at the menagerie. He ate Avith avidity the most disgusting things to satiate his depraved appe- tite. He shoAved further signs of a perverted mind by classifying the animals of the menagerie according to the form of their excrement, of Avhich he had a col- lection. He died of indigestion folloAving a meal of eight pounds of hot bread. Percy c saw the famous Tarrare, Avho died at Versailles, at about tAventy- six years of age. At seventeen he weighed 100 pounds. He ate a quarter of beef in twenty-four hours. He Avas fond of the most revolting things. He particularly relished the flesh of serpents and Avould quickly devour the largest. In the presence of Lorenze he seized a live cat with his teeth, eventrated it, sucked its blood, and ate it, lea\'ing the bare skeleton only. In about thirty minutes he rejected the hairs in the manner of birds of prey and carnivorous animals. He also ate dogs in the same manner. On one occasion it Avas said that he SAvalloAved a living eel without chewing it; but he had first bitten off its head. He ate almost instantly a dinner that had been prepared for 15 vigorous Avorkmen and drank the accompanying water and took their aggre- gate alloAvance of salt at the same time. After this meal his abdomen was so swollen that it resembled a balloon. He Avas seen by Courville, a surgeon- major in a military hospital, Avhere he had swalloAved a Avooden box Avrapped in plain Avhite paper. This he passed the next day Avith the paper intact. The General-in-chief had seen him dcA-our thirty pounds of raw liver and lungs. Nothing seemed to diminish his appetite. He Availed around butcher-shops to eat what Avas discarded for the d< >gs. He drank the bleedings of the hos- pital and ate the dead from the dead-houses. He avus suspected of eating a child of fourteen months, but no proof could be produced of this. He was of middle height and was always heated and sweating. He died of a puru- lent diarrhea, all his intestines and peritoneum being in a suppurating condi- tion. Fulton d mentions a girl of six Avho exhibited a marked taste for feeding on slugs, beetles, cockroaches, spiders, and repulsive insects. This child had been carefully brought up and was one of 13 children, none of Avhom displayed any similar depravity of appetite. The child Avas of good dispo- sition and slightly beloAv the normal mental standard for her age. At the age of fourteen her appetite became normal. In the older writings many curious instances of abnormal appetite are a Med. Critic, 1862, ii., 711. b 302, iv., 199. c 302, iv., 200 d 180, 1879. 412 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. seen. Borellus speaks of individuals sAvalloAving stones, horns, serpents, and toads. Plater a mentions snail-eating and eel-eating, tAvo customs still extant. Rhodius is accredited Avith seeing persons Avho sAvalloAved spiders and scor- pions. Jonston447 says that Avicenna, Rufus, and Gentilis relate instances of young girls avIio acquired a taste for poisonous animals and substances, avIio could ingest them with impunity. Colonia Agrippina was supposed to have eaten spiders Avith impunity. Van AVoenselb is said to have seen persons who devoured live eels. The habit of dirt-eating or clay-eating, called pica, is avcII authenticated in many countries. The Ephemerides contains mention of it; Hunter speaks of the blacks who eat potters' clay ; Bartholinus190 describes dirt-eating as does also k Castro.c Properly speaking, dirt-eating should be called geophagism ; it is common in the Antilles and South America, among the Ioav classes, and is seen in the negroes and poorest classes of some portions of the Southern United States. It has also been reported from Java, China, Japan, and is said to have been seen in Spain and Portugal. Peat-eating or bog- eating is still seen in some parts of Ireland. There Avere a number of people in the sixteenth and seventeenth centuries Avho had formed the habit of eating small pebbles after each meal. They formed the habit from seeing birds SAvalloAving gravel after eating. A number of such cases are on record.d There is on record the account of a man living in AVurtemberg Avho Avith much A'oracity had eaten a suckling pig, and sometimes dcA'oured an entire sheep. He sAvallowed dirt, clay, pebbles, and glass, and was addicted to intoxication by brandy. He lived sixty years in this manner and then he became abstemious ; he died at seventy-nine. His omentum Avas very lean, but the liver covered all his abdominal viscera. His stomach was Arery large and thick, but the intestines Avere very narroAV. Ely e had a patient who Avas addicted to chalk-eating ; this he said in- variably relieved his gastric irritation. In the twenty-five years of the habit he had used over J ton of chalk ; but notAvithstanding this he ahvays enjoyed good health. The Ephemerides contains a similar instance, and Axerzascha mentions a lime-eater. Adamsf mentions a child of three who had an in- stinctive desire to eat mortar. This baby was rickety and had carious teeth. It AAould pick its preferred diet out of the Avail, and if prevented Avould cry loudly. AVhen deprived of the mortar it would vomit its food until this substance Avas given to it again. At the time of report part of the routine duties of the sisters of this boy was to supply him with mortar containing a little sand. Lime-Avater Avas substituted, but he insisted so vigorously on the solid form of food that it had to be replaced in his diet. He suffered from small-pox; on Avaking up in the night Avith a fever, he ahvays cried for a 635, L. i. and L. ii. b 105, 1748, viii., 62-64. c 257, L. iii., 399. d 629, 1700. e 218, 1868, 101. f 476, 1885, i., 235. FASTING. 413 a piece of mortar. The quantity consumed in twenty-four hours Avas about | teacupful. The child had neA'er been weaned. Arsenic Eaters.—It has been frequently stated that the peasants of Styria are in the habit of taking from two to five grains of arsenious acid daily for the purpose of improving the health, avoiding infection, and raising the Avhole tone of the body. It is a Avell-substantiated fact that the quanti- ties taken habitually are quite sufficient to produce immediate death ordi- narily. But the same might be easily said of those addicted to opium and chloral, a subject that Avill be considered later. Perverted appetites during pregnancy have been discussed on pages 80 and 81. Glass-eaters, penknife-swalloAvers, and sword-sAvalloAvers, being exhibi- tionists and jugglers, and not individuals Avith perverted appetites, Avill be con- sidered in Chapter XII. Fasting.—The length of time which a person can live Avith complete abstinence from food is quite variable. Hippocrates admits the possibility of fasting more than six days without a fatal issue ; but Pliny and others alloAv a much longer time, and both the ancient and modern literature of medicine are replete Avith examples of abstinence to almost incredible lengths of time. Formerly, and particularly in the Middle Ages when religious frenzy Avas at its highest pitch, prolonged abstinence was prompted by a desire to do pen- ance and to gain the approbation of Heaven. In many religions fasting has become a part of Avorship or religious cere- mony, and from the earliest times certain sects have carried this custom to extremes. It is Avell known that some of the priests and anchorites of the East noAV subsist on the minimum amount of food, and from the earliest times before the advent of Christianity Ave find instances of prolonged fasting associated with religious Avorship. The Assyrians, the HebreAvs, the Egyp- tians, and other Eastern nations, and also the Greeks and Romans, as Avell as feasting days, had their times of fasting, and some of these were quite pro- longed. At the present day religious fervor accounts for but few of our remark- able instances of abstinence, most of them being due to some form of nervous disorder, varying from hysteria and melancholia to absolute insanity. The ability seen in the Middle Ages to live on the Holy Sacrament and to resist starvation may possibly have its analogy in some of the fasting girls of the present day. In the older times these persons were said to have been nour- ished by angels or devils; but according to Hammond many cases both of diabolical abstinence from-food and of holy fasting exhibited manifest signs of hysteric symptoms. Hammond, in his exhaustive treatise on the subject of " Fasting Girls," also remarks that some of the chronicles detail the exact symptoms of hysteria and Avithout hesitation ascribe them to a devilish agency. For instance, he speaks of a young girl in the A-alley of Calepino Avho had all her limbs tAvisted and contracted and had a sensation in her esophagus as if a 414 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. ball AA'as sometimes rising in her throat or falling into the stomach—a rather lay description of the characteristic hysteric " lump in the throat," a frequent sign of nervous abstinence. Abstinence, or rather anorexia, is naturally associated Avith numerous dis- eases, particularly of the febrile type ; but in all of these the patient is main- tained by the use of nutrient enemata or by other means, and the abstinence is never complete. A peculiar type of anorexia is that striking and remarkable digestive dis- turbance of hysteria which Sir AVilliam Gull has called anorexia nervosa. In this malady there is such annihilation of the appetite that in some cases it seems impossible ever to eat again. Out of it groAvs an antagonism to food Avhich results at last, and in its Avorst forms, in spasm on the approach of food, and this in its turn gives rise to some of those remarkable cases of survival for long periods Avithout food. As this goes on there may be an extreme de- gree of muscular restlessness, so that the patients Avander about until exhausted. According to Osier, avIio reports a fatal case in a girl avIio, at her death, only Aveighed 49 pounds, nothing more pitiable is to be seen in medical practice than an advanced case of this malady. The emaciation and exhaustion are extreme, and the patient is as miserable as one Avith carcinoma of the esopha- gus, food either not being taken at all or only upon urgent compulsion. Gull a mentions a girl of fourteen, of healthy, plump appearance,A\'ho in the beginning of February, 1887, Avithout apparent cause evinced a great repug- nance to food and soon afterAvard declined to take anything but a half cup of tea or coffee. Gull suav her in April, Avhen she Avas much emaciated; she persisted in Avalking through the streets, where she Avas the object of remark of passers-by. At this time her height Avas five feet four inches, her weight 63 pounds, her temperature 97° F., her pulse 46, and her respiration from 12 to 14. She had a persistent Avish to be moving all the time, despite her emaciation and the exhaustion of the nutritiA'e functions. There is another class of abstainers from food exemplified in the exhibi- tionists AArho either for notoriety or for AA'ages demonstrate their ability to forego eating, and sometimes drinking, for long periods. Some have been cleA^er frauds, who by means of artifices have carried on skilful deceptions; others haA'e been really interesting physiologic anomalies. Older Instances.—Democritus in 323 B. C. is said to have lived forty days by simply smelling honey and hot bread. Hippocrates remarks that most of those aa-1io endeavored to abstain five days died AA'ithin that period, and eAren if they Avere preA'ailed upon to eat and drink-before the termination of their fast they still perished. There is a possibility that some of these cases of Hippocrates AA'ere instances of pyloric carcinoma or of stenosis of the pylorus. In the older Avritings there are instances reported in Avhich the period of abstinence has \Taried from a short time to endurance beyond the a 476, 1888, i., 321. OLDER INSTANCES OF FASTING. 415 bounds of credulity. Hufeland mentions total abstinence from food for seventeen days, and there is a contemporary case of abstinence for forty days in a maniac Avho subsisted solely on water and tobacco. Bolsota speaks of abstinence for fourteen months, and Consbruchb mentions a girl aaIio fasted eighteen months. Mullerc mentions an old man of forty-five avIio lived six Aveeks on cold water. There is an instance of a person living in a cave twenty-four days Avithout food or drink,d and another of a man avIio survived five Aveeks' burial under ruins.e Ramazzini speaks of fasting sixty-six days; AVillian, sixty days (resulting in death); A-on AVocher, thirty-se\'en days (associated with tetanus) ; Lantana, sixty days ; Hobbes,f forty days ; Marcardier,g six months ; Cruikshank,h tAvo months ; the Ephe- merides, thirteen months ; Gerard,1 sixty-nine days (resulting in death) ; and in 1722 there Avas recorded an instance of abstinence lasting twenty-fh'e months.-" Desbarreaux-Bernard k says that Guillaume Granie died in the prison of Toulouse in 1831, after a voluntary suicidal abstinence of sixty-three days. Haller1 cites a number of examples of long abstinence, but most ex- traordinary was that of a girl of Confolens, described by Citois of Poitiers, Avho published a history of the case in the beginning of the seventeenth cen- tury. This girl is said to have passed three entire years, from eleven to four- teen, Avithout taking any kind of aliment. In the " Harleian Miscellanies " is a copy of a paper humbly offered to the Royal Society by John Reynolds, containing a discourse upon prodigious abstinence, occasioned by the tweh'e months' fasting of a Avoman named Martha Taylor, a damsel of Derbyshire. Plot637 gh'es a great A-ariety of curious anecdotes of prolonged abstinence. Ames m refers to " the true and admirable history of the maiden of Con- folens," mentioned by Haller. In the Annual Register, \-ol. i., is an account of three persons Avho avc re buried fh'e Aveeks in the snoAv ; and in the same journal, in 1762, is the history of a girl Avho is said to haAre sub- sisted nearly four years on Avater. In 1684 four miners Avere buried in a coal-pit in Horstel, a half mile from Liege, Belgium, and lived tAventy-four days Avithout food, eventually making good reco\7eries. An analysis of the Avater used during their confinement showed an almost total absence of organic matter and only a slight residue of calcium salts.11 Joanna Crippen lay six days in the shoav Avithout nutriment, being over- come by the cold Avhile on the Avay to her house; she recovered despite her exposure.0 Somis, physician to the King of Sardinia, gives an account of three Avomen of Piedmont, Italy, Avho Avere saved from the ruins of a stable a 470, 1685. b 452, L. ix., 115. 0 452, L. xxiv. d 629, 158. e 586, xv., 45. f 629, 1668. 8 462. T. xxiii. b " Anat. of the Absorbent Vessels," 101. ! 462, T. vi., 147. J 708, 1722. k789, 1880, xxx., 350. l 400, T. vi., 171 et seq. m " Topographical Antiquities." n 629, 1684. ° 629, 1700-20, v., 358. 416 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Avhere they had been buried by an avalanche of suoav, March 19, 1755, thirty-seven days before. Thirty houses and 22 inhabitants avc re buried in this catastrophe, and these three Avomen, together Avith a child of two, Avere sheltered in a stable OArer Avhich the suoav lodged 42 feet deep. They Avere in a manger 20 inches broad and upheld by a strong arch. Their enforced position Avas with their backs to the Avail and their knees to their faces. One woman had 15 chestnuts, and, fortunately, there Avere two goats near by, and Avithin reach some hay, sufficient to feed them for a short time. By milking one of the goats Avhich had a kid, they obtained about tAvo pints daily, upon Avhich they subsisted for a time. They quenched their thirst Avith melted snoAv liquefied by the heat of their hands. Their sufferings Avere greatly in- creased by the filth, extreme cold, and their uncomfortable positions ; their clothes had rotted. AVhen they Avere taken out their eyes Avere unable to endure the light, and their stomachs at first rejected all food. AVhile returning from Cambridge, February 2, 1799, Elizabeth AVood- cock dismounted from her horse, Avhich ran away, leaving her in a violent suoav- storm. She Avas soon overwhelmed by an enormous drift six feet high. The sensation of hunger ceased after the first day and that of thirst predominated, Avhich she quenched by sucking snoAv. She Avas discovered on the 10th of February, and although suffering from extensh'e gangrene of the toes, she recovered. Hamilton8, says that at a barracks near Oppido, celebrated for its earthquakes, there were rescued two girls, one sixteen and the other eleven ; the former had remained under the ruins Avithout food for eleven days. This poor creature had counted the days by a light coming through a small opening. The other girl remained six days under the ruin in a confined and distressing posture, her hands pressing her cheek until they had almost made a hole in it. Tavo persons Avere buried under earthquake ruins at Messina for tAventy-three and tAventy-tAvo days each. Thomas Creaserbgives the history of Joseph Lockier of Bath, Avho, Avhile going through a Avoods between 6 and 7 p. m., on the 18th of August, Avas struck insensible by a violent thunderbolt. His senses gradually re- turned and he felt excessively cold. His clothes Avere wet, and his feet so sAVollen that the poAver of the loAver extremities was totally gone and that of the arms Avas much impaired. For a long time he Avas unable to articulate or to summon assistance. Early in September he heard some persons in the Avood and, having managed to summon them in a feeble voice, told them his story. They declared him to be an impostor and left him. On the evening of the same day his late master came to his assistance and removed him to SAvan Inn. He affirmed that during his exposure in the Avoods he had nothing to eat; though distressing at first, hunger soon subsided and yielded to thirst, Avhich he appeased by cheAving grass having beads of Avater thereon. He slept during the warmth of the day, but the cold kept him a 629, lxxiii. b « Case Joseph Lockier." 8°, Bath, 1806. OLDER INSTANCES OF FASTING. 417 awake at night. During his sleep he dreamt of eating and drinking. On November 17, 1806, several surgeons of Bath made an affidavit, in Avhich they stated that this man Avas admitted to the Bath City Dispensary on September 15th, almost a month after his reputed stroke, in an extremely emaciated condition, Avith his legs and thighs shriveled as Avell as motionless. There were several livid spots on his legs and one toe Avas grangrenous. A fter some time they amputated the toe. The poAver in the lower extremities soon returned. In relating his travels in the Levant, Hasselquist mentions 1000 Abyssini- ans avIio became destitute of provisions Avhile en route to Cairo, and who lh'ed tAA'o months on gum arabic alone, arriving at their destination without any unusual sickness or mortality. Dr. Franklin lived on bread and Avater for a fortnight, at the rate of ten pounds per week, and maintained himself stout and healthy. Sir John Pringle knew a lady of ninety Avho lived on pure fat meat. GoAver of Chelmsford had a patient Avho lived ten years on a pint of tea daily, only noAV or then chewing a half dozen raisins or almonds, but not swalloAving them. Once in long intervals she took a little bread. Brassavolus describes a younger daughter of Frederick King of Naples, avIio lived entirely without meat, and could not endure even the taste of it; as often as she put any in her mouth she fell fainting. The monks of Monte Santo (Mount Athos) never touched animal food, but lived on vegetables, olives, and cheese. In 1806 one of them at the age of one hundred and twenty AA'as healthy. Sometimes in the older writings we find records of incredible abstinence. Jonstona speaks of a man in 1460 Avho, after an unfortunate matrimonial experience, lived alone for fifteen years, taking neither food nor drink. Petrus Aponensis cites the instance of a girl fasting for eight years. According to Jonston, Hermolus lhred forty years on air alone. This same author has also collected eases of abstinence lasting ekwen, tAventy-tAvo, and thirty years, and cites Aristotle as an authority in substantiating his instances of fasting girls. Wadd, the celebrated authority on corpulence, quotes Pennant in mentioning a Avoman in Rosshire Avho lived one and three-quarters years Avithout meat or drink. Granger had under observation a Avoman by the name of Ann Moore, fifty-eight years of age, avIio fasted for tAvo years. Fabricius Hildanus334 re- lates of Apollonia Schreiera that she lh'ed three years AA'ithout meat or drink. lie also tells of Eva Flegen, Avho began to fast in 1596, and from that time on, for sixteen years, lhTed Avithout meat or drink. According to the Rev. Thos. Steill, Janet Young fasted sixteen years and partially prolonged her absti- nence for fifty years. The Edinburgh Medical and Surgical Journal,b Avhich contains a mention of the foregoing case, also describes the case of Janet Macleod, Avho fasted for four years, shoAving no signs of emaciation. Benja- a 447, 444. b 318, 1813, ix., 157. 27 418 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. min Rush speaks of a case mentioned in a letter to St. George Tucker, from J. A. Stuart, of a man avIio, after receh'ing no benefit from a year's treatment for hemiplegia, resolved to starA'e himself to death. He totally abstained from food for sixty days, lh'ing on AA'ater and cheAving apples, but spitting Out the pulp; at the expiration of this time he died. Keeles a relates the history of a beautiful young Avoman of sixteen, avIio upon the death of a most indulgent father refused food for thirty-four days, and soon afterAvard for fifty-four days, losing all her senses but that of touch. There is an accountb of a French adA'enturer, the Chevalier de Saint- Lubin, AA'ho had a loathing for food and abstained from every kind of meat and drink for fifty-eight days. Saint-Sanver, at that time Lieutenant of the Bastille, put a close Avatch on this man and certified to the A'erity of the fast. The European Magazine in 1783 contained an account of the Calabria earth- quake, at Avhich time a girl of eighteen AA'as buried under ruins for six days. The edge of a barrel fell on her ankle and partly separated it, the dust and mortar effectually stopping the hemorrhage. The foot dropped off and the Avound healed Avithout medical assistance, the girl making a complete re- coA'ery. There is an account taken from a document in the Vatican of a man living in 1306, in the reign of Pope Clement V., avIio fasted for tAvo years.0 McNaughton d mentions Rubin Kelsey, a medical student afflicted Avith melancholia, Avho voluntarily fasted for fifty-three days, drinking copiously and greedily of AA'ater. For the first six Aveeks he Avalked about, and Avas strong to the day of his death. Hammond has proA'ed many of the reports of " fasting girls " to have been untrustAvorthy. The case of Miss Faucher of Brooklyn, who Avas sup- posed to haA'e taken no food for fourteen years, Avas fraudulent. He says that Ann Moore Avas fed by her daughter in several ways ; when Avashing her mother's face she used towels Avet with gravy, milk, or strong arroAV-root meal. She also eonA'eyed food to her mother by means of kisses. One of the " fast- ing girls," Margaret AVeiss, although only ten years old, had such poAvers of deception that after being Avatched by the priest of the parish, Dr. Bucol- dianus, she Avas considered free from juggling, and, to everybody's astonish- ment, she greAV, walked, and talked like other children of her age, still maintaining that she used neither food nor drink. In seA'eral other cases reported all attempts to discoArer imposture failed. As we approach more modern times the detection is more frequent. Sarah Jacobs, the AVelsh fast- ing girl Avho attained such celebrity among the laity, Avas taken to Guy's Hospital on December 9, 1869, and after being Avatched by eight experienced nurses for eight days she died of starvation. A postmortem examination of Anna Garbero of Racconis, in Piedmont,e Avho died on May 19, 1828, after having endured a supposed fast of tAvo years, eight months, and eleA^en days, a 527, 1774, v., part ii., 471 et seq. b 328, 1790, 124. c Journal de Pharmacia, etc., de Lisboa. d 763, 1830, i., 113. e 151, 1828. MODERN INSTANCES OF FASTING. 419 revealed remarkable intestinal changes. The serous membranes Avere all callous and thickened, and the canal of the sigmoid flexure Avas totally obliter- ated. The mucous membranes were all soft and friable, and presented the appearance of incipient gangrene. Modern Cases.—Turning now to modern literature, we have cases of mar- velous abstinence well substantiated by authoritative evidence. Dickson a describes a man of sixty-tAvo, suffering from monomania, avIio refused food for four months, but made a successful recovery. Richardsonb mentions a case, happening in 1848, of a man of thirty-three who voluntarily fasted for fifty-five days. His reason for fasting, Avhich it Avas impossible to combat, was that he had no gastric juice and that it Avas utterly useless for him to take any nutrition, as he had no means of digesting it. He lived on Avater until the day of his death. Richardson gives an interesting account of the changes noticed at the necropsy. There is an account of a religious mendi- cant of the Jain castec Avho as a means of penance fasted for ninety-one days. The previous year he had fasted eighty-six days. He had spent his life in strict asceticism, and during his fasting he Avas always engrossed in prayer. Collins d describes a maiden lady of eighty, always a moderate eater, who was attacked by bronchitis, during Avhich she took food as usual. Two days after her recovery, Avithout any knoAvn cause, she refused all food and con- tinued to do so for thirty-three days, AA'hen she died. She was delirious throughout this fast and slept daily seven or eight hours. As a rule, she drank about a Avineglassful of Avater each day and her urine was scanty and almost of the consistency of her feces. There is a remarkable case of a girl of seventeene Avho, suffering with typhoid feArer associated with engorgement of the abdomen and suppression of the functions of assimilation, fasted for four months Avithout visible diminution in Aveight. Piercef reports the history of a woman of twenty-six Avho fasted for three months and made an excellent recovery. Grantg describes the " Market Harborough fasting-girl," a maiden of nineteen, who abstained from food from April, 1874, until December, 1877, although continually using morphia. Throughout her fast she had periodic conA'ulsions, and voided no urine or feces for tAvelve months before her death. There Avas a middle-aged woman in England in 1860 avIio for two years lh'ed on opium, gin, and Avater. Her chief symptoms were almost daily sickness and epileptic fits three times a Aveek. She was absolutely constipated, and at her death her abdomen was so distended as to present the appearance of ascites. After death, the distention of the abdomen was found to be due to a coating of fat, four inches thick, in the parietes. There was no obstruction to the intestinal canal and no fecal or other accumulation Avithin it. a 476, 1853, i., 512. b 173, 1890. c 536, 1882, i., 11. <* 224, 1880, ii., 214. e 276, 1828-9, iii., 283. f 124, 1852, 571. 8 224, 1878, i., 152. 420 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Christina Marshall,8, a girl of fourteen, Avent fifteen and one-half months without taking solid nourishment. She slept very little, seldom spoke, but occasionally asked the time of day. She took sAveets and water, with beef tea at intervals, and occasionally a small piece of orange. She died April 18, 1882, after haA'ing been confined to her bed for a long Avhile. King,b a surgeon, U. S. A., gives an account of the deprivation of a squad of cavalry numbering 40. AVhile scouting for Indians on the plains thev went for eighty-six hours Avithout water; when relieved their mouths and throats Avere so dry that ca'ch brown sugar Avould not dissolve on their tongues. Many avc re delirious, and all had draAvn fresh blood from their horses. Despite repeated vomiting, some drank their oavii urine. They were nearly all suffering from overpoAvering dyspnea, tAvo Avere dead, and tAvo Avere missing. The suffering Avas increased by the acrid atmosphere of the dry plains ; the slightest exercise in this climate provoked a thirst. MacLoughlin,c the surgeon in charge of the S. S. City of Chester, speaks of a young stoAv- aAvay found by the stevedores in an insensible condition after a voyage of eleA'en days. The man Avas brought on deck and revived sufficiently to be sent to St. Vincent's Hospital, N. Y., about one and one-half hours after discovery, in an extremely emaciated, cold, and nearly pulseless condi- tion. He gave his name as John Donnelly, aged tAventy, of Dumbarton, Scotland. On the Avhole voyage he had nothing to eat or drink. He had found some salt, of AA'hich he ate tAvo handfuls, and he had in his pocket a small flask, empty. Into this flask he voided his urine, and afterward drank it. Until the second day he Avas intensely hungry, but after that time Avas consumed by a burning thirst; he shouted four or fh'e hours every day, hoping that he might be heard. After this he became insensible and re- membered nothing until he awakened in the hospital where, under careful treatment, he finally recovered. Fodere mentions some Avorkmen who Avere buried alive fourteen days in a cold, damp cavern under a ruin, and yet all lived. There is a modern instance of a person being buried thirty-two days beneath snow, without food.d The Lancet e notes that a pig fell off Dover Cliff and Avas picked up alive one hundred and sixty days after, having been partially imbedded in debris. It was so surrounded by the chalk of the cliff that little motion Avas possible, and Avarmth was secured by the enclosing material. This animal had there- fore lived on its own fat during the entire period. Among the modem exhibitionists may be mentioned Merlatti, the fast- ing Italian, and Succi, both of Avhom fasted in Paris; Alexander Jacques, Avho fasted fifty days; and the American, Dr. Tanner, who achieved great notoriety by a fast of forty days, during Avhich time he exhibited progressive emaciation. Merlatti, who fasted in Paris in 1886, lost 22 pounds in a a 224, 1882, i., 631. b 124, April, 1878. c 476, 1878. ii.. 646. d 556, 1861, i., 67. e 476, 1890, i., 978. ANOMALIES OF TEMPERATURE. 421 month ; during his fast of fifty days he drank only pure filtered water. Prior to the fast his fareAvell meal consisted of a whole fat goose, including the bones two pounds of roast beef, vegetables for two, and a plate of Avalnuts, the lat- ter eaten whole. Alexander Jacques a fasted fifty days and Succi fasted forty days. Jacques lost 28 pounds and 4 ounces (from 142 pounds, 8 ounces to 114 pounds, 4 ounces), Avhile Succi's loss was 34 pounds and 3 ounces. Succi diminished in height from 65f to 641 inches, Avhile Jacques increased from 64i to 65J inches. Jacques smoked cigarettes incessantly, using 700 in the fifty days, although, by professional advice, he stopped the habit on the forty-second day. Three or four times a day he took a poAvder made of herbs, to which he naturally attributed his power of prolonging life without food. Succi remained in a room in which he kept the temperature at a very high point. In speaking of Succi's latest feat a recent report says : " It has come to light in his latest attempt to go for fifty days Avithout food that he privately regaled himself on soup, beefsteak, chocolate, and eggs. It was also discovered that one of the 'committee,' Avho Avere supposed to Avatch and see that the experiment Avas conducted in a bona fide manner, ' stood in' Avith the faster and helped him deceive the others. The result of the ATienna ex- periment is bound to cast suspicion on all previous fasting accomplishments of Signor Succi, if not upon those of his predecessors." Although all these modern fasters have been accused of being jugglers and deceivers, throughout their fasts they shoAved constant decrease in weight, and inspection by visitors AAras Avelcomed at all times. They invariably invited medical attention, and some Avere under the closest surveillance ; although we may not implicitly belieAe that the fasts were in every respect bona fide, yet avc must acknoAvledge that these men displayed great endurance in their apparent indifference for food, the deprh-ation of Avhich in a normal individual for one day only causes intense suffering. Anomalies of Temperature.—In revieAAdng the reports of the highest recorded temperatures of the human body, it must be remembered that no matter Iioav good the eA'idenee or Iioav authentic the reference there is always chance for malingering. It is possible to send the index of an ordinary ther- mometer up to the top in ten or fifteen seconds by rubbing it betAveen the slightly moistened thumb and the finger, exerting considerable pressure at the time. There are scweral other means of artificially producing enormous tem- peratures Avith little risk of detection, and as the sensith'eness of the ther- mometer becomes greater the easier is the deception. Mackenzie b reports the temperature-range of a Avoman of forty -tAvo Avho suffered with erysipelatous inflammation of a stump of the leg. Throughout a someAvhat protracted illness, lasting from February 20 to April 22, 1879, the temperature many times registered between 108° and 111° F. About a year later she Avas again troubled Avith the stump, and this time the tempera- a 224, 1890, i., 1444. b 476, 1881, ii., 796. 422 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. ture reached as high as 114°. Although under the circumstances, as any rational physician would, Alackenzie suspected fraud, he could not detect any method of deception. Finally the Avoman confessed that she had pro- duced the temperature artificially by means of hot-Avater bottles, poultices, etc. MacNab a records a case of rheumatic fever in AA'hich the temperature Avas 111.4° F. as indicated by tAvo thermometers, one in the axilla and the other in the groin. This high degree of temperature Avas maintained after death. Before the Clinical Society of London, Teale b reported a case in Avhich, at dif- ferent times, there Avere recorded temperatures from 110° to 120° F. in the mouth, rectum, and axilla. According to a comment in the Lancet, there Avas no Avay that the patient could have artificially produced this temperature, and during com'alescence the thermometer used registered normal as avcII as sub- normal temperatures. Ca?sar c speaks of a girl of fifteen Avith enteric fever, Avhose temperature, on two occasions 110° F., reached the limit of the mer- cury in the thermometer. There have been instances mentioned in which, in order to escape duties, prisoners have artificially produced high temperatures, and the same has occa- sionally been observed among conscripts in the army or navy. There is an accountd of a habit of prisoners of introducing tobacco into the rectum, thereby reducing the pulse to an alarming degree and insuring their exemp- tion from labor. In the Adelaide Hospital in Dublin e there was a case in which the temperature in the vagina and groin registered from 120° to 130°, and one day it reached 130.8° F.; the patient recovered. Ormerodf men- tions a nervous and hysteric Avoman of thirty-two, a sufferer Avith acute rheumatism, AA'hose temperature rose to 115.8° F. She insisted on leaving the hospital Avhen her temperature Avas still 104°. AVunderlich mentions a case of tetanus in which the temperature rose to 46.40° C. (115.5° F.), and before death it was as high as 44.75° C. Ober- niers mentions 108° F. in typhoid fever. Kartulush speaks of a child of five, Avith typhoid fever, Avho at different times had temperatures of 107°, 108°, and 108.2° F.; it finally recovered. He also quotes a case of pyemia in a boy of seven, Avhose temperature rose to 107.6° F. He also speaks of Wunderlich's case of remittent fever, in Avhich the temperature reached 107.8° F. AVilson Fox, in mentioning a case of rheumatic fever, says the tempera- ture reached 110° F. Philipson1 gives an account of a female servant of tAventy-three who suffered from a neurosis Avhich influenced the vasomotor nervous system, and caused hysteria associated with abnormal temperatures. On the evening of July 9th her temperature was 112° F. ; on the 16th, it Avas 111° ; on the 18th, 112° ; on the 24th, 117° (axilla) ; on the 28th, in the left axilla it a 476, 1873, ii., 341. b 476, 1875, ii., 107. c 476, 1879, i., 868. d 476, 1876, i., 28. e 548, 1880, i., 585. f 476, 1878. ii., 658. g 199, 1867. h476) i879) it> 609. i 476? 1880> Lj 641 REMARKABLE HYPERTHERMY. 423 Avas 117°, in the right axilla, 114°, and in the mouth, 112°; on the 29th, it Avas 115° in the right axilla, 110° in the left axilla, and 116° in the mouth. The patient was discharged the folloAving September. Steel of Manchester a speaks of a hysteric female of tAventy, whose temperature AAas 116.4°. Mahomedb mentions a hysteric Avoman of twenty-tAvo at Guy's Hospital, London, with phthisis of the left lung, associated Avith marked hectic fevers. Having registered the limit of the ordinary thermometers, the physicians procured one with a scale reaching to 130° F. She objected to using the large thermometers, saying they Avere "horse thermometers." On October 15, 1879, hoAvever, they succeeded in obtaining a temperature of 128° F. with the large thermometer. In March of the following year she died, and the necropsy revealed nothing indicative of a cause for these enormous tempera- tures. She Avas suspected of fraud, and was closely watched in Guy's Hos- pital, but never, in the slightest Avay, was she detected in using artificial means to elevate the temperature record. In cases of insolation it is not at all unusual to see a patient A\diose tem- perature cannot be registered by an ordinary thermometer. Any one who has been resident at a hospital in Avhich heat-cases are received in the sum- mer Avill substantiate this. At the Emergency Hospital in AVashington, dur- ing recent years, seA'eral cases have been brought in which the temperatures Avere above the ordinary registering point of the hospital thermometers, and one of the most extraordinary cases recovered. At a meeting of the Association of American Physicians in 1895, Jacobi of Nca\- York reported a case of hyperthermy reaching 148° F. This instance occurred in a profoundly hysteric fireman, who suffered a rather severe injury as the result of a fall betAveen the reATohTing rods of some machinery, and Avas rendered unconscious for four days. Thereafter he com- plained of various pains, bloody expectoration, and had convulsions at A'ary- ing intervals, Avith loss of consciousness, rapid respiration, unaccelerated pulse, and excessively high temperature, the last on one occasion reaching the height of 148° F. The temperature was taken carefully in the presence of a number of persons, and all possible precautions Avere observed to pre- vent deception. The thermometer was variously placed in the mouth, anus, axilla, popliteal space, groin, urethra, and different instruments were from time to time employed. The behavior of the patient avus much influenced by attention and by suggestion. For a period of five days the temperature averaged continuously between 120° and 125° F. In the discussion of the foregoing case, Welch of Baltimore referred to a case that had been reported in which it was said that the temperature reached as high as 171° F. These extraordinary elevations of temperature, he said, appear physically impossible when they are long continued, as they are fatal to the life of the animal cell. a 476, 1881, ii., 790. b 476, 1881, ii., 790. 424 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. In the same connection Shattuck of Boston added that he had observed a temperature of 117° F. ; every precaution had been taken to prevent fraud or deception. The patient Avas a hysteric young Avoman. Jacobi closed the discussion by insisting that his observations had been made with the greatest care and precautions and under many different cir- cumstances. He had at first vieAved the case Avith skepticism, but he could not doubt the results of his observation. He added, that although avc cannot explain anomalies of this kind, this constitutes no reason avIiv avc should deny their occurrence. Duffy8 records one of the lowest temperatures on record in a negress of thirty-five who, after an abortion, showed only 84° F. in the mouth and axilla?. She died the next day. The amount of external heat that a human being can endure is sometimes remarkable, and the range of temperature compatible Avith life is none the less extraordinary. The Esquimaux and the inhabitants of the ex- treme north at times endure a temperature of—60° F., Avhile some of the people living in equatorial regions are apparently healthy at a temperature as high as 130° F., and Avork in the sun, Avhere the temperature is far higher. In the engine-rooms of some steamers plying in tropical Avaters temperatures as high as 150° F. have been registered, yet the engineers and the stokers become habituated to this heat and labor in it without apparent suffering. In Turkish baths, by progressively exposing themselves to graduated tempera- tures, persons have been able to endure a heat considerably above the boiling point, though havdng to protect their persons from the furniture and floors and Avails of the rooms. The hot air in these rooms is intensely dry, provoking profuse perspiration. Sir Joseph Banks remained some time in a room the temperature of Avhich Avas 211° F., and his own temperature never mounted aboA^e normal. There have been exhibitionists who claimed particular ability to endure intense heats Avithout any visible disadA-antage. These men are generally styled " human salamanders," and must not be confounded Avith the "fire- eaters," Avho, as a rule, are simply jugglers. Martinez,b the so-called " French Salamander," was born in HaATana. As a baker he had exposed himself from boyhood to very high temperatures, and he subsequently gave public exhibi- tions of his extraordinary ability to endure heat. He remained in an oven erected in the middle of the Gardens of Tivoli for fourteen minutes when the temperature in the oven Avas 338° F. His pulse on entering Avas 76 and on coming out 130. He often duplicated this feat before vast assemblages, though hardly ever attaining the same degree of temperature, the ther- mometer generally A^arying fr0m 250° F. upvrard. Chamouni AA'as the cele- brated " Russian Salamander," assuming the title of " The Incombustible." c His great feat Avas to enter an oven Avith a raAV leg of mutton, not retiring a 681, 1874, vii., 365. b 226, 1827, 276. c 476, 1827-8, 585. " HUMAN SALAMANDERS." 425 until the meat AA'as well baked. This person eventually lost his life in the performance of this feat; his ashes were conveyed to his native town, where a monument was erected over them. Since the time of these tAvo contempo- raneous salamanders there have been many others, but probably none have attained the same notoriety. In this connection Tillet speaks of some servant girls to a baker who for fifteen minutes supported a temperature of 270° F.; for ten minutes, 279° F.; and for several minutes, 364° F., thus surpassing Martinez. In the GlasgOAV Medical Journal, 1859, there is an account of a baker's daughter Avho remained twelve minutes in an oven at 274° F. Chantrey, the sculptor, and his Avork- man are said to have entered Avith impunity a furnace of over 320° F. In some of the saA'age ceremonies of fire worship the degree of heat en- dured by the participants is really remarkable, and e\Ten if the rites are per- formed by skilful juggling, nevertheless, the ability to endure intense heat is worthy of comment. A recent report says :— " The most remarkable ceremonial of fire worship that survh'es in this country is practised by the Navajos. They believe in purification by fire, and to this end they literally wash themselves in it. The feats they perform Avith it far exceed the most Avonderful acts of fire-eating and fire-handling accom- plished by civilized jugglers. In preparation for the festival a gigantic heap of dry Avood is gathered from the desert. At the appointed moment the great pile of inflammable brush is lighted and in a few moments the Avhole of it is ablaze. Storms of sparks fly 100 feet or more into the air, and ashes fall about like a shoAver of snow. The ceremony always takes place at night and the effect of it is both weird and impressive. " Just when the fire is raging at its hottest a whistle is heard from the outer darkness and a dozen Avarriors, lithe and lean, dressed simply in narroAV white breech-cloths and moccasins and daubed with white earth so as to look like so many living statues, come bounding through the entrance to the corral that incloses the flaming heap. Yelping like wolves, they move slowly toward the fire, bearing aloft slender wands tipped Avith balls of eagle-down. Rush- ing around the fire, ahAays to the left, they begin thrusting their Avands toward the fire, trying to burn off the down from the tips. Owing to the intensity of the heat this is difficult to accomplish. One Avarrior dashes Avildly toward the fire and retreats ; another lies as close to the ground as a frightened lizard, endeavoring to Avriggle himself up to the fire ; others seek to catch on their Avands the sparks that fly in the air. At last one by one they all succeed in burning the doAvny balls from the wands. The test of endurance is very severe, the heat of the fire being so great. " The remarkable feats, however, are performed in connection with another dance that folloAvs. This is heralded by a tremendous bloAving of horns. The noise grows louder and louder until suddenly ten or more men run into the corral, each of them carrying tAvo thick bundles of shredded cedar bark. 426 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Four times they run around the fire Avaving the bundles, Avhich are then lighted. Now begins a wild race around the fire, the rapid running causing the brands to throAV out long streamers of flames over the hands and arms of the dancers. The latter apply the brands to their OAvn nude bodies and to the bodies of their comrades in front. A Avarrior will seize the flaming mass as if it Avere a sponge, and, keeping close to the man he is pursuing, will rub his back with it as if bathing him. The sufferer in turn catches up Avith the man in front of him and bathes him in flame. From time to time the dancers sponge their OAvn backs Avith the flaming brands. AVhen a brand is so far consumed that it can no longer be held it is dropped and the dancers disappear from the corral. The spectators pick up the flaming bunches thus dropped and bathe their own hands in the fire. " No satisfactory explanation seems to be obtainable as to the means by Avhich the dancers in this extraordinary performance are able to escape injury. Apparently they do not suffer from any burns. Doubtless some protection is afforded by the earth that is applied to their bodies." Spontaneous combustion of the human body, although doubted by the medical men of this day, has for many years been the subject of much discussion ; only a few years ago, among the writers on this subject, there were as many credulous as there were skeptics. There is, however, no reliable evidence to support the belief in the spontaneous combustion of the body. A feAV apochryphal cases only have been recorded. The opinion that the tissues of drunkards might be so saturated with alcohol as to render the body com- bustible is disproved by the simple experiment of placing flesh in spirits for a long time and then trying to burn it. Liebig and others found that flesh soaked in alcohol Avould burn only until the alcohol was consumed. That various substances ignite spontaneously is explained by chemic phenomena, the conditions of Avhich do not exist in the human frame. AVatkins a in speak- ing of the inflammability of the human body remarks that on one occasion he tried to consume the body of a pirate given to him by a U. S. Marshal. He built a rousing fire and piled wood on all night, and had not got the body consumed by the forenoon of the folloAving day. Quite a feasible reason for supposed spontaneous human combustion is to be found in several cases quoted by Taylor,757 in which persons falling asleep, possibly near a fire, have been accidentally ignited, and becoming first stupefied by the smoke, and then suffo- cated, h&ve been burned to charcoal Avithout aAvaking. Drunkenness or great exhaustion may also explain certain cases. In substantiation of the possi- bility of Taylor's instances several prominent physiologists have remarked that persons haA'e endured severe burns during sleep and have neATer wakened. There is an account of a man who lay down on the top of a lime kiln, Avhich Avas fired during his sleep, and one leg Avas burned entirely off Avithout awaking the man, a fact explained by the very sIoav and gradual increase of temperature. a 593, 1870. SPONTANEOUS HUMAN COMBUSTION. 427 The theories advanced by the ad\Tocates of spontaneous human combus- tion are very ingenious and deserve mention here. An old authority has said : " Our blood is of such a nature, as also our lymph and bile : all of Avhich, Avhen dried by art, flame like spirit of Avine at the approach of the least fire and burn away to ashes." Lord Bacon mentions spontaneous com- bustion, and Marcellus Donatus 306 says that in the time of Godefroy of Bouillon there were people of a certain locality who supposed themseh^es to have been burning of an invisible fire in their entrails, and he adds that some cut off a hand or a foot Avhen the burning began, that it should go no further. What may have been the malady Avith which these people suffered must be a matter of conjecture. Overton,8 in a paper on this subject, remarks that in the " Memoirs of the Royal Society of Paris," 1751, there is related an account of a butcher who, opening a diseased beef, avus burned by a flame AA'hich issued from the maAV of the animal; there Avas first an explosion Avhich rose to a height of five feet and continued to blaze several minutes with a highly offen- sive odor. Morton saAV a flame emanate from beneath the skin of a hog at the instant of making an incision through it. Ruysch, the famous Dutch physician, remarks that he introduced a holloAv bougie into a Avoman's stomach he had just opened, and he observed a vapor issuing from the mouth of the tube, and this lit on contact with the atmosphere. This is probably an exag- geration of the properties of the hydrogen sulphid found in the stomach. There is an account b of a man of forty-three, a gross feeder, who Avas par- ticularly fond of fats and a victim of psoriasis palmaria, who on going to bed one night, after extinguishing the light in the room, Avas surprised to find him- self enveloped in a phosphorescent halo; this continued for seA^eral days and recurred after further indiscretions in diet. It is well knoAvn that there are insects and other creatures of the lower animal kingdom which possess the peculiar quality of phosphorescence. There are numerous cases of spontaneous combustion of the human body reported by the older writers. Bartholinus mentions an instance after the person had drunk too much Avine. Fouquetc mentions a person ignited by lightning. Schraderd speaks of a person from whose mouth and fauces after a debauch issued fire. Schurig e tells of flames issuing from the vulva, and Moscatif records the same occurrence in parturition ; Sinibaldus,737 Borellus,841 and Bierling 2n have also written on this subject, and the Ephemerides con- tains a number of instances. In 1763 Bianchini, Prebendary of Verona, published an account of the death of Countess Cornelia Bandi of Cesena, who in her sixty-second year AA'as consumed by a fire kindled in her own body. In explanation Bianchini a 774, 1835, 9 et seq. b 476, 1842, ii., 2, 374. c 462, T. lxviii., 436. d "Observat. rar.," fasc. i., No. 10. e " Chylologia," f>24. f " Mem. di Matem. e di Fisica della di Modena," x. 428 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. said that the fire was caused in the entrails by the inflamed effluvia of the blood, by the juices and fermentation in the stomach, and, lastly, by fiery evaporations which exhaled from the spirits of wine, brandy, etc. In the Gentleman's Magazine, 1763, there is recorded an account of three noble- men Avho, in emulation, drank great quantities of strong liquor, and tAvo of them died scorched and suffocated by a flame forcing itself from the stomach. There is an account of a poor Avoman in Paris in the last century Avho drank plentifully of spirits, for three years taking virtually nothing else. Her body became so combustible that one night Avhile lying on a stnuv couch she Avas spontaneously burned to ashes and smoke. The evident cause of this com- bustion is too plain to be commented on. In the Lancet, 1845, there are hvo cases reported in which shortly before death luminous breath has been seen to issue from the mouth.a There is an instance reported of a professor of mathematics b of thirty-five years of age and temperate, Avho, feeling a pain in his left leg, discovered a pale flame about the size of a ten-cent piece issuing therefrom. As recent as March, 1850, in a Court of Assizes in Darmstadt during the trial of John Stauff, accused of the murder of the Countess Goerlitz, the counsel for the defense adA'anced the theory of spontaneous human combustion, and such emi- nent doctors as A'on Siebold, Graff, A'on Liebig, and other prominent members of the Hessian medical fraternity Avere called to comment on its possibility; principally on their testimony a coiiA'iction and life-imprisonment was secured. In 1870c there Avas a Avoman of thirty-seven, addicted to alcoholic liquors, who AAas found in her room Avith her A'iscera and part of her limbs consumed by fire, but the hair and clothes intact. According to AValford,813 in the Scientific American for 1870, there was a case reported by Flowers of Louisiana of a man, a hard drinker, avIio Avas sitting by a fire surrounded by his Christmas guests, when- suddenly flames of a bluish tint burst from his mouth and nos- trils and he was soon a corpse. Flowers states that the body remained ex- tremely Avarm for a much longer period than usual. Statistics.—From an examination of 28 cases of spontaneous combus- tion, Jacobs d makes the folloAving summary :— (1) It has always occurred in the human living body. (2) The subjects were generally old persons. (3) It Avas noticed more frequently in Avomen than in men. (4) All the persons Avere alone at the time of occurrence. (5) They all led an idle life. (6) They Avere all corpulent or intemperate. (7) Most frequently at the time of occurrence there was a light and some ignitible substance in the room. (8) The combustion Avas rapid and was finished in from one to seven hours. a 476, 1845, ii., 274 ; 1845, i., 11. b 124, xvii., 266. c 789, 1870. d 235, May 15 and 30, 1841. MA GNETIC, PHOSPHORESCENT, ELECTRIC ANOMALIES. 429 (9) The room Avhere the combustion took place was generally filled with a thick vapor and the walls covered with a thick, carbonaceous substance. (10) The trunk avus usually the part most frequently destroyed ; some part of the head and extremities remained. (11) AVith but two exceptions, the combustion occurred in winter and in the northern regions. Magnetic, Phosphorescent, and Electric Anomalies.—There have been certain persons Avho have appeared before the public under such names as the " human magnet," the " electric lady," etc. There is no doubt that some persons are supercharged Avith magnetism and electricity. For instance, it is quite possible for many persons by draAving a rubber comb through the hair to produce a crackling noise, and even produce sparks in the dark. Some exhibitionists haATe been genuine curiosities of this sort, while others by skil- fully arranged electric apparatus are enabled to perforin their feats. A curious case was reported in this country many years ago,a which apparently emanates from an authoritative source. On the 25th of January, 1837, a cer- tain lady became suddenly and unconsciously charged Avith electricity. Her newly acquired power was first exhibited Avhen passing her hand over the face of her brother; to the astonishment of both, vivid electric sparks passed from the ends of each finger. This power continued Avith augmented force from the 25th of January to the last of February, but finally became extinct about the middle of May of the same year. Schneiderb mentions a strong, healthy, dark-haired Capuchin monk, the remoAral of whose head-dress always induced a number of shining, crackling sparks from his hair or scalp. Bartholinus observed a similar peculiarity in Gonzaga, Duke of Mantua. In another case luminous sparks Avere given out Avhenever the patient passed urine. Marsh relates tAvo cases of phthisis in Avhich the heads of the patients Avere surrounded by phosphorescent lights. Raster mentions an instance in Avhich light Avas seen in the perspiration and on the body linen after violent exertion. After exertion Jurine,c Guyton, and Dries- sen observed luminous urine passed by healthy persons, and Nasse mentions the same phenomenon in a phthisical patient. Percy and Stokes haA'e ob- served phosphorescence in a carcinomatous ulcer. There is a description of a Zulu boy exhibited in Edinburgh in 1882 d Avhose body Avas so charged Avith electricity that he could impart a shock to any of his patrons. He Avas about six and a-half years of age, bright, happy, and spoke English thoroughly Avell. From infancy he had been distinguished for this faculty, variable Avith the state of the atmosphere. As a rule, the act of shaking hands AAas generally attended by a quivering sensation like that produced by an electric current, and contact with his tongue gave a still sharper shock. a 124, Jan., 1838. b Casper's Wochenschrift, No. 15, 1849. o 458, 1813, 48. d 536, 1882, ii., 360. 430 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Sir Charles Bell has made extensive investigation of the subject of human magnetism and is probaldy the best authority on the subject, but many celebrated scientists haA'e studied it thoroughly. In the Pittsburg Medical Review a there is a description of a girl of three and a half, a blonde, and extremely Avomanly for her age, AA'ho possessed a Avonderful magnetic power. Metal spoons Avould adhere to her finger-tips, nose, or chin. The child, however, could not pick up a steel needle, an article generally very sensitive to the magnet; nor Avould a penny stick to any portion of her body. Only recently there avus exhibited through this country a Avoman named Annie May Abbott, Avho styled herself the " Georgia Electric Lady." This person gave exhibitions of Avonderful magnetic poAver, and invited the inspec- tion and discussion of medical men. Besides her chief accomplishment she possessed wonderful strength and Avas a skilled equilibrist. By placing her hands on the sides of a chair upon AA'hich a heavy man Avas seated, she Avould raise it without apparent effort. She defied the strongest person in the audi- ence to take from her hand a stick which she had once grasped. Recent reports say that Miss Abbott is amusing herself noAv with the strong men of China and Japan. The Japanese Avrestlers, whose physical strength is cele- brated the world OA-er, Avere unable to raise Miss Abbott from the floor, Avhile with the tips of her fingers she neutralized their most strenuous efforts to lift even light objects, such as a cane, from a table. The possibilities, in this advanced era of electric mechanism, make fraud and deception so easy that it is extremely difficult to pronounce on the genuineness of any of the modern exhibitions of human electricity. The Effects of Cold.—Gmelin, the famous scientist and investigator of this subject, says that man has lived Avhere the temperature falls as low as —157° F. Habit is a marked factor in this endurance. In Russia men and women Avork Avith their breasts and arms uncoA'ered in a temperature many degrees beloAv zero and Avithout attention to the fact. In the most rigorous Avinter the inhabitants of the Alps work Avith bare breasts and the children sport about in the snoAv. AV rapping himself in his jhH.w the Russian sleeps in the siioav. This influence of habit is seen in the inability of intruders in northern lands to endure the cold, Avhich has no effect on the indigenous people. On their Avay to besiege a NorAvegian stronghold in 1719, 7000 SAvedes perished in the siioavs and cold of their neighboring country. On the retreat from Prague in 1742, the French army, under the rigorous sky of Bohemia, lost 4000 men in ten days. It is needless to speak of the thousands lost in Napoleon's campaign in Russia in 1812. Pinel has remarked that the insane are less liable to the effects of cold than their normal felloAvs, and mentions the escape of a naked maniac, who, Avith- out any visible after-effect, in January, eA'en, AA'hen the temperature Avas —4° F., ran into the siioav and gleefully rubbed his body with ice. In the French a 634, 1888, ii., 5. PSYCHOLOGIC EFFECTS OF COLD. 431 journals in 1814 there is the record of the rescue of a naked crazy Avoman Avho AA'as found in the Pyrenees, and avIio had apparently suffered none of the ordinary effects of cold. Psychologic Effects of Cold.—Lambert says that the mind acts more quickly in cold Aveather, and that there has been a notion ad\ranced that the emotion of hatred is much stronger in cold Aveather, a theory exemplified by the assassination of Paul of Russia, the execution of Charles of England, and that of Louis of France. Emotions, such as love, bravery, patriotism, etc., together Avith diverse forms of excitement, seem to augment the ability of the human body to endure cold. Cold seems to have little effect on the generative function. In both SAveden, NorAvay, and other Northern countries the families are as large, if not larger, than in other countries. Cold undoubtedly imparts A'igor, and, according to DeThou, Henry III. lost his effeminacy and love of pleasure in winter and reacquired a spirit of progress and reformation. Zimmerman has remarked that in a rigorous winter the lubberly Hollander is like the gayest Frenchman. Cold increases appetite, and Plutarch says Brutus ex- perienced intense bulimia Avhile in the mountains, barely escaping perishing. AVith full rations the Greek soldiers under Xenophon suffered intense hunger as they traversed the snow-clad mountains of Armenia. Beaupre remarks that those avIio have the misfortune to be buried under the snow perish less quickly than those Avho are exposed to the open air, his observations haA'ing been made during the retreat of the French army from Moscoav. In Russia it is curious to see fish frozen stiff, Avhich, after trans- portation for great distances, return to life Avhen plunged into cold water. Sudden death from cold baths and cold drinks has been knoAvn for many centuries. Mauriceau a mentions death from cold baptism on the head, and Graseccus,385 Scaliger, Rush,696 Schenck,718 and Velschius798 mention deaths from cold drinks. AA'entii, Fabricius Hildanus,334 the Ephemerides, and (\irry relate instances of a fatal issue folloAving the ingestion of cold AA'ater by an individual in a superheated condition. Cridland b describes a case of sudden insensibility following the drinking of a cold fluid. It is said that Alexander the Great narrowly escaped death from a constrictive spasm, due to the fact that AA'hile in a copious SAveat he plunged into the river Cydnus. Tissot gives an instance of a man dying at a fountain after a long draught on a bot day. Hippocrates mentions a similar fact, and there are many modern instances. The ordinary effects of cold on the skin locally and the system generally Avill not be mentioned here, except to add the remark of Captain AVood that in Greenland, among his party, could be seen ulcerations, blisters, and other painful lesions of the skin. In Siberia the Russian soldiers cover their noses and ears with greased paper to protect them against the cold. The Lap- a 513, ii., 348. b 476, 1843, i., 70. 432 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. landers and Samoi'edes, to avoid the dermal lesions caused by cold (possibly augmented by the friction of the Avind and beating of snoAv), anoint their skins Avith rancid fish oil, and are able to endure temperatures as Ioav as —40° F. In the retreat of the 10,000 Xenophon ordered all his soldiers to grease the parts exposed to the air. Effects of Working in Compressed Air.—According to a writer in Cassier's Magazine," the highest Avorking pressures recorded have been close to 50 pounds per square inch, but Avith extreme care in the selection of men, and corresponding care on the part of the men, it is very probable that this limit may be considerably exceeded. Under average conditions the top limit may be placed at about 45 pounds, the time of Avorking, according to conditions, Aarving from four to six hours per shift. In the cases in Avhich higher pressures might be used, the shifts for the men should be restricted to tAvo of two hours each, separated by a considerable inter ATal. As an example of heavy pressure Avork under favorable conditions as to ventilation, Avithout very bad effects on the men, Messrs. Sooysmith & Company had an experi- ence Avith a Avork on Avhich men were engaged in six-hour shifts, separated into tAvo parts by half-hour intervals for lunch. This work Avas excavation in open, seamy rock, carried on for several weeks under about 45 pounds pres- sure. The character of the material through which the caisson is being sunk or upon which it may be resting at any time bears quite largely upon the ability of the men to stand the pressure necessary to hold back the AA'ater at that point. If the material be so porous as to permit a considerable leakage of air through it, there Avill naturally result a continuous change of air in the Avorking chamber, and a corresponding relief of the men from the deleterious effects which are nearly ahvays produced by over-used air. From Strasburg in 1861 Bucuoy reports that during the building of a bridge at Kehl laborers had to Avork in compressed air, and it was found that the respirations lost their regularity ; there were sometimes intense pains in the ears, AA'hich after a Avhile ceased. It required a great effort to speak at 2\ atmospheres, and it Avas impossible to whistle. Perspiration Avas very pro- fuse. Those Avho had to Avork a long time lost their appetites, became emaciated, and congestion of the lung and brain was observed. The move- ments of the limbs Avere easier than in normal air, though afterward muscular and rheumatic pains were often observed. The peculiar and extraordinary development of the remaining special senses when one of the number is lost has ahvays been a matter of great interest. Deaf people have ahvays been remarkable for their acute- ness of vision, touch, and smell. Blind persons, again, almost invariably have the sense of hearing, touch, and what might be called the senses of location and temperature exquisitely developed. This substitution of the senses is but an example of the great laAv of compensation AA'hich Ave find throughout nature. a Scientific American, May, 18, 1885, 307. COMPENSATORY SUBSTITUTION OF THE SENSES. 433 Jonston a quotes a case in the seventeenth century of a blind man who, it is said, could tell black from Avhite by touch alone; several other instances are mentioned in a chapter entitled " De compensatione naturae monstris facta." It must, however, be held impossible that blind people can thus distinguish colors in any proper sense of the Avords. Different colored yarns, for example, may have other differences of texture, etc., that Avould be manifest to the sense of touch. We knoAV of one case in AA'hich the different colors were accurately distinguished by a blind girl, but only when located in customary and definite positions. Le Cat b speaks of a blind organist, a native of Holland, avIio still played the organ as well as ever. He could distinguish money by touch, and it is also said that he made himself familiar Avith colors. He Avas fond of playing cards, but became such a dangerous opponent, because in shuffling he could tell what cards and hands had been dealt, that he was never alloAved to handle any but his own cards. It is not only in those Avho are congenitally deficient in any of the senses that the remarkable examples of compensation are seen, but sometimes late in life these are developed. The celebrated sculptor, Daniel de Volterre, became blind after he had obtained fame, and notAvithstanding the deprivation of his chief sense he could, by touch alone, make a statue in clay after a model. Le Cat also mentions a woman, perfectly deaf, Avho Avithout any instruction had learned to comprehend anything said to her by the movements of the lips alone. It Avas not necessary to articulate any sound, but only to give the labial movements. AVhen tried in a foreign language she Avas at a loss to understand a single Avord. Since the establishment of the modern high standard of blind asylums and deaf-and-dumb institutions, Avhere so many ingenious methods have been de- veloped and are practised in the education of their inmates, feats Avhich Avere formerly considered marvelous are Avithin the reach of all those under tuition. To-day, those born deaf-mutes are taught to speak and to understand by the movements of the lips alone, and the blind read, become expert Avorkmen, musicians, and even draughtsmen. D. D. AVood of Philadelphia, although one of the finest organists in the country, has been totally blind for years. It is said that he acquires neAV compositions Avith almost as great facility as one not afflicted with his infirmity. " Blind Tom," a semi-idiot and blind negro, achieved Avorld-Avide notoriety by his skill upon the piano. In some extraordinary cases in aa hich both sight and hearing, and some- times even taste and smell, are Avanting, the individuals in a most Avonderful Avay have developed the sense of touch to such a degree that it almost replaces the absent senses. The extent of this compensation is most beautifully illus- trated in the cases of Laura Bridgman and Helen Keller. No better examples could be found of the compensatory ability of differentiated organs to replace absent or disabled ones. a 147, 469. b " Traite des Sens." 28 434 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Laura Dewey Bridgmana Avas born December 21, 1829, at Hanover, X. H. Her parents Avere farmers and healthy people. They Avere of average height, regular habits, slender build, and of rather nervous dispositions. Laura inherited the physical characteristics of her mother. In her infancy she AA'as subject to convulsions, but at tAventy months had improved, and at this time had learned to speak several Avords. At the age of tAvo years, in common Avith tAvo of the other children of the family, she had an attack of severe scarlet fever. Her sisters died, and she only recovered after both eyes and ears had suppurated; taste and smell Avere also markedly impaired. Sight in the left eye AA'as entirely abolished, but she had some sensation for large, bright objects in the right eye up to her eighth year; after that time she became totally blind. After her recovery it Avas tAvo years before she could sit up all day, and not until she was five years old had she entirely regained her strength. Hearing being lost, she naturally never deA'eloped any speech ; however, she Avas taught to seAV, knit, braid, and perform several other minor household duties. In 1837 Dr. S. AV. HoAve, the Director of the Massachusetts Asylum for the Blind, took Laura in charge, and Avith her commenced the ordinary deaf-mute education. At this time she Avas seven years and ten months old. Two years later she had made such Avonderful progress and shoAvn such ability to learn that, notAvithstanding her infirmi- ties, she surpassed any of the pupils of her class. Her advancement Avas particularly noticed immediately after her realization that an idea could be expressed by a succession of raised letters. In fact, so rapid Avas her pro- gress, that it AA'as deemed ad\'isable by the authorities to hold her back. Bv her peculiar sensibility to vibration she could distinguish the difference be- tween a Avhole and a half note in music, and she struck the notes on the piano quite correctly. During the first years of her education she could not smell at all, but later she could locate the kitchen by this sense. Taste had devel- oped to such an extent that at this time she could distinguish the different degrees of acidity. The sense of touch, howeA'er, Avas exceedingly delicate and acute. As to her moral habits, cleanliness was the most marked. The slightest dirt or rent in her clothes caused her much embarrassment and shame, and her sense of order, neatness, and propriety Avas remarkable. She seemed quite at home and enjoyed the society of her OAvn sex, but Avas uncomfortable and distant in the society of males. She quickly comprehended the intel- lectual capacity of those Avith Avhom she was associated, and soon showed an affiliation for the more intelligent of her friends. She Avas quite jealous of any extra attention shoAvn to her felloAV scholars, possibly arising from the fact that she had ahvays been a favorite. She cried only from grief, and partially ameliorated bodily pain by jumping and by other excessive muscular move- ments. Like most mutes, she articulated a number of noises,—50 or more, a "Anatomy and Observations on the Brain and Several Sense Organs of the Blind Deaf-mute, Laura Dewey Bridgman," by H. H. Donaldson. HELEN KELLAR. 435 all monosyllabic; she laughed heartily, and Avas quite noisy in her play. At this time it AA'as thought that she had been heard to utter the Avords doctor, pin, ship, and others. She attached great importance to orienta- tion, and seemed quite ill at ease in finding her Avay about Avhen not absolutely sure of directions. She was ahvays timid in the presence of ani- mals, and by no persuasion could she be induced to caress a domestic animal. In common Avith most maidens, at sixteen she became more sedate, reseiwed, and thoughtful ; at twenty she had finished her education. In 1878 she Avas seen by G. Stanley Hall, avIio found that she located the approach and depart- ure of people through sensation in her feet, and seemed to have substituted the cutaneous sense of vibration for that of hearing. At this time she could distinguish the odors of Aarious fragrant floAvers and had greater suscepti- bility to taste, particularly to sweet and salty substances. She had Avritten a journal for ten years, and had also composed three autobiographic sketches, was the authoress of several poems, and some remarkably clever letters. She died at the Perkins Institute, May 24, 1889, after a life of sixty years, bur- dened Avith infirmities such as feAV ever endure, and which, by her superior development of the remnants of the original senses left her, she had oA'ercome in a degree nothing less than marvelous. According to a Avell-knoAvn ob- server, in speaking of her mental development, although she Avas eccentric she was not defective. She necessarily lacked certain data of thought, but even this fact Avas not very marked, and Avas almost counterbalanced by her exceptional poAver of using what remained. In the present day there is a girl as remarkable as Laura Bridgman, and avIio bids fair to attain even greater fame by her superior deA'elop- ment. This girl, Helen Kellar, is both deaf and blind; she has been seen in all the principal cities of the United States, has been examined by thousands of persons, and is famous for her ATictories over infirmities. On account of her Avonderful poAver of comprehension special efforts have been made to educate Helen Kellar, and for this reason her mind is far more finely developed than in most girls of her age. It is true that she has the adA'antage over Laura Bridgman in haA'ing the senses of taste and smell, both of Avhich she has developed to a most marA'elous degree of acuteness. It is said that by odor alone she is ahvays conscious of the presence of another person, no matter Iioav noiseless his entrance into the room in Avhich she may be. She cannot be persuaded to take food Avhich she dislikes, and is never de- ceived in the taste. It is, hoAvever, by the means of Avhat might be called "touch-sight" that the most miraculous of her feats are performed. By placing her hands on the face of a visitor she is able to detect shades of emotion Avhich the normal human eye fails to distinguish, or, in the Avords of one of her lay observers, " her sense of touch is developed to such an exquis- ite extent as to form a better eye for her than are yours or mine for us; and, Avhat is more, she forms judgments of character by this sight." According 436 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. to a recent report of a conversation Avith one of the principals of the school in Avhich her education is being completed, it is said that since the girl has been under his care he has been teaching her to sing with great success. Placing the fingers of her hands on the throat of a singer, she is able to folloAv notes covering Iavo octaves Avith her oavu voice, and sings synchronously witli her instructor. The only difference betAveen her voice and that of a normal person is in its resonant qualities. So acute has this sense become, that by placing her hand upon the frame of a piano she can distinguish tAvo notes not more than half a tone apart. Helen is expected to enter the preparatory school for Radcliffe College in the fall of 1896. At a meeting of the American Association to Promote the Teaching of Speech to the Deaf, in Philadelphia, July, 1896, this child appeared, and in a well-chosen and distinct speech told the interesting story of her oavu progress. Miss Sarah Fuller, principal of the Horace Mann School for the Deaf, Boston, is credited with the history of Helen Kellar, as folloAvs :— " Helen Kellar's home is in Tuscumbia, Ala. At the age of nineteen months she became deaf, dumb, and blind after convulsions lasting three days. Up to the age of seven years she had received no instruction. Her parents engaged Miss SulliA-an of the Perkins Institute for the Blind, South Boston, to go to Alabama as her teacher. She AAas familiar with methods of teaching the blind, but knoAV nothing about instructing deaf children. Miss Sullivan called upon Miss Fuller for some instruction on the subject. Miss Fuller avus at that time experimenting Avith two little deaf girls to make them speak as hearing children do, and called Miss Sullivan's attention to it. Miss Sul- livan left for her charge, and from time to time made reports to Dr. A nagnos, the principal of the Perkins School, which mentioned the remarkable mind which she found this little Alabama child possessed. The folloAving year Miss Sullivan brought the child, then eight years old, to Boston, and Mrs. Kellar came Avith her. They A'isited Miss Fuller's school. Miss Sullivan had taught the child the manual alphabet, and she had obtained much infor- mation by means of it. Miss Fuller noticed hoAv quickly she appreciated the ideas given to her in that Avay. " It is interesting to note that before any attempt had been made to teach the child to speak or there had been any thought of it, her own quickness of thought had suggested it to her as she talked by hand alphabet to Miss Fuller. Her mother, hoAvcwer, did not approve Miss Fuller's suggestion that an at- tempt should be made to teach her speech. She remained at the Perkins School, under Miss Sullivan's charge, another year, when the matter Avas brought up again, this time by little Helen herself, who said she must speak. Miss SulKvan brought her to Miss Fuller's school one day and she received her first lesson, of about tAvo hours' length. " The child's hand avus first passed over Miss Fuller's face, mouth, and neck, then into her mouth, touching the tongue, teeth, lips, and hard palate, EDITH THOMAS. 437 to give her an idea of the organs of speech. Miss Fuller then arranged her mouth, tongue, and teeth for the sound of i as in it. She took the child's finger and placed it upon the Avindpipe so that she might feel the vibration there, put her finger betAveen her teeth to show her Iioav Avide apart they Avere, and one finger in the mouth to feel the tongue, and then sounded the voAvel. The child grasped the idea at once. Her fingers fleAV to her own mouth and throat, and she produced the sound so nearly accurate that it sounded like an echo. Next the sound of ah avus made by dropping the jaw a little and let- ting the child feel that the tongue Avas soft and lying in the bed of the jaAV, with the teeth more Avidely separated. She in the same way arranged her oavii, but AA'as not so successful as at first, but soon produced the sound per- fectly. " EleAren such lessons Avere given, at inteiwals of three or four days, until she had acquired all the elements of speech, Miss Sullivan in the meantime practising Avith the child on the lessons received. The first word spoken Avas arm, Avhich was at once associated Avith her arm ; this gaA'e her great delight. She soon learned to pronounce words by herself, combining the elements she had learned, and used them to communicate her simple Avants. The first con- nected language she used avus a description she gaA'e Miss Fuller of a visit she had made to Dr. Oliver AVendell Holmes, in all over 200 Avords. They were, all but two or three, pronounced correctly. She now, six years after- ward, converses quite fluently Avith people who knoAV nothing of the manual alphabet by placing a couple of fingers on the speaker's lips, her countenance showing great intentness and brightening as she catches the meaning. Any- body can understand her answers." In a beautiful eulogy of Helen Kellar in a recent number of Harper's Magazine, Charles Dudley AVarner expresses the opinion that she is the purest- minded girl of her age in the world. Edith Thomas, a little inmate of the Perkins Institute for the Blind, at South Boston, is not only deaf and dumb but also blind. She Avas a fellow- pupil Avith Helen Kellar, and in a measure duplicated the rapid progress of her former playmate. In commenting on progress in learning to talk the Boston Herald says : " And as the teacher said the word ' Kitty' once or twice she placed the finger-tips of one hand upon the teacher's lips and Avith the other hand clasped tightly the teacher's throat; then, guided by the mus- cular action of the throat and the position of the teeth, tongue, and lips, as interpreted by that maiwelous and delicate touch of hers, she said the word ' Kitty' over and OATer again distinctly in a A'ery pretty Avay. She can be called dumb no longer, and before the summer \-acation comes she Avill have mastered quite a number of Avords, and such is her intelligence and patience, in spite of the loss of three senses, she may yet speak quite readily. "Her history is very interesting. She Avas born in Maplewood, and up to the time of contracting diphtheria and scarlet fever, which occurred when 438 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. she AA'as four years old, had been a \Tery healthy child of more than ordinary quickness and ability. She had attained a greater command of language than most children of her age. AVhat a contrast betAveen these ' other davs,' as she calls them, and the days which folloAved, Avhen hearing and sight were completely gone, and gradually the senses of speech and smell Avent, too! After the A'aried instruction of the blind school the little girl had advanced so far as to make the rest of her study comparatively easy. The extent of her vocabulary is not definitely knoAvn, but it numbers at least 700 words. Reading, Avhich Avas once an irksome task, has become a pleasure to her. Her ideas of locality and the independence of movement are remarkable, and her industry and patience are more noticeable from day to day. She has great ability, and is in every respect a very Avonderful child." According to recent reports, in the A'icinity of Rothesay, on the Clyde, there resides a lady totally deaf and dumb, avIio, in point of intelligence, scholarship, and skill in various ways, far excels many who have all their faculties. Having been educated partly in Paris, she is a good French scholar, and her general composition is really Avonderful. She has a short- hand system of her oavu, and when Avriting letters, etc., she uses a peculiar machine, somewhat of the nature of a typewriter. Among the deaf persons who have acquired fame in literature and the arts have been Dibil Alkoffay, an A rabian poet of the eighth century; the tactician, Folard; the German poet, Engelshall; Le Sage ; La Condamine, Avho composed an epigram on his OAvn infirmity ; and Beethoven, the famous musician. Fernandez, a Spanish painter of the sixteenth century, was a deaf-mute. All the world pities the blind, but despite their infirmities many have achieved the highest glory in every profession. Since Homer there haAre been numerous blind poets. Milton lost none of his poetic power after he had become blind. The Argovienne, Louise Egloff, and Daniel Leopold, avIio died in 1753, were blind from infancy. Blacklock, Avisse, KosIoa7, and La Motte-Houdart are among other blind poets. Asconius Pedianus, a gram- marian of the first century; Didyme, the celebrated doctor of Alexandria; the Florentine, Bandolini, so Avell A^ersed in Latin poetry ; the celebrated Italian grammarian, Pontanus; the German, Griesinger, Avho spoke seven languages ; the philologist, Grassi, who died in 1831, and many others have become blind at an age more or less advanced in their working lives. Probably the most remarkable of the blind scientists Avas the English- man, Saunderson, who in 1683, in his first year, was deprived of sight after an attack of small-pox. In spite of his complete blindness he assiduously studied the sciences, and graduated Avith honor at the University of Cambridge in mathematics and optics. His sense of touch was remarkable. He had a col- lection of old Roman medals, all of Avhich, Avithout mistake, he could distin- guish by their impressions. He also seemed to have the ability to judge dis- FEATS OF MEMORY. 439 tance, and Avas said to have knoAvn how far he had walked, and bv the velocity he could even tell the distance traversed in a vehicle. Among other blind mathematicians Avas the Dutchman, Borghes (died in 1652); the French astron- omer, the Count de Pagan, Avho died in 1655 ; Galileo ; the astronomer, Cassini and Berard, who became blind at twenty-three years, and was for a long time Professor of Mathematics at the College of Briancon. In the seventeenth century the sculptor, Jean Gonnelli, born in Tuscany, became blind at twenty years ; but in spite of his infirmity he afterward exe- cuted what Avere regarded as his masterpieces. It is said that he modeled a portrait of Pope Urban VIIL, using as a guide his hand, passed from time to time over the features. Lomazzo, the Italian painter of the eighteenth century, is said to haA'e continued his Avork after becoming blind. Several men distinguished for their bravery and ability in the art of Avar have been blind. Jean de Ttoczoav, most commonly knoAvn by the name of Ziska, in 1420 lost his one remaining eye, and was afterAvard knoAvn as the " old blind dog," but, nevertheless, led his troops to many A'ictories. Frois- sart beautifully describes the glorious death of the blind King of Bohemia at the battle of Crecy in 1346. Louis III., King of Provence; Boleslas III., Duke of Bohemia; Magnus IV., King of Nonvay, and Bela II., King of Hungary, Ave re blind. Nathaniel Price, a librarian of Norwich in the last century, lost his sight in a A'oyage to America, Avhich, hoAvever, did not inter- fere in any degree Avith his duties, for his books Avere in as good condition, and their location as directly under his knoAvledge, during his blindness as they were in his earlier days. At the present day in NeAV York there is a blind billiard expert who occasionally gives exhibitions of his proAvess. Feats of Memory.—From time to time there have been individuals, principally children, Avho gave wonderful exhibitions of memory, some for dates, others for names, and some for rapid mental calculation. Before the Anthropological Society in 1880 Broca exhibited a lad of eleven, a Pied- montese, named Jacques Inaudi. This boy, Avith a trick monkey, had been found earning his livelihood by begging and by solving mentally in a few minutes the most difficult problems in arithmetic. A gentleman residing in Marseilles had seen him Avhile soliciting alms perform most astonishing feats of memory, and brought him to Paris. In the presence of the Society Broca gaArc him verbally a task in multiplication, composed of some trillions to be multiplied by billions. In the presence of all the members he accom- plished his task in less than ten minutes, and without the aid of pencil and paper, solving the Avhole problem mentally. Although not looking intelli- gent, and not being able to read or Avrite, he perhaps could surpass any one in the Avorld in his particular feat. It Avas stated that he proceeded from left to right in his calculations, instead of from right to left in the usual manner. In his personal appearance the only thing indicative of his wonder- ful abilities Avas his high forehead. 440 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. An infant prodigy named Oscar Moore Avas exhibited to the physician- of Chicago at the Central Music Hall in 1888, and excited considerable comment at the time. The child Avas born of mulatto parents at Waco, Texas, on August 19, 1885, and Avhen only thirteen months old manifested remarkable mental ability and precocity. S. A". Clevenger, a physician of Chicago, has described the child as folloAvs :— "Oscar AA'as born blind and, as frequently occurs in such cases, the touch- sense compensating!v developed extraordinarily. It Avas observed that after touching a person once or tAvice Avith his stubby baby fingers, he could there- after unfailingly recognize and call by name the one Avhose hand he again felt. The optic sense is the only one defective, for tests reveal that his hear- ing, taste, and smell are acute, and the tactile development surpasses in re- finement. But his memory is the most remarkable peculiarity, for Avhen his sister conned her lessons at home, baby Oscar, less than two years old, would recite all he heard her read. Unlike some idiot savants, in Avhich category he is not to be included, avIio repeat parrot-like Avhat they haA'e once heard, baby Oscar seems to digest Avhat he hears, and requires at least more than one repetition of Avhat he is trying to remember, after which he possesses the information imparted and is able to yield it at once when questioned. It is not necessary for him to commence at the beginning, as the possessors of some notable memories were compelled to do, but he skips about to any re- quired part of his repertoire. " He sings a number of songs and counts in different languages, but it is not supposable that he understands every word he utters. If, however, his understanding develops as it promises to do, he will become a decided polyglot. He has mastered an appalling array of statistics, such as the areas in square miles of hundreds of countries, the population of the world's prin- cipal cities, the birthdays of all the Presidents, the names of all the cities of the United States of over 10,000 inhabitants, and a lot of mathematical data. He is greatly attracted by music, and this leads to the expectation that when more mature he may rival Blind Tom. " In disposition he is very amiable, but rather grave beyond his years. He sIioavs great affection for his father, and is as playful and as happy as the ordinary child. He sleeps soundly, has a good childish appetite, and appears to be in perfect health. His motions are quick but not nervous, and, are as well coordinated as in a child of ten. In fact, he impresses one as having the intelligence of a much older child than three years (iioav five years), but his height, dentition, and general appearance indicate the truthfulness of the age assigned. An evidence of his symmetrical mental development appears in his extreme inquisitiveness. He wants to understand the meaning of what he is taught, and some kind of an explanation must be given him for what he learns. AVere his memory alone abnormally great and other faculties defective, this would hardly be the case; but if so, it cannot at present be determined. FEATS OF MEMORY. 441 " His complexion is vcIIoav, AA'ith African features, flat nose, thick lips, but not prognathous, superciliary ridges undeveloped, causing the forehead to protrude a little. His head measures 19 inches in circumference, on a line with the upper ear-tips, the forehead being much narroAver than the occipito- parietal portion, AA'hich is noticeably A'ery wide. The occiput protrudes back- Avard, causing a fonvard sAveep of the back of the neck. From the nose-root to the nucha over the head he measures 13J inches, and between upper ear- tips across and over the head 11 inches, which is so close to the eight- and ten-inch standard that he may be called mesocephalic. The bulging in the vicinity of the parietal region accords remarkably with speculations upon the location of the auditory memory in that region, such as those in the Ameri- can Naturalist, July, 1888, and the fact that injury of that part of the brain may cause loss of memory of the meaning of Avords. It may be that the premature death of the mother's children has some significance in connection with Oscar's phenomenal development. There is certainly a hypernutrition of the parietal brain AA'ith atrophy of the optic tract, both of which condi- tions could arise from abnormal A'ascular causes, or the extra groAvth of the auditory memory region may haA'e deprived of nutrition, by pressure, the adjacent optic centers in the occipital brain. The otherwise normal motion of the eyes indicates the nystagmus to be functional. " Sudden exaltation of the memory is often the consequence of grave brain disease, and in children this symptom is most frequent. Pritchard, Rush, and other writers upon mental disorders record interesting instances of re- markable memory-increase before death, mainly in adults, and during fever and insanity. In simple mania the memory is often very acute. Romberg tells of a young girl Avho lost her sight after an attack of small-pox, but acquired an extraordinary memory. He calls attention to the fact that the scrofulous and rachitic diatheses in childhood are sometimes accompanied by this disorder. WinsloAV notes that in the incipient state of the brain disease of earl)' life connected Avith fevers, disturbed conditions of the cerebral cir- culation and A'cssels, and in affections of adA'anced life, there is often Avitnessed a remarkable exaltation of the memory, which may herald death by apoplexy. " Not only has the institution of intelligence in idiots dated from falls upon the head, but extra mentality has been conferred by such an event. Pritchard tells of three idiot brothers, one of Avhom, after a seA'ere head injury, brightened up and became a barrister, Avhile his brothers remained idiotic. ' Father Mabillon,' says AVinslow, ' is said to have been an idiot until twenty- six years of age, Avhen he fractured his skull against a stone staircase. He AA'as trepanned. After recoA'ering, his intellect fully developed itself in a mind endoAved with a lively imagination, an amazing memory, and a zeal for study rarely equaled.' Such instances can be accounted for by the brain having previously been poorly nourished by a defective blood supply, Avhich defect Avas remedied by the increased circulation afforded by the head-injury. 442 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. " It is a commonly known fact that activity of the brain is attended Avith a greater head-circulation than when the mind is dull, Avithin certain limits. Anomalous development of the brain through blood-vessels, affording an extra nutritive supply to the mental apparatus, can readily be conceived as occurring before birth, just as aberrant nutrition elsewhere produces giants from parents of ordinary size. " There is but one sense-defect in the child Oscar, his eyesight-absence, and that is atoned for by his hearing and touch-acuteness, as it generally is in the blind. Spitzka and others demonstrate that in such cases other parts of the brain enlarge to compensate for the atrophic portion AA'hich is connected Avith the functionlcss neiwes. This, considered AA'ith his apparently perfect mental and physical health, leaves no reason to suppose that Oscar's extrava- gant memory depends upon disease any more than we can suspect all giants of being sickly, though the anomaly is doubtless due to pathologic condi- tions. Of course, there is no predicting what may develop later in his life, but in any event science Avill be benefited. " It is a popular idea that great vigor of memory is often associated with loAv-grade intelligence, and cases such as Blind Tom and other ' idiot savantx' who could repeat the contents of a newspaper after a single reading, justify the supposition. Fearon, on ' Mental Vigor,' tells of a man who could remember the day that every person had been buried in the parish for thirty- five years, and could repeat AA'ith unvarying accuracy the name and age of the deceased and the mourners at the funeral. But he Avas a complete fool. Out of the line of burials he had not one idea, could not give an intelligible reply to a single question, nor be trusted even to feed himself. AVhile mem- ory-development is thus apparent in some otherwise defective intellects, it has probably as often or oftener been observed to occur in connection AA'ith full or great intelligence. Edmund Burke, Clarendon, John Locke, Archbishop Tillotson, and Dr. Johnson Avere all distinguished for having great strength of memory. Sir AV. Hamilton observed that Grotius, Pascal, Leibnitz, and Euler Avere not less celebrated for their intelligence than for their memory. Ben Jonson could repeat all that he had Avritten and whole books he had read. Themistocles could call by name the 20,000 citizens of Athens. Cyrus is said to have known the name of every soldier in his army. Hortensius, a great Roman orator, and Seneca had also great memories. Niebuhr, the Dan- ish historian, Avas remarkable for his acuteness of memory. Sir James Mack- intosh, Dugald SteAvart, and Dr. Gregory had similar reputations. " Nor does great mental endowment entail physical enfeeblement; for, Avith temperance, literary men have reached extreme old age, as in the cases of Klopstock, Goethe, Chaucer, and the average age attained by all the signers of the American Declaration of Independence AAras sixty-four years, many of them being highly gifted men intellectually. Thus, in the case of the phe- nomenal Oscar it cannot be predicted that he will not develop, as he now FEATS OF MEMORY. 443 promises to do, equal and extraordinary powers of mind, even though it would be rare in one of his racial descent, and in the face of the fact that precocity gives no assurance of adult brightness, for it can be urged that John Stuart Mill read Greek Avhen four years of age. " The child is strumous, hoAvever, and may die young. His exhibitors, who are coining him into money, should seek the best medical care for him and avoid surcharging his memory with rubbish. Proper cultivation of his special senses, especially the tactile, by competent teachers, will give Oscar the best chance of developing intellectually and acquiring an education in the proper sense of the Avord." By long custom many men of letters have developed Avonderful feats of memory; and among illiterate persons, by means of points of association, the power of memory has been little short of marvelous. At a large hotel in Saratoga there was at one time a negro AA'hose duty Avas to take charge of the hats and coats of the guests as they entered the dining-room and return to each his hat after the meal. It was said that, Avithout checks or the assist- ance of the OAvners, he invariably returned the right articles to the right per- sons on request, and no matter hoAV large the croAvd, his limit of memory never seemed to be reached. Many persons have seen expert players at draughts and chess who, blindfolded, could carry on numerous games Avith many competitors and win most of the matches. To realize what a Avon- derful feat of memory this performance is, one need only see the absolute exhaustion of one of these men after a match. In Avhist, some experts have been able to detail the succession of the play of the cards so many hands back that their competitors had long since forgotten it. There is reported to be in Johnson County, Missouri, a mathematical wonder by the name of Rube Fields. At the present day he is between forty and fifty years of age, and his external appearance indicates poverty as Avell as indifference. His temperament is most sluggish; he rarely speaks unless spoken to, and his replies are erratic. The boyhood of this strange character Avas that of an OA^ergroAvn country lout with boorish manners and silly mind. He did not and Avould not go to school, and he asserts noAV that if he had done so he " Avould have become as big a fool as other people." A shiftless felloAV, left to his oavii deA'ices, he performed some Avonderful feats, and among the many stories connected Avith this period of his life is one Avhich describes hoAV he actually ate up a good- sized patch of sugar cane, simply because he found it good to his taste. Yet from this clouded, illiterate mind a Avonderful mathematical gift shines. Just Avhen he began to assert his poAvers is not known ; but his feats have been remembered for twenty years by his neighbors. A report says:— " Give Rube Fields the distance by rail betAveen any tAvo points, and the dimensions of a car-Avheel, and almost as soon as the statement has left your lips he Avill tell you the number of revolutions the Avheel Avill make in 444 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. traveling over the track. Call four or five or any number of columns of figures doAvn a page, and AA'hen you have reached the bottom he will announce the sum. Given the number of yards or pounds of articles and the price, and at once he will return the total cost—and this he will do all day long, Avithout apparent effort or fatigue. " A gentleman relates an instance of Fields' knoAvledge of figures. After having called several columns of figures for addition, he Avent back to the first column, saying that it Avas Avrong, and repeating it, purposely miscalling the next to the last figure. At once Fields threAV up his hand, exclaiming: 1 You didn't call it that Avay before.' " Fields' ansAvers come quick and sharp, seemingly by intuition. Calcu- lations Avhich Avould require hours to perform are made in less time than it takes to state the question. The size of the computations seems to offer no bar to their rapid solution, and ansAvers in Avhich long lines of figures are reeled off come Avith perfect ease. In Avatching the effort put forth in reach- ing an answer, there Avould seem to be some process going on in the mind, and an incoherent mumbling is often indulged in, but it is highly probable that Fields does not himself knoAV hoAV he derhes his ansAvers. Certain it is that he is unable to explain the process, nor has any one ever been able to draw from him anything concerning it. Almost the only thing he knows about the poAver is that he possesses it, and, Avhile he is not altogether aA'erse to receiving money for his work, he has steadily refused to alloAv himself to be exhibited." In revieAving the peculiar endowment of Fields, the Chicago Record says :— " Hoav this feat is performed is as much a mystery as the process by which he solves a problem in arithmetic. He ansAvers no questions. Rapid mathematicians, men of study, avIio by intense application and short methods have become expert, have sought to probe these two mysteries, but Avithout results. Indeed, the man's intelligence is of so low an order as to prevent him from aiding those who seek to know. AVith age, too, he grows more surly. Of Avhat \^ast value this ' gift' might be to the Avorld of science, if coupled Avith average intelligence, is readily imagined. That it will ever be understood is unlikely. As it is, the power staggers belief and makes modern psychology, with its study of brain-cells, stand aghast. As to poor Fields himself, he excites only sympathy. Homeless, unkempt, and uncouth, traveling aimlessly on a journey which he does not understand, he hugs to his heart a marvelous poAver, Avhich he declares to be a gift from God. To his weak mind it lifts him above his fellow-men, and yet it is as useless to the Avorld as a diamond in a dead man's hand." Wolf-Children.—It is interesting to knoAV to what degree a human being will resemble a beast when deprived of the association with man. AVe seem to get some insight to this question in the investigation of so-called cases of " wolf-children." WOLF-CHILDREN 445 Saxo Grammaticus speaks of a bear that kidnapped a child and kept it a long time in his den. The tale of the Roman she-wolf is Avell known, and may have been something more than a myth, as there have been several apparently authentic cases reported in which a child has been rescued from its associations Avith a Avolf who had stolen it some time previously. Most of the stories of Avolf-children come from India. According to Oswalda in Ball's "Jungle Life in India," there is the following curious account of two children in the Orphanage of Sekandra, near Agra, who had been discovered among Avolves : " A trooper sent by a native Governor of Chandaur to demand payment of some reA'enue Avas passing along the bank of the river about noon when he saAV a large female Avolf leave her den, folloAved by three whelps and a little boy. The boy went on all-fours, and AA'hen the trooper tried to catch him he ran as fast as the Avhelps, and kept up AA'ith the old one. They all entered the den, but were dug out by the people and the boy was secured. He struggled hard to rush into every hole or gully they came near. AVhen he saw a groAvn-up person he became alarmed, but tried to fly at children and bite them. He rejected cooked meat with disgust, but delighted in raAV flesh and bones, putting them under his paAvs like a dog." The other case occurred at Chupra, in the Presidency of Bengal. In March, 1843, a Hindoo mother Avent out to help her husband in the field, and Avhile she was cutting rice her little boy was carried off by a Avolf. About a year afterAvard a wolf, folloAved by several cubs and a strange, ape-like creature, Avas seen about ten miles from Chupra. After a lively chase the nondescript was caught and recognized (by the mark of a burn on his knee) as the Hindoo boy that had disappeared in the rice-field. This boy Avould not eat anything but raw flesh, and could neA^er be taught to speak, but expressed his emotions in an inarticulate mutter. His elbows and the pans of his knees had become horny from going on all-fours Avith his foster mother. In the Avinter of 1850 this boy made seA'eral attempts to regain his freedom, and in the folloAving spring he escaped for good and disappeared in the jungle-forest of Bhangapore. The Zoologist for March, 1888, reproduced a remarkable pamphlet printed at Plymouth in 1852, which has been epitomized in the Lancet, b This interesting paper gives an account of Avolves nurturing small children in their dens. Six cases are given of boys who have been rescued from the maternal care of Avolves. In one instance the lad Avas traced from the moment of his being carried off by a lurking Avolf Avhile his parents Avere Avorking in the field, to the time Avhen, after having been recovered by his mother six years later, he escaped from her into the jungle. In all these cases certain marked features reappear. In the first, the boy Avas very in- offensive, except Avhen teased, and then he groAvled surlily. He would eat anything throAvn to him, but preferred meat, Avhich he devoured with canine a " Zoological Sketches," Philadelphia, 1883, p. 195. b 476, 1888, i., 593. 446 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. voracity. He drank a pitcher of buttermilk at one gulp, and could not be induced to Avear clothing eA'en in the coldest Aveather. He showed the great- est fondness for bones, and gnawed them contentedly, after the manner of his adopted parents. This child had coarse features, a repulsive countenance, was filthy in his habits, and could not articulate a Avord. In another case the child Avas kidnapped at three and recovered at nine. He muttered, but could not articulate. As in the other case, he could not be enticed to wear clothes. From constantly being on all-fours the front of this child's knees and his elboAvs had become hardened. In the third case the father identified a son avIio had been carried away at the age of six, and Avas found four years afterAvard. The intellectual deterioration was not so marked. The boy understood signs, and his hearing was exceedingly acute ; when directed by movements of the hands to assist the cultivators in turning out cattle, he readily comprehended what Avas asked of him; yet this lad, whose Amlpine career was so short, could neither talk nor utter any decidedly articulate sound. The author of the pamphlet expressed some surprise that there Avas no case on record in which a grown man had been found in such association. This curious collection of cases of Avolf-children is attributed to Colonel Sleeman, a well-knoAvn officer, who is known to haATe been greatly interested in the subject, and Avho for a long time resided in the forests of India. A copy, noAV a rarity, is in the South Kensington Museum. An interesting case of a Avolf-child Avas reported many years ago in Chambers' Journal. In the Etwah district, near the banks of the river Jumna, a boy Avas captured from the wolves. After a time this child Avas restored to his parents, who, however, " found him Arery difficult to manage, for he AA-as most fractious and troublesome—in fact, just a caged Avild beast. Often during the night for hours together he Avould give vent to most unearthly yells and moans, destroying the rest and irritating the tempers of his neighbors and generally making night hideous. On one occasion his people chained him by the Avaist to a tree on the outskirts of the village. Then a rather curious incident occurred. It Avas a bright moonlight night, and tAvo Avolf cubs (undoubtedly those in Avhose companionship he had been captured), attracted by his cries Avhile on the prowl, came to him, and Avere distinctly seen to gambol around him with as much familiarity and affection as if they considered him quite one of themselves. They only left him on the approach of morning, Avhen movement and stir again arose in the village. This boy did not survive long. He never spoke, nor did a single ray of human intelligence ever shed its refining light over his debased features." Recently a Avriter in the Badmington Magazine, in speaking of the authen- ticity of wolf-children, says :— " A jemidar told me that when he was a lad he remembered going, Avith others, to see a wolf-child which had been netted. Some time after this, while WOLF- CHILDREN 447 staying at an up-country place called Shaporeooundie, in East Bengal, it Avas my fortune to meet an Anglo-Indian gentleman Avho had been in the Indian civil service for upAvard of thirty years, and had traveled about during most of that time; from him I learned all I Avanted to knoAV of wolf-children, for he not only kneAV of several cases, but had actually seen and examined, near Agra, a child which had been recovered from the Avolves. The story of Romulus and Remus, which all schoolboys and the vast majority of groAvn people regard as a myth, appears in a different light when one studies the question of Avolf-children, and ascertains how it comes to pass that boys are found living on the very best terms Avith such treacherous and rapacious animals as wolves, sleeping with them in their dens, sharing the raw flesh of deer and kids which the she-Avolf provides, and, in fact, leading in all essentials the actual life of a wolf. " A young she-Avolf has a litter of cubs, and after a time her instinct tells her that they will require fresh food. She steals out at night in quest of prey. Soon she espies a Aveak place in the fence (generally constructed of thatching grass and bamboos) AA'hich encloses the compound, or ' unguah,' of a poor villager. She enters, doubtless, in the hope of securing a kid ; and Avhile prowling about inside looks into a hut Avhere a Avoman and infant are soundly sleeping. In a moment she has pounced on the child, and is out of reach before its cries can attract the villagers. Arriving safely at her den under the rocks, she drops the little one among her cubs. At this critical time the fate of the child hangs in the balance. Either it Avill be immediately torn to pieces and devoured, or in a most Avonderful Avay remain in the cave unharmed. In the eArent of escape, the fact may be accounted for in several Avays. Perhaps the cubs are already gorged Avhen the child is thrown before them, or are being supplied Avith solid food before their carnivorous instinct is awakened, so they amuse themsehres by simply licking the sleek, oily body (Hindoo mothers daily rub their boy babies Avith some native Arege- table oil) of the infant, and thus it lies in the nest, by degrees getting the odor of the Avolf cubs, after AA'hich the mother wolf Avill not molest it. In a little time the infant begins to feel the pangs of hunger, and hearing the cubs sucking, soon follows their example. Noav the adoption is complete, all fear of harm to the child from woh'es has gone, and the foster-mother will guard and protect it as though it Avere of her OAvn flesh and blood. " The mode of progression of these children is on all fours—not, as a rule, on the hands and feet, but on the knees and elboAvs. The reason the knees are used is to be accounted for by the fact that, owing to the great length of the human leg and thigh in proportion to the length of the arm, the knee would naturally be brought to the ground, and the instep and top of the toes would be used instead of the sole and heel of the almost inflexible foot. Why the elbow should be employed instead of the hand is less easy to understand, but probably it is better suited to give support to the head and fore-part of the body. 448 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. " Some of these poor waifs have been recovered after spending ten or more years in the felloAVship of wolves, and, though Avild and savage at Hist, have in time become tractable in some degree. They are rarely seen to stand upright, unless to look around, and they ginnv bones in the manner of a dog, holding one end betAveen the forearms and hands, aa bile snarling and snap- ping at everybody avIio approaches too near. The Avolf-child has little except his outAvard form to show that it is a human being Avith a soul. It is a fear- ful and terrible thing, and hard to understand, that the mere fact of a child's complete isolation from its OAvn kind should bring it to such a state of abso- lute degradation. Of course, they speak no language, though some, in time, have learned to make knoAvn their Avants by signs. AVhen first taken they fear the approach of adults, and, if possible, Avill slink out of sight; but should a child of their oavii size, or smaller, come near, they Avill groAvl, and even snap and bite at it. On the other hand, the close proximity of " pa- riah " dogs or jackals is unresented, in some cases welcomed ; for I have heard of them sharing their food with these animals, and even petting and fondling them. They have in time been brought to a cooked-meat diet, but would ahvays prefer raw flesh. Some have been kept alive after being reclaimed for as long as tAvo years, but for some reason or other they all sicken and die, generally long before that time. One would think, however, that, having undoubtedly robust constitutions, they might be saved if treated in a scientific manner and properly managed." Rudyard Kipling, possibly inspired by accounts of these Avolf-children in India, has ingeniously constructed an interesting series of fabulous stories of a child who was brought up by the beasts of the jungles and taught their habits and their mode of communication. The ingenious way in Avhich the author has woacii the facts together and interspersed them Avith his intimate knoAvledge of animal-life commends his " Jungle-Book " as a legiti- mate source of recreation to the scientific observer. Among observers mentioned in the " Index Catalogue " who have studied this subject are Giglioli,a Mitra,b and Ornstein.c The artificial manufacture of " wild men " or " wild boys " in the Chinese Empire is shown by recent reports. MacgoAvan d says the traders kid- nap a boy and skin him alive bit by bit, transplanting on the denuded surfaces the hide of a bear or dog. This process is most tedious and is by no means complete when the hide is completely transplanted, as the subject must be ren- dered mute by destruction of the vocal cords, made to use all fours in Avalking, and submitted to such degradation as to completely blight all reason. It is said that the process is so severe that only one in five survive. A " wild boy " ex- hibited in Kiangse had the entire skin of a dog substituted and Avalked on all fours. It was found that he had been kidnapped. His proprietor Avas decapi- a "Arch, per l'Antrop.," Firenze, 1882, xii.,49. b J.Anthrop. Soc,Bombay, 1893, iii., 107. c " Verhandl. d. Berl. Gesselsch. f. Anthrop.," 1891, 817. d 616, 1893, viii., 34. EQUILIBRISTS. 449 tated on the spot. MacgOAvan says that parasitic monsters are manufactured in China by a similar process of transplantation. He adds that the depriva- tion of light for several years renders the child a great curiosity, if in conjunc- tion its growth is dwarfed by means of food and drugs, and its vocal apparatus destroyed. A certain priest subjected a kidnapped boy to this treatment and exhibited him as a sacred deity. Macgowan mentions that the child looked like wax, as though continually fed on lardaceous substances. He squatted Avith his palms together and Avas a driveling idiot. The monk Avas discov- ered and escaped, but his temple Avas razed. Equilibrists.—Many individuals have cultivated their senses so acutely that by the eye and particularly by touch they are able to perform almost in- credible feats of maintaining equilibrium under the most difficult circumstances. Professional rope-walkers have been known in all times. The Greeks had a particular passion for equilibrists, and called them " neurobates," " ori- bates," and " stsenobates." Blondin would have been one of the latter. An- tique medals showing equilibrists making the ascent of an inclined cord haA'e been found. The Romans had walkers both of the slack-rope and tight-rope. Alany of the Fathers of the Church have pronounced against the dangers of these exercises. Among others, St. John Chrysostom speaks of men Avho execute movements on inclined ropes at unheard-of heights. In the ruins of Herculaneum there is still visible a picture representing an equilibrist execut- ing several different exercises, especially one in which he dances on a rope to the tune of a double flute, played by himself. The Romans particularly liked to witness ascensions on inclined ropes, and sometimes these Avere attached to the summits of high hills, and Avhile mounting them the acrobats performed dif- ferent pantomimes. It is said that under Charles VI. a Genoese acrobat, on the occasion of the arrival of the Queen of France, carried in each hand an illuminated torch Avhile descending a rope stretched from the summit of the toAvers of Notre Dame to a house on the Pont au Change. According to Guyot-Daubes, a similar performance was seen in London in 1547. In this instance the rope Avas attached to the highest pinnacle of St. Paul's Cathedral. Under Louis XII. an acrobat' named Georges Menustre, during a passage of the King through Macon, executed several performances on a rope stretched from the grand toAver of the Chateau and the clock of the Jacobins, at a height of 156 feet. A similar performance Avas gh7en at Milan before the French Ambassadors, and at Venice under the Doges and the Senate on each St. Mark's Day, rope-walkers performed at high altitudes. In 1649 a man attempted to traverse the Seine on a rope placed betAveen the Tour de Nesles and the Tour du Grand-Prevost. The performance, however, was interrupted by the fall of the mountebank into the Seine. At subsequent fairs in France other acrobats haATe appeared. At the commencement of this century there Avas a person named Madame Saqui who astonished the public with her nimbleness and extraordinary skill in rope-walking. Her specialty 29 450 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Avas military maneuvers. On a cord 20 meters from the ground she executed all sorts of military pantomimes Avithout assistance, shooting off phtols, rockets, and various colored fires. Napoleon aAvarded her the title of the first acrobat of France. She gave a performance as late as 1S(J1 at the Hippo- drome of Paris. In 1814 there Avas a Avoman called "La Malaga," avIio, in the presence of the allied sovereigns at Versailles, made an ascension on a rope 200 feet above the SavIss Lake. In the present generation probably the most famous of all the equilibrists Avas Blondin. This person, AA'hose real name Avas Eniile Gravelet, acquired a universal reputation ; about I860 he traversed the Niagara Falls on a cable at an elevation of nearly 200 feet. Blondin introduced many novelties in his per- formances. Sometimes he Avould carry a man over on his shoulders ; again he Avould eat a meal Avhile on hisAvire ; cook and cat an omelet, using a table and ordinary cooking utensils, all of Avhich he kept balanced. In France Blondin Avas almost the patron saint of the rope-Avalkers ; and at the present day the performers imitate his feats, but never Avith the same grace and per- fection. In 1882 an acrobat bearing the natural name of Arsons Blondin traversed one river after another in France on a Avire stretched at high altitudes. AVith the aid of a balancing-rod he Avalked the rope blindfolded ; AA'ith baskets on his feet; sometimes he Avheeled persons OA'er in a Avheelbarrow. He Avas a man of about thirty, short, but Avonderfully muscled and extremely supple. It is said:m that a negro equilibrist named Malcom several times traA'ersed the Mouse at Sedan on a Avire at about a height of 100 feet. Once Avhile attempting this feat, Avith his hands and feet shackled Avith iron chains, alloAving little moA'ement, the support on one side fell, after the cable had parted, and landed on the spectators, killing a young girl and Avounding many others. Malcom Avas precipitated into the river, but AA'ith Avonderful presence of mind and remarkable strength he broke his bands and saa am to the shore, none the Averse for his high fall; he immediately helped in attention to his Avounded spectators. A close inspec- tion of all the exhibitionists of this class Avill sIioav that they are of superior physique and calm courage. They only acquire their ability after long gym- nastic exercise, as AA'ell as actual practice on the rope. Most of these persons used means of balancing themselves, generally a long and heaA'v pole ; but some used nothing but their outstretched arms. In 1895, at the Royal Aquarium in London, there Avas an individual Avho sIoavIv mounted a long Avire reaching to the top of this huge structure, and, after haA'ing made the ascent, Avithout the aid of any means of balancing but his arms, slid the Avhole length of the Avire, landing AA'ith enormous A'elocitv into an outstretched net. JUGGLERS. 451 The equilibrists mentioned thus far have invariably used a tightly stretched rope or Avire ; but there are a number of persons Avho perform feats of course not of such magnitude, on a slack Avire, in which they haAre to defy not only the force of gravity, but the to-and-fro motion of the cable as well. It is particularly Avith the Oriental performers that we see this exhibition. Some use open parasols, which, Avith their Chinese or Japanese costumes, render the performance more picturesque ; Avhile others seem to do equally Avell Avithout such adjuncts. There have been performers of this class who play Avith sharp daggers Avhile maintaining themselves on thin and sAvinging wires. Another class of equilibrists are those who maintain the upright position, resting on their heads Avith their feet in the air. At the Hippodrome in Paris some years since there was a man who remained in this position seven minutes and ate a meal during the interval. There Avere tAvo cIoavus at the Cirque Franconi Avho duplicated this feat, and the program called their din- ner " Un dejeuner en ttte-d,-ttte" Some other persons perform Avonderful feats of a similar nature on an oscillating trapeze, and many similar per- formances haA'e been Avitnessed by the spectators of our large circuses. The * * human pyramids '' are interesting, combining, as they do, AAron- derful poAver of maintaining equilibrium with agility and strength. The rapidity Avith Avhich they are formed and are tumbled to pieces is marvelous ; they sometimes include as many as 16 persons—men, women, and children. The exhibitions given by the class of persons commonly designated as " Juggiers " exemplify the perfect control that by continual practice one may obtain over his various senses and muscles. The most Avonderful feats of dexterity arc thus reduced into mere automatic moA^ements. Either standing, sitting, mounted on a horse, or even on a Avire, they are able to keep three, four, five, and even six balls in continual motion in the air. They use articles of the greatest difference in specific gravity in the same manner. A. juggler called " Kara," appearing in London and Paris in the summer of 1895, juggled Avith an open umbrella, an eye-glass, and a traveling satchel, and received each after its course in the air Avith unerring precision. Another man called " Paul Cinquevalli," Avell knoAvn in this country, does not hesi- tate to juggle Avith lighted lamps or pointed knives. The tricks of the cloAvns Avith their traditional pointed felt hats are Avell knoAvn. Recently there appeared in Philadelphia a man Avho recehred six such hats on his head, one on top of the other, throAvn by his partner from the rear of the first balcony of the theater. Others Avill place a number of rings on their fingers, and with a sAvift and dexterous movement toss them all in the air, catching them again all on one finger. AVithout resorting to the fabulous method of Colum- bus, they balance eggs on a table, and in extraordinary Avays defy all the poAvers of gravity. In India and China Ave see the most marvelous of the knife-jugglers. 452 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. With unerring skill they keep in motion many pointed knives, ahvays receiving them at their fall by the handles. They throAv their implements Avith such precision that one often sees men, avIio, placing their partner against a soft board, will stand at some distance and so pen him in with daggers that he cannot move until some are AvithdraAvn, marking a silhouette of his form on the board,—yet never once does one as much as graze the skin. AVith these same people the foot-jugglers are most common. These persons, both male and female, will Avith their feet juggle substances and articles that it requires several assistants to raise. A curious trick is given by Roussolet in his magnificent Avork entitled "Elude des Rajahs," and quoted by Guyot-Daubes. It is called in India the "dance of the eggs." The dancer, dressed in a rather short skirt, places on her head a large a\ heel made of light Avood, and at regular intervals haA'- ing hanging from it pieces of thread, at the ends of Avhich are running knots kept open by beads of glass. She then brings forth a basket of e^^, and passes them around for inspection to assure her spectators of their genuine- ness. The monotonous music commences and the dancer sets the Avheel on her head in rapid motion; then, taking an egg, Avith a quick movement she puts it on one of the running knots and increases the A'elocitv of the revolu- tion of the Avheel by gyrations until the centrifugal force makes each cord stand out in an almost horizontal line Avith the circumference of the Avheel. Then one after another she places the eggs on the knots of the cord, until all are flying about her head in an almost horizontal position. At this moment the dance begins, and it is almost impossible to distinguish the features of the dancer. She continues her dance, apparently indifferent to the revolving eggs. At the A'elocitv Avith Avhich they revolve the slightest false moA'ement Avould cause them to knock against one another and surely break. Finally, Avith the same lightning-like moAcmcnts, she reniOA'es them one by one, cer- tainly the most delicate part of the trick, until they are all safely laid aAvay in the basket from Avhich they came, and then she suddenly brings the Avheel to a stop; after this Avonderful performance, lasting possibly thirty minutes, she boAvs herself out. A unique Japanese feat is to tear pieces of paper into the form of butter- flies and launch them into the air about a vase full of flowers; then Avith a fan to keep them in motion, making them light on the floAvers, fly away, and return, after the manner of several living butterflies, Avithout alloAving one to fall to the ground. Marksmen.—It Avould be an incomplete paper on the acute development of the senses that did not pay tribute to the men Avho exhibit marvelous skill with firearms. In the old frontier days in the Territories, the Avoodsmen far eclipsed Tell Avith his boAv or Robin Hood's famed band by their unerring aim Avith their rifles. It is only lately that there disappeared in this country the last of many Avoodsmen, avIio, though standing many paces aAvay and VENTRIL 0 Q UISTS. 453 without the aid of the improved sights of modern guns, could by means of a rifle-ball, Avith marvelous precision, drive a nail "home" that had been placed partly in a board. The experts who shoot at glass balls rarely miss, and Avhen Ave consider the number used each year, the proportion of inaccurate shots is surprisingly small. Ira Paine, Doctor Carver, and others have been seen in their marvelous performances by many people of the present genera- tion. The records made by many of the competitors of the modern army- shooting matches arc none the less wonderful, exemplifying as they do the degree of precision that the eye may attain and the control Avhich may be developed over the nerves and muscles. The authors know of a country- man avIio successfully hunted squirrels and small game by means of pebbles throAvn Avith his hand. Physiologic Avonders are to be found in all our modern sports and games. In billiards, base-ball, cricket, tennis, etc., there are experts Avho are really physiologic curiosities. In the trades and arts Ave see development of the special senses that is little less than marvelous. It is said that there are AA-orkmen in Krupp's gun factory in Germany who ha\re such control over the enormous trip hammers that they can place a Avatch under one and let the hammer fall, stopping it Avith unerring precision just on the crystal. An expert tool juggler in one of the great English needle factories, in a recent test of skill, performed one of the most delicate mechanical feats imaginable. He took a common sewing needle of medium size (length If inches) and drilled a hole through its entire length from eye to point—the opening being just large enough to admit the passage of a very fine hair. Another Avorkman in a Avatch-factory of the United States drilled a hole through a hair of his beard and ran a fiber of silk through it. Ventriloquists, or " tAvo-voiced men," are interesting anomalies of the present day ; it is common to see a person who possesses the power of speak- ing Avith a A'oice apparently from the epigastrium. Some acquire this faculty, Avhile Avith others it is due to a natural resonance, formed, according to Dupont, in the space betAveen the third and fourth ribs and their cartilaginous union and the middle of the first portion of the sternum. Examination of many of these cases proves that the vibration is greatest here. It is certain that ventriloquists have existed for many centuries. It is quite pos- sible that some of the old Pagan oracles were simply the deceptions of priests by means of ventriloquism. Dupont, Surgeon-in-chief of the French Army about a century since, examined minutely an individual professing to be a ventriloquist. AVith a stuffed fox on his lap near his epigastrium, he imitated a conA'ersation with the fox. By lying on his belly, and calling to some one supposed to be beloAv the surface of the ground, he Avould imitate an ansAver seeming to come from the depths of the earth. AVith his belly on the ground he not only made the illusion more complete, but in this Avay he smothered " the epigastric voice." 454 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. He AA'as ahvays noticed to place the inanimate objects Avith Avhich he held con- versations near his umbilicus. Aentriloquists must not be confounded Avith persons avIio by means of skilful mechanisms, creatures Avith moA'able fauces, etc., imitate ventriloquism. The latter class are in no sense of the Avord true \Tentriloquists, but simulate the anomaly by quickly changing the tones of their voice in rapid succes- sion, and thus seem to make their puppets talk in many different voices. After having acquired the ability to suddenly change the tone of their voice, they practise imitations of the A'oices of the aged, of children, dialects, and feminine tones, and, Avith a set of mechanical puppets, are ready to appear as ventriloquists. By contraction of the pharyngeal and laryngeal muscles they also imitate tones from a distance. Some give their performance Avith little labial movement, but close inspection of the ordinary performer of this class sIioavs visible movements of his lips. The true ventriloquist pretends only to speak from the belly and needs no mechanical assistance. The Avonderful poAvers of mimicry displayed by expert A'entriloquists are marvelous ; they not only imitate individuals and animals, but do not hesi- tate to imitate a conglomeration of familiar sounds and noises in such a man- ner as to deceive their listeners into believing that they hear the discussions of an assemblage of people. The following description of an imitation of a domestic riot by a Chinese ventriloquist is given by the author of " The Chinaman at Home " and avcII illustrates the extent of their abilities : " The ventriloquist Avas seated behind a screen, where there Avere only a chair, a table, a fan, and a ruler. AVith this ruler he rapped on the table to enforce silence, and Avhen everybody had ceased speaking there was suddenly heard the barking of a dog. Then Ave heard the movements of a woman. She had been Avaked by the dog and Avas shaking her husband. AVe were just expecting to hear the man and wife talking together when a child began to cry. To pacify it the mother gave it food ; Ave could hear it drinking and crying at the same time. The mother spoke to it soothingly and then rose to change its clothes. Meanwhile another child had wakened and Avas begin- ning to make a noise. The father scolded it, Avhile the baby continued cry- ing. By-and-by the Avhole family Avent back to bed and fell asleep. The patter of a mouse was heard. It climbed up some A7ase and upset it. AVe heard the clatter of the vase as it fell. The Avoman coughed in her sleep. Then cries of " Fire ! fire ! " Avere heard. The mouse had upset the lamp ; the bed curtains Avere on fire. The husband and Avife Avaked up, shouted, and screamed, the children cried, people came running and shouting. Children cried, dogs barked, squibs and crackers exploded. The fire brigade came racing up. AVater Avas pumped up in torrents and hissed in the flames. The representation aa^s so true to life that every one rose to his feet and Avas start- ing aAvay AA'hen a second bloAV of the ruler on the table commanded silence. We rushed behind the screen, but there was nothing there except the ven- triloquist, his table, his chair, and his ruler." ATHLETIC FEATS. 455 Athletic Feats.—The ancients called athletes those who were noted for their extraordinary agility, force, and endurance. The history of athletics is not foreign to that of medicine, but, on the contrary, the tAvo are in many Avavs intimately blended. The instances of feats of agility and endurance are in every sense of the Avord examples of physiologic and functional anomalies, and have in all times excited the interest and investigation of capable physicians. The Greeks Avere famous for their love of athletic pastimes ; and classical study serves poAverfully to strengthen the belief that no institution exercised greater influence than the public contests of Greece in molding national character and producing that admirable type of personal and intellectual beauty that Ave see reflected in her art and literature. These contests Avere held at four national festivals, the Olympian, the Pythian, the Nemean, and the Isthmean games. On these occasions every one stopped labor, truce Avas declared behveen the States, and the Avhole country paid tribute to the con- testants for the highly-prized laurels of these games. Perhaps the enthusiasm shoAvn in athletics and interest in physical deA7elopment among the Greeks has never been equaled by any other people. Herodotus and all the Greek writers to Plutarch have elaborated on the glories of the Greek athlete, and tell us of the honors rendered to the A'ictors by the spectators and the van- quished, dAvelling Avith complacency on the fact that in accepting the laurel they cared for nothing but honor. The Romans in " ludi publici," as they called their games, Avere from first to last only spectators ; but in Greece every eligible person aahs an active participant. In the regimen of diet and training the physicians from the time of Hippocrates, and ev^en before, have been the originators and professional advisers of the athlete. The change in the manner of living of athletes, if Ave can judge from the Avritings of Hippo- crates, Avas anterior to his time ; for in Book AT. of the "Epidemics" Ave read of Bias, Avho, " suapte natura vorax, in choleram-morbum incidit ex earnium esu, pneeipueque suillarum crudarum, etc." From the time of the Avell-knoAvn fable of the hero avIio, by practising dailv from his birth, avus able to lift a full-grown bull, thus gradually accustoming himself to the increased Aveight, physiologists and scientists have collaborated AA'ith the athlete in evolving the present ideas and system of training. In his aphorisms Hippocrates bears Avitness to the dangers of over- exercise and superabundant training, and Galen is particularly averse to an art Avhich so preternaturally develops the constitution and nature of man ; manv subsequent medical authorities believed that excessive development of the human frame Avas necessarily followed by a compensatory shortening of life. The foot-race Avas the oldest of the Greek institutions, and in the first of the Olympiads the " dromos," a course of about 200 yards, Avas the only con- test ; but gradually the " dialers," in Avhich the course Avas double that of the 456 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. dromos, Avas introduced, and, finally, tests of endurance as Avell as speed were instituted in the long-distance races and the contests of racing in heavy armor, which Avere so highly commended by Plato as preparation for the arduous duties of a soldier. Among the Greeks Ave read of Lasthenes the Theban, Avho vanquished a horse in the course; of Polynmestor, who chased and caught a hare ; and Philonides, the courier of Alexander the (Jreal, who in nine hours traversed the distance between the (Jreck cities Sieyone and Elis, a distance of over 150 miles. AVe read of the famous soldier of Marathon, avIio ran to announce the victory to the Magistrates of Athens and fell dead at their feet. In the Olympian games at Athens in 1X96 this distance (about 26 miles) Avas traversed in less than three hours. It is said of Euchidas, who carried the fire necessary for the sacrifices which Avere to replace those AA'hich the Persians had spoiled, that he ran a thousand stadia (about 125 miles) and fell dead at the end of his mission. The Roman historians have also recited the extraordinary feats of the cour- iers of their times. Pliny speaks of an athlete who ran 235 kilometers (almost 150 miles) Avithout once stopping. He also mentions a child Avho ran almost half this distance. In the Middle Ages the Turks had couriers of almost supernatural agility and endurance. It is said that the distance some of them would tra- verse in twenty-four hours Avas 120 miles, and that it Avas common for them to make the round trip from Constantinople to Adrianople, a distance of 80 leagues, in two days. They Avere dressed very lightly, and by constant usage the soles of their feet Avere transformed into a leathery consistency. In the last century in the houses of the rich there were couriers Avho preceded the carriages and Avere knoAvn as " Basques," Avho could run for a very long time Avithout apparent fatigue. In France there is a common proverb, " Courir comme un Basque." Rabelais says : " Grand-Gousier depeche le Basque son laquais pour querir Gargantua en toute hate." In the olden times the English nobility maintained running footmen Avho, living under special regimen and training, were enabled to traverse unusual distances Avithout apparent fatigue. There is an anecdote of a noble- man living in a castle not far from Edinburgh, avIio one evening charged his courier to carry a letter to that city. The next morning Avhen he arose he found this A'alet sleeping in his antechamber. The nobleman Avaxed wroth, but the courier gave him a response to the letter. He had traveled 70 miles during the night. It is said that one of the noblemen under Charles II. in preparing for a great dinner perceived that one of the indispensable pieces of his service Avas missing. His courier was dispatched in great haste to another house in his domain, 15 miles distant, and returned in two hours Avith the necessary article, haA'ing traversed a distance of over 30 miles. It is also said394that a courier carrying a letter to a London physician returned Avith the potion prescribed Avithin twenty-four hours, having traversed 148 FEATS OF RUNNING. 457 miles. There is little doubt of the ability of these couriers to tire out any horse. The couriers who accompany the diligences in Spain often fatigue the animals who draw the vehicles. At the present time in this country the Indians furnish examples of marvelous feats of running. The Tauri-Mauri Indians, who live in the heart of the Sierra Mad re Mountains, are probably the most wonderful long-dis- tance runners in the Avorld. Their name in the language of the mountain Mexicans means foot-runners ; and there is little doubt that they perform athletic feats which equal the best in the days of the Olympian games. They are possibly the remnants of the Avonderful runners among the Indian tribes in the beginning of this century. There is an account of one of the Tauri- Mauri Avho was mail carrier betAveen Guarichic and San Jose de los Cruces, a distance of 50 miles of as rough, mountainous road as ever tried a moun- taineer's lungs and limbs. Bareheaded and barelegged, with almost no clothing, this man made this trip each day, and, carrying on his back a mail- pouch Aveighing 40 pounds, moved gracefully and easily over his path, from time to time increasing his speed as though practising, and then again more sloAvly to smoke a cigarette. The Tauri-Mauri are long-limbed and slender, giving the impression of being above the average height. There is scarcely any flesh on their puny arms, but their legs are as muscular as those of a greyhound. In short running they have the genuine professional stride, something rarely seen in other Indian racers. In traversing long distances they leap and bound like deer. " Deerfoot," the famous Indian long-distance runner, died on the Catta- raugus Reservation in January, 1896. His proper name was Louis Bennett, the name " Deerfoot" having been given to him for his prowess in running. He Avas born on the reservation in 1828. In 1861 he Avent to England, where he defeated the English champion runners. In April, 1863, he ran 11 miles in London in fifty-six minutes fifty-two seconds, and 12 miles in one hour tAvo minutes and tAvo and one-half seconds, both of which have stood as Avorld's records ever since. In Japan, at the present day, the popular method of conveyance, both in cities and in rural districts, is the tAVO-Avheeled vehicle, looking like a baby- carriage, knoAvn to foreigners as the jinrickisha, and to the natives as the kuruma. In the city of Tokio there is estimated to be 38,000 of these little carriages in use. They are draAvn by coolies, of Avhose endurance remark- able stories are told. These men wear light cotton breeches and a blue cotton jacket bearing the license number, and the indispensable umbrella hat. In the course of a journey in hot weather the jinrickisha man will gradually remove most of his raiment and stuff it into the carriage. In the rural sections he is covered Avith only two strips of cloth, one Avrapped about his head and the other about his loins. It is said that when the roadway is good, these " human horses " prefer to travel bare-footed; when working in 458 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. the mud they Avrap a piece of straAv about each big toe, to preA'ent slipping and to give them a firmer grip. For any of these men a five-mile spurt on a good road Avithout a breathing spell is a small affair. A pair of them Avill roll a jinrickisha along a country road at the rate of four miles an hour, and they Avill do this eight hours a day. The general aA'erage of the distance traversed in a day is 25 miles. Cockerill, avIio has recently described these men, says that the majority of them die early. The terrible physical strain brings on hypertrophy and A-ahular diseases of the heart, and many of them suffer from hernia. Occasionally one sees a veteran jinrickisha man, and it is interesting to note how tenderly he is helped by his confreres. They give him preference as regards Avages, help push his vehicle up heavy grades, and shoAv him all manner of consideration. Figure 180 represents two Japanese porters and their usual load, AA'hich is much more difficult to transport than a jinrickisha carriage. In other Eastern countries, palanquins and other means of conveyance are still borne on the shoulders of couriers, and it is not so long since our ancestors made their calls in Sedan-chairs borne by sturdy porters. Some of the letter-car- riers of India make a daily journey of 30 miles. They carry in one hand a stick, at the extremity of Avhich is a ring containing seAreral little plates of iron, AA'hich, agitated during the course, produce a loud noise designed to keep off ferocious beasts and serpents. In the other hand they carry a Avet cloth, with Avhich they frequently refresh themselves by wiping the countenance. It is said that a regular Hindustanee carrier, Avith a Aveight of 80 pounds on his shoulder,—carried, of course, in two divisions, hung on his neck by a yoke,—will, if properly paid, lope along over 100 miles in twenty-four hours—a feat which Avould exhaust any but the best trained runners. The "go-as-you-please" pedestrians, whose powers during the past years have been exhibited in this country and in England, have given us marvelous examples of endurance, over 600 miles having been accomplished in a six-days' contest. Hazael, the professional pedestrian, has run over 450 miles in ninety-nine hours, and Albert has traveled over 500 miles in one hundred and ten hourg. RoAvell, Hughes, and Fitzgerald have astonishingly high records for long-distance running, comparing favorably Avith the older, and presum- ably mythical, feats of this nature. In California, C. A. Harriman of Fig. 180.—Japanese porters. LONG-DISTANCE RUNNERS. 459 Truckee in April, 1883, Avalked twenty-six hours without once resting, traversing 122 miles. For the purpose of comparison we give the best modem records for running:— 100 Yards.—9if seconds, made by Edward Donavan, at Natick, Mass., September 2,1895. 220 Yards.—21% seconds, made by Harry Jewett, at Montreal, September 24, 1892. Quarter-Mile—¥1% seconds, made by W. Baker, at Boston, Mass., July 1, 1886. Half-Mile.—1 minute 53| seconds, made by C. J. Kirkpatrick, at Manhattan Field, New York, September 21, 1895. 1 Mile.—4 minutes 12| seconds, made by W. G. George, at London, England, August 23, 1886. 5 Mill's.—24 minutes 40 seconds, made by J. White, in England, May 11, 1863. 10 Miles.—51 minutes 6| seconds, made by William Cummings, at London, England, September 18, 1895. 25 Miles.—2 hours 33 minutes 44 seconds, made by G. A. Dunning, at London, England, December 26, 1S81. 50 Miles.—5 hours 55 minutes 4V seconds, made by George Cartwright, at London, Eng- land, February 21, 1887. 75 Mites.—8 hours 48 minutes 30 seconds, made by George Littlewood, at London, Eng- land, November 24, 1884. 100 Mites.—13 hours 26 minutes 30 seconds, made by Charles Rowell, at New York, February 27, 1882. In instances of long-distance traversing, rapidity is only a secondary consideration, the remarkable fact being in the endurance of fatigue and the continuity of the exercise. William Galea Avalked 1500 miles in a thousand consecutive hours, and then Avalked 60 miles every tAventy-four hours for six Aveeks on the Lillie Bridge cinder_ path. He Avas five feet five inches tall, forty-nine years of age, and Aveighed 121 pounds, and Avas but little developed muscularly. He Avas in good health during his feat; his diet for the tAventv- four hours avus lh pounds of meat, five or six eggs, some cocoa, tAvo quarts of milk, a quart of tea, and occasionally a glass of bitter ale, but never Avine nor spirits. Strange to say, he suffered from constipation, and took daily a com- pound rhubarb pill. He was examined at the end of his feat by Gant. His pulse avus 75, strong, regular, and his heart was normal. His temperature Avas 97.25° F., and his hands and feet warm; respirations Avere deep and averaged 15 a minute. He suffered from frontal headache and Avas droAvsy. During the six Aveeks he had lost only seven pounds, and his appetite maintained its normal state. Zeuner of Cincinnatib refers to John Snyder of Dunkirk, whose Avalk- ing feats AA'ere marvelous. He was not an impostor. During forty-eight hours he was AA'atched by the students of the Ohio INIedical College, Avho stated that he Avalked constantly ; he assured them that it did not rest him to sit (Ioavii, but made him uncomfortable. The celebrated Weston walked 5000 miles in one hundred days, but Snyder was said to hav^e traveled a ±M, 1881. i., <;:!. b 224, 1887, 321. 460 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 25,000 miles in fh'e hundred days and Avas apparently no more tired than Avhen he began. Recently there Avas a person avIio pushed a AvheelbarroAv from San Francisco to New York in one hundred and eighteen days. In 1809 the celebrated Captain Barclay Avagcrcd that he could Avalk 1000 miles in one thousand consecutive hours, and gained his bet Avith some hours to spare. In 1834 Ernest Mensen astonished all Europe by his pedestrian exploits. lie Avas a Noi'Avegian sailor, Avho Avagered that he could Avalk from Paris to Moscoav in fifteen days. On June 25, 1834, at ten o'clock a. ai., he entered the Kremlin, after having traversed 2500 kilometers (1550 miles) in fourteen days and eighteen hours. His performances all over Europe avc re so mar- velous as to be almost incredible. In 1836, in the service of the East India Company, he Avas dispatched from Calcutta to Constantinople, across Central Asia. He traversed the distance in fifty-nine days, accomplishing 9000 kilometers (5580 miles) in one-third less time than the most rapid caravan. He died while attempting to discover the source of the Nile, having reached the village of Syang. A most marvelous feat of endurance is recorded in England in the first part of this century. It is said that on a Avager Sir Andrew Leith Hay and Lord Kennedy walked tAvo days and a night under pouring rain, over the Grampian range of mountains, Avading all one day in a bog. The distance traversed was from a village called Banchory on the rh^er Dee to Inverness. This feat Avas accomplished without any previous preparation, both men start- ing shortly after the time of the wager. Riders.—The feats of endurance accomplished by the couriers who ride great distances Avith many changes of horses are noteAvorthy. According to a contemporary medical journala there is, in the Friend of India, an account of the Thibetan couriers Avho ride for three Aveeks Avith intervals of only half an hour to eat and change horses. It is the duty of the officials at the Dak bungaloAVS to see that the courier makes no delay, and even if dying he is tied to his horse and sent to the next station. The celebrated English huntsman, " Squire " Osbaldistone, on a Avager rode 200 miles in seven hours ten minutes and four seconds. He used 28 horses; and as one hour twenty- tAvo minutes and fifty-six seconds were alloAved for stoppages, the Avhole time, changes and all, occupied in accomplishing this Avonderful feat Avas eight hours and forty-two minutes. The race was ridden at the NeAvmarket Houghton Meeting OA7er a four-mile course. It is said that a Captain Home of the Madras Horse Artillery rode 200 miles on Arab horses in less than ten hours along the road betAveen Madras and Bangalore. When Ave consider the sloAver speed of the Arab horses and the roads and climate of India, this per- formance equals the 200 miles in the shorter time about an English race track and on thoroughbreds. It is said that this Avonderful horseman lost a 548, 1868, i., 515. LONG DISTANCE SWIMMING.* 461 his life in riding a horse named "Jumping Jenny" 100 miles a dav for eio-ht days. The heat Avas excessive!, and although the horse was none the worse for the performance, the Captain died from the exposure he encountered. There is a record of a Mr. Bacon of the Bombay Civil Service, avIio rode one camel from Bombay to Allygur (perhaps 800 miles) in eight davs. As regards the physiology of the runners and walkers, it is quite in- teresting to follow the effects of training on the respiration, Avhereby in a measure is explained the ability of these persons to maintain their respiratory function, although excessively exercising. A curious discussion, persisted in since antiquity, is as to the supposed influence of the Spleen on the ability of couriers. For ages runners have believed that the spleen Avas a hindrance to their vocation, and that its reduction was folloAved by greater agility on the course. With some, this opinion is perpetuated to the present dav. In France there is a proverb, " Courir comme un derate." To reduce the size of the spleen, the Greek athletes used certain beverages, the composition of which AA'as not generally known ; the Romans had a similar belief and habit. Pliny speaks of a plant called eqiiM-Uim, a decoction of which taken for three days after a fast of twenty-four hours Avould effect absorption of the spleen. The modern pharmacopeia does not possess any substance having a similar virtue, although quinin has been noticed to diminish the size of the spleen Avhen engorged in malarial fevers. Strictly speaking, however, the facts are not analogous. Hippocrates advises a moxa of mushrooms applied over the spleen for melting or dissolving it. Godefroy Moebius is said to have seen in the village of Halberstadt a courier whose spleen had been cauterized after incision; and about the same epoch (seventeenth century) some men pretended to be able to successfully extirpate the spleen for those who desired to be couriers. This operation we know to be one of the most delicate in modern surgery, and as Ave are progressing with our physiologic knoAvledge of the spleen Ave see nothing to justify the old theory in regard to its relations to agility and coursing. Swimming.—The instances of endurance that Ave see in the aquatic sports are equally as remarkable as those that Ave find among the runners and walkers. In the ancient days the Greeks, lh'ing on their A'arious islands and being in a mild climate, Avere celebrated for their proAvess as SAvimmers. Soc- rates relates the feats of swimming among the inhabitants of Delos. The journeys of Leander across the Hellespont are well celebrated in verse and prose, but this feat has been easily accomplished many times since, and is hardly to be classed as extraordinary. Herodotus says that the Macedonians Avere skilful SAvimmers ; and all the savage tribes about the borders of Avater- Avays are found possessed of remarkable dexterity and endurance in SAvim- ming. In 1875 the celelebrated Captain Webb sAvam from Dover to Calais.* On a 476, 1875, ii., 359. 462 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. landing he felt extremely cold, but his body Avas as Avarm as when he started. He Avas exhausted and very sleepy, falling in deep slumber on his way to the hotel. On getting into bed his temperature Avas 98° F. and his pulse normal. In five hours he Avas feverish, his temperature rising to 101° F. During the passage he AAas blinded from the salt Avater in his eyes and the spray beating against his face. He strongly denied the neAvspaper reports that he Avas de- lirious, and after a good rest AAas apparently none the Avorse for the task. In 1876 he again traversed this passage Avith the happiest issue. In 1883 he avus engaged by speculators to SAvim the rapids at Niagara, and in attempting this Avas overcome by the poAverful currents, and his body Avas not recovered for some davs after. The passage from Dover to Calais has been duplicated. In 1877 Cavill, another Englishman, sAvam from Cape Griz-Nez to South Forland in less than thirteen hours. In 1880 Webb SAvam and floated at Scarborough for seventy-four consecutive hours—of course, having no current to contend Avith and no point to reach. This Avas merely a feat of staying in the AA'ater. In London in 1881, Beck with, sAvimming ten hours a day over a 32-lap course for six days, tniAersed 94 miles. Since the time of Captain Webb, avIio was the pioneer of modern long-distance sAvimming, many men have attempted and some have duplicated his feats ; but these foolhardy per- formances have in late years been diminishing, and many of the older feats are forbidden by hnv. Jumpers and acrobatic tumblers have been popular from the earliest time. By the aid of springing boards and Aveights in their hands, the old jumpers coA7ered great distances. Phayllus of Croton is accredited Avith jumping the incredible distance of ^)i) feet, and Ave haA'e the authority of Eus- tache and Tzetzes a that this jump is genuine. In the Avritings of many Greek and Roman historians are chronicled jumps of about 50 feet by the athletes; if they are true, the modern junipers haA'e greatly degenerated. A jump of OA'er 20 feet to-day is considered A'ery cleA'er, the record being 29 feet seven inches AA'ith AAreights, and 23 feet eight inches Avithout Aveights, although much greater distances haA'e been jumped Avith the aid of apparatus, but neA'er an approximation to 50 feet. The most surprising of all these athletes are the tumblers, avIio turn somersaults OA'er several animals arranged in a roAv. Such feats are not only the most amusing sights of a modern circus, but also the most interesting as avcII. The agility of these men is mar- velous, and the force Avith Avhich they throAV themselves in the air apparently enables them to defy gravity. In London, Paris, or Ncav York one may see these Avonderful tumblers and marvel at the capabilities of human physi- cal deA'elopment. In September, 1895, M. F. SAveeney, an American amateur, at Manhattan Field in Ncav York jumped six feet of inches high in the running high jump Avithout Aveights. With Aveights, J. H. Fitzpatrick at Oak Island, Mass., a 302, vol. 1., 69. EXTRAORDINARY STRENGTH. 463 jumped six feet six inches high. The record for the running high kick is nine feet eight inches, a marvelous performance, made by C. C. Lee at NeAV Haven, Conn., March 19, 1887. Extraordinary physical development and strength has been a grand means of natural selection in the human species. As (J uyot-Daubes remarks, in prehistoric times, Avhen our ancestors had to battle against hunger, savage beasts, and their neighbors, and Avhen the struggle for existence was so extremely hard, the strong man alone resisted and the Aveak succumbed. This natural selection has been perpetuated almost to our day ; during the long succession of centuries, the chief or the master Avas selected on account of his being the strongest, or the most A'aliant in the combat. Originally, the cavaliers, the members of the nobility, Avere those Avho Avere noted for their courage and strength, and to them Avere given the lands of the van- quished. Even in times other than those of war, disputes of succession Avere settled by jousts and tourneys. This fact is seen in the present day among the loAver animals, avIio in their natural state live in tribes ; the leader is usually the strongest, the wisest, and the most courageous. The strong men of all times have excited the admiration of their felloAvs and have ahvays been objects of popular interest. The Bible celebrates the exploits of Samson of the tribe of Dan. During his youth he, single handed, strangled a lion ; Avith the jaAV-bone of an ass he is said to have killed 1000 Philistines and put the rest to flight. At another time during the night he transported from the village of Gaza enormous burdens and placed them on the top of a mountain. Betrayed by Delilah, he Avas delivered into the hands of his enemies and employed in the most servile labors. When old and blind he Avas attached to the columns of an edifice to serve as an object of public ridicule; AA'ith a A'iolent effort he overturned the columns, destroying himself and 3000 Philistines. In the Greek mythology Ave find a great number of heroes, celebrated for their feats of strength and endurance. Many of them have received the name of Hercules ; but the most common of these is the hero Avho Avas sup- posed to be the son of Jupiter and Alcmena. He was endoAA'ed with pro- digious strength by his father, and avus pursued Avith unrelenting hatred by Juno. In his infancy he killed Avith his hands the serpents AA'hich Avere sent to devour him. The legends about him are innumerable. He Avas said to have been armed Avith a massive club, Avhich only he Avas able to carry. The most famous of his feats Avere the tweh'e labors, with AA'hich all readers of mythology are familiar. Hercules, personified, meant to the Greeks physical force as Avell as strength, generosity, and bravery, and Avas equiva- lent to the Assyrian Hercules. The Gauls had a Hercules-Pantopage, who, in addition to the ordinary qualities attributed to Hercules, had an enormous appetite. As late as the sixteenth century, and in a most amusing and picturesque 464 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. manner, Rabelais has gh'en us the history of Gargantua, and even to this day, in some regions, there are groups of stones Avhich are believed by igno- rant people to have been thrown about by Gargantua in his play. In their citations the older authors often speak of battles, and in epic ballads of heroes Avith marvelous strength. In the army of Charlemagne, after Camerarius, and quoted by Guyot-Daubes (avIio has made an extensive collection of the literature on this subject and to Avhom the authors are indebted for much information), there Avas found a giant named Oenother, a native of a village in Suabia, avIio performed marvelous feats of strength. In his history of Bavaria Aventin speaks of this monster. To Roland, the nephew of Charlemagne, the legends attributed prodigious strength ; and, dying in the valley of Roncesvcaux, he broke his good SAA'ord "Durandal" by striking it against a rock, making a breach, which is stilled called the " Breche de Roland." Three years before his death, on his return from Palestine, Chris- topher, Duke of Bavaria, Avas said to have lifted to his shoulders a stone Avhich Aveighed more than 340 pounds. Louis de Boufflers, surnamed the "Robust," Avho lh^ed in 1534, AA'as noted for his strength and agility. When he placed his feet together, one against the other, he could find no one able to disturb them. He could easily bend and break a horseshoe Avith his hands, and could seize an ox by the tail and drag it against its Avill. More than once he Avas said to have carried a horse on his shoulders. According to Guyot-Daubes:m there Avas, in the last century, a Major Barsaba who could seize the limb of a horse and fracture its bone. There Avas a tale of his lift- ing an iron anvil, in a blacksmith's forge, and placing it under his coat. To the Emperor Maximilian I. Avas ascribed enormous strength; even in his youth, Avhen but a simple patriot, he \Tanquished, at the games given by Severus, 16 of the most vigorous wrestlers, and accomplished this feat Avith- out stopping for breath. It is said that this feat Avas the origin of his for- tune. Among other celebrated persons in history endoAved Avith uncommon strength Avere Edmund " Ironsides," King of England ; the Caliph Mostascm- Billah ; Baudouin, " Bras-de-Fer," Count of Flanders ; William IV., called by the French " Fier-a-Bras," Duke of Aquitaine ; Christopher, son of Albert the Pious, Duke of Bavaria ; Godefroy of Bouillon ; the Emperor Charles IV. ; Seanderbeg ; Leonardo da Vinci ; Marshal Saxe ; and the recently deceased Czar of Russia, Alexander III. Turning iioav to the authentic modern Hercules, avc have a man by the name of Eckeberg, born in Anhalt, and Avho traveled under the name of " Samson." He Avas exhibited in London, and performed remarkable feats of strength. He Avas observed by the celebrated Desaguliers (a pupil of NeAAton) in the commencement of the last century, Avho at that time Avas interested in the physiologic experiments of strength and agility. Desaguliers belieA^ed that the feats of this neAV Samson were more due to agility than strength. One day, accompanied by two of his confreres, although a man of MODERN HERCULES. 465 ordinary strength, he duplicated some of Samson's feats, and followed his performance by a communication to the Royal Society. One of his tricks was to resist the strength of five or six men or of two horses. Desaguliers claimed that this Avas entirely due to the position taken. This person Avould lift a man by one foot, and bear a heavy Aveight on his chest when resting Avith his head and t\vo feet on two chairs. By supporting himself Avith his arms he could lift a piece of cannon attached to his feet. A little later Desaguliers studied an individual in London named Thomas Topham, Avho used no ruse in his feats and was not the skilful equilibrist that the German Samson Avas, his performances being merely the results of abnormal physical force. He was about thirty years old, five feet ten inches in height and Avell proportioned, and his mus- cles Avell developed, the strong ligaments showing under the skin. He ignored entirely the art of appearing supernaturally strong, and some of his feats were rendered difficult by disadvantageous positions. In the feat of the German—resisting the force of several men or horses—Topham exhibited no knowledge of the principles of physics, like that of his predecessor, "but, seated on the ground and putting his feet against two stirrups, he Avas able to resist the traction of a single horse ; Avhen he attempted the same feat against two horses he Avas severely strained and wounded about the knees. Accord- ing to Desaguliers, if Topham had taken the advantageous positions of the German Samson, he could have resisted not only Iavo, but four horses. On another occasion, Avith the aid of a bridle passed about his neck, he lifted three hogsheads full of Avater, Aveighing 1386 pounds. If he had utilized the force of his limbs and his loins, like the German, he Avould have been able to perform far more difficult feats. With his teeth he could lift and main- tain in a horizontal position a table OArer six feet long, at the extremity of Avhich he Avould put some Aveight. Tavo of the feet of the table he rested on his knees. He broke a cord five cm. in diameter, one part of Avhich Avas attached to a post and the other to a strap passed under his shoulder. He was able to carry in his hands a rolling-pin weighing 800 pounds, about tAvice the weight a strong man is considered able to lift. Tom Johnson AAras another strong man Avho lived in London in the last century, but he Avas not an exhibitionist, like his predecessors. He was a porter on the banks of the Thames, his duty being to carry sacks of wheat and corn from the Avharves to the Avarehouses. It Avas said that Avhen one of his comrades Avas ill, and could not provide support for his Avife and children, Johnson assumed double duty, carrying twice the load. He could seize a sack of Avheat, and Avith it execute the movements of a club-SAvinger, and with as great facility. He became quite a celebrated boxer, and, besides his strength, he soon demonstrated his poAvers of endurance, never seeming fatigued after a lively bout. The porters of Paris Avere accustomed to lift and carry on their shoulders bags of flour Aveighing 159 kilograms (350 30 466 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. pounds) and to mount stairs with them. Johnson, on hearing this, duplicated the feat AA'ith three sacks, and on one occasion attempted to carry four, and resisted this load some little time. These four sacks Aveighed 1400 pounds. Some years since there AAas a female Hercules Avho Avould get on her hands and knees under a carriage containing six people, and, forming an arch Avith her body, she Avould lift it off the ground, an attendant turning the wheels while in the air to prove that they Avere clear from the ground. Fig. 181.—Extreme muscular development. Fig. 182.—Sandow (after a photograph by Falk). Guyot-Daubes considers that one of the most remarkable of all the men noted for their strength Avas a butcher living in the mountains of Margeride, known as Lapiada (the extraordinary). This man, Avhose strength avus leg- endary in the neighboring country, one day seized a mad bull that had escaped from his stall and held him by the horns until his attendants could bind him. For amusement he Avould lie on his belly and alloAv seATeral men to get on his back ; with this human load he would rise to the erect position. MODERN HERCULES. 467 One of Lapiada's great feats Avas to get under a cart loaded AA'ith hay and, form- ing an arch Avith his body, raise it from the ground, then little by little he would mount to his haunches, still holding the cart and hay. Lapiada ter- minated his Herculean existence in attempting a mighty effort. Having charged himself alone with the task of placing a heavy tree-trunk in a cart, he seized it, his muscles stiffened, but the blood gushed from his mouth and nostrils, and he fell, overcome at last, The end of Lapiada presents an analogue to that of the celebrated athlete, Polydamas, Avho Avas equally the victim of too great confidence in his muscular force, and avIio died crushed by the force that he hoped to maintain. Figures 181 and 183 portray the muscular development of an individual noted for his feats of strength, and Avho exhibited not long since. In recent years we have had Sebastian Miller, Avhose specialty Avas Avrestling and stone- breaking ; Samson, a re- cent English exhibition- ist, Louis Cyr, and San- dow, who, in addition to his remarkable strength and control OArer his mus- cles, is a A'ery cleA'er gym- nast. SandoAv gh'es an excellent exposition of the so-called " checker- board " arrangement of the muscular fibers of the loAver thoracic and ab- dominal regions, and in _,. 1QO ., , . . . . ... , ... , . o ' Fig. 183.—Marked development of the muscles of the back. a brilliant light demon- strates his extraordinary poAver OA'er his muscles, contracting muscles ordinarily involuntary in time Avith music, a feat really more remarkable than his exhibition of strength. Figures 182 and 184 sIioav the beautiful muscular development of this remarkable man. Joseph Pospischilli, a convict recently imprisoned in the Austrian fort- ress of Olen, surprised the Avhole Empire by his AA'onderful feats of strength. One of his tricks avus to add a fifth leg to a common table (placing the use- less addition in the exact center) and then balance it Avith his teeth Avhile two full-grown gipsies danced on it, the music being furnished by a A'iolinist seated in the middle of the well-balanced platform. One day Avhen the prison in Avhich this Hercules Avas confined Avas undergoing repairs, he picked up a 468 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. large carpenter's bench AA'ith his teeth and held it balanced aloft for nearly a minute. Since being released from the Olen prison, Pospischilli and his cousin, another local ''strong man" named Martenstine, have formed a com- bination and are iioav starring Southern Europe, performing all kinds of startling feats of strength. Among other things they have had a 30-foot bridge made of strong timbers, AA'hich is used in one of their great muscle acts. This bridge has tAvo living piers—Pospischilli acting as one and Martenstine the other. Besides supporting this monstrous structure (weight, 1866 pounds) upon their shoulders, these freaks of superhuman strength alloAv a team of horses and a wagon loaded AA'ith a ton of cobble-stones to be driven across it. It is said that Selig Whitman, knoAvn as " Ajax," a Ncav York police- man, has lifted 2000 pounds Avith his hands and has maintained 450 pounds Avith his teeth. This man is five feet Sc- inches tall and Aveighs 162 pounds. His chest meas- urement is 40 inches, the biceps 17 inches, that of his neck 16^ inches, the forearm 11, the Avrist 9-J, the thigh 23, and the calf 17. One of the strongest of the " strong women " is Madame Elise, a French- woman, Avho performs Avith her husband. Her greatest feat is the lifting of eight Fig. 184-Sandow (after a photograph by Sarony). men weighing altogether about 1700 pounds. At her performances she supports across her shoulders a 700-pound dumb-bell, on each side of Avhich a person is suspended. Miss Darnett, the " singing strong lady," extends herself upon her hands and feet, face uppermost, Avhile a stout platform, Avith a semicircular groove for her neck, is fixed upon her chest, abdomen, and thighs by means of a AA'aist-belt which passes through brass receiA'ers on the under side of the board. An ordinary upright piano is then placed on the platform by four men ; a performer mounts the platform and plays while the " strong lady " sings a loA'e song Avhile supporting possibly half a ton. Strength of the Jaws.—There are some persons Avho exhibit extra- ordinary poAver of the jaAV. In the curious experiments of Regnard and STRENGTH OF THE JAWS. 469 Blanchard at the Sorbonne, it Avas found that a crocodile Aveighing about 120 pounds exerted a force betAveen its jaws at a point corresponding to the insertion of the masseter muscles of 1540 pounds ; a dog of 44 pounds exerted a similar force of 363 pounds. It is quite possible that in animals like the tiger and lion the force Avould equal 1700 or 1800 pounds. The anthropoid apes can easily break a cocoa- nut Avith their teeth, and Guyot-Daubes thinks that possibly a gorilla has a jaAV-force of 200 pounds. A human adult is said to exert a force of from 45 to 65 pounds betAveen his teeth, and some individuals exceed this aArerage as much as 100 pounds. In Buffon's experiments he once found a Frenchman avIio could exert a force of 534 pounds Avith his jaAvs. In several American circuses there have been seen Avomen avIio hold themselves by a strap be- tAveen their teeth Avhile they are being hauled up to a trapeze some distance from the ground. A young mulatto girl by the name of" Miss Kerra" exhibited in the Winter Circus in Paris; suspended from a trapeze, she supported a man at the end of a strap held betAveen her teeth, and even permitted herself to be Fig 185 _Signor Law0„da, ■< the iron-jawed man." turned round and round. She also held a cannon in her teeth Avhile it Avas fired. This feat has been done by several others. According to Guyot-Daubes, at Epernay in 1882, while a man named Bucholtz, called " the human cannon," AA'as performing this feat, the cannon, which was over a yard long and weighed nearly 200 pounds, burst and Avounded several of the spectators. There Avas another Hercules in Paris, who with his teeth lifted and held a heavy cask of Avater on Avhich was seated a man and varying weights, ac- cording to the size of bis audience, at the same time keeping his hands occu- pied Avith other Aveights. Figure 185 represents a well-known modern exhibitionist lifting with his teeth a cask on which are seated four men. f*$ 470 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. The celebrated Mile. Gauthier, an actress of the Comedie-Franoais, had marvelous power of her hands, bending coins, rolling up silver plate, and performing divers other feats. Major Barsaba had enormous poAvers of hand and fingers. He could roll a silver plate into the shape of a goblet. Being challenged by a Gascon, he seized the hand of his unsuspecting adversary in the ordinary maimer of salutation and crushed all the bones of the fingers, thus rendering unnecessary any further trial of strength. It is said that Marshal Saxe once visited a blacksmith ostensibly to have his horse shod, and seeing no shoe ready he took a bar of iron, and with his hands fashioned it into a horseshoe. There are Japanese dentists who extract teeth with their Avonderfully developed fingers. There are stories of a man living in the village of Cantal avIio received the sobriquet of " La Coupia " (The Brutal). He Avould exercise his function as a butcher by strangling with his fingers the calves and sheep, instead of killing them in the ordinary manner. It is said that one day, by placing his hands on the shoulders of the strong man of a local fair, he made him faint by the pressure exerted by his fingers. Manual strangulation is a Avell-known crime and is quite popular in some countries. The Thugs of India sometimes murdered their A'ictims in this Avay. Often such force is exerted by the murderer's fingers as to completely fracture the cricoid cartilage. In vicAvintr the feats of strength of the exhibitionist Ave must bear in consideration the numerous frauds perpetrated. A man of extraordinary strength sometimes finds peculiar stone, so stratified that he is able to break it Avith the force he can exert by a bloAv from the hand alone, although a man of ordinary strength Avould try in vain. In most of these instances, if one Avere to take a piece of the exhibitionist's stone, he Avould find that a slight tap of the hammer Avould break it. Again, there are many instances in which the stone has been found already separated and fixed quite firmly together, plac- ing it out of the poAver of an ordinary man to break, but which the exhibitionist finds Avithin his ability. This has been the solution of the feats of many of the individuals Avho invite persons to send them marked stones to use at their performances. By skilfully arranging stout tAvine on the hands, it is surprising Iioav easily it is broken, and there are many devices and tricks to deceive the public, all of AA'hich are more or less used by " strong men." The recent officially recorded feats of strength that stand unequaled in the last decade are as folloAvs :— Weight-lifting.—Hands alone, 15711 pounds, done by C. Gr. Jefferson, an amateur, at Clinton, Mass., December ]0, 1890; with harness, 3239 pounds, by W. B. Curtis, at New York, December 20, lSf>s ; Louis Cyr, at Berthierville, Can., October 1, 1888, pushed up 3536 pounds of pig-iron with his back, arms, and legs. Dumb-bells.— H. Pennock, in New York, 1870, put up a 10-pound dumb-bell 8431 times in four hours thirty-four minutes; by using both hands to raise it to the PLATE 6. Feats of contortion. CONTOR TIONISTS. 473 shoulder, and then using one hand alone, R. A. Perinell, in New York, January 31, 1874, managed to put up a bell weighing 201 pounds 5 ounces; and Eugene Sandow, at London, February 11, 1891, surpassed this feat with a 250-pound bell. Throicing 16-pound Hammer.— J. S. Mitchell, at Travers Island, N. Y., October 8, 1892, made a record-throw of 145 feet f inch. Putting 16-pound Shot.—George R Gray, at Chicago, September 16, 1893, made the record of 47 feet. Throwing 56-pound Weight.—J. S. Mitchell, at New York, September 22, 1894, made the distance record of 35 feet 10 inches; and at Chicago, September 16, 1893, made the height record of 15 feet 4\ inches. The class of people commonly knoAvn as contortionists by the laxity of their muscles and ligaments are able to dislocate or preternaturally bend their joints. In entertainments of an arena type and even in what are iioav called "variety performances" are to be seen individuals of this class. These persons can completely straddle two chairs, and do Avhat they call " the split;" they can place their foot about their neck Avhile maintaining the up- right position ; they can bend almost double at the Avaist in such a manner that the back of the head will touch the calves, while the legs are perpen- dicular Avith the ground; they can bring the popliteal region over their shoulders and in this position walk on their hands ; they can put themselves in a narroAV barrel; eat AA'ith a fork attached to a heel Avhile standing on their hands, and perform divers other remarkable and almost incredible feats. Their performances are genuine, and they are real physiologic curiosities. Plate 6 represents tAvo well-known contortionists in their favorite feats. Wentworth, the oldest living contortionist, is about seventy years of age, but seems to haA'e lost none of his earlier sinuosity. His chief feat is to stow himself aAvay in a box 23 X 29 X 16 inches. When inside, six dozen Avooden bottles of the same size and shape as those Avhich ordinarily contain English soda water are carefully stowed aAvay, packed in Avith him, and the lid slammed doAvn. He bestoAvs upon this act the curious and suggestive name of " Packanatomicalization." Another class of individuals are those Avho can either partially or com- pletely dislocate the major articulations of the body. Many persons exhibit this capacity in their fingers. Persons vulgarly called " double jointed " are quite common. Charles Warren, an American contortionist, has been examined by several medical men of prominence and descriptions of him have appeared from time to time in prominent medical journals.a AVhen he Avas but a child he was constantly tumbling doAvn, due to the heads of the femurs slipping from the acetabula, but reduction was always easy. AVhen eight years old he joined a company of acrobats and strolling performers, and was called by the eupho- nious title of " the Yankee dish-rag." His muscular system was Avell-devel- oped, and, like SandoAV, he could make muscles act in concert or separately. a 224, 1882, i., 650, and 476, 1882, i., 576. 474 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES He could throAV into energetic single action the biceps, the supinator longus, the radial extensors, the platysma myoides, and many other muscles. AVhen he " strings," as he called it, the sartorius, that ribbon muscle sIioavs itself as a tight cord, extending from the front of the iliac spine to the inner side of the knee. Another trick Avas to leave flaccid that part of the serratus magnus Avhich is attached to the inferior angle of the scapula whilst he roused energetic contraction in the rhomboids. He could displace his muscles so that the loAver angles of the scapula? projected and presented the appearance historically attributed to luxation of the scapula. AVarren Avas well informed on surgical landmarks and had evidently been a close student of Sir Astley Cooper's classical illustrations of disloca- Fig. 186. Fig. 187. Fig. 188. Charles AVarren, the celebrated dislocationist. tions. He Avas able so to contract his abdominal muscles that the aorta could be distinctly felt with the fingers. In this feat nearly all the abdominal contents were croAvded beneath the diaphragm (Fig. 187). On the other hand, he could produce a phantom abdominal tumor by drh'ing the coils of the intestine Avithin a peculiar grasp of the rectus and oblique muscles. The "groAvth" (Fig. 188) Avas rounded, dull on percussion, and looked as if an exploratory incision or puncture would be advisable for diagnosis. By extraordinary muscular poAver and extreme laxity of his ligaments, he simulated all the dislocations about the hip joint (Fig. 186). Sometimes he produced actual dislocation, but usually he said he could so distort his muscles as to imitate in the closest degree the dislocations. He could imitate ENDURANCE OF PAIN. 475 the various forms of talipes, in such a Avay as to deceive an expert. He dis- located nearly every joint in the body Avith great facility. It Avas said that he could contract at Avill both pillars of the fauces. He could contract his chest to 34 inches and expand it to 41 inches. Warren Aveighed 150 pounds, Avas a total abstainer, and Avas the father of Iavo children, both of Avhom could readily dislocate their hips. In France in 1886 there AAas shown a man avIio AAas called " Phomme prot6e," or protean man. He had an exceptional poAver over his muscles. Fven those muscles ordinarily involuntary he could exercise at Avill. He could produce such rigidity of stature that a blow by a hammer on his body fell as though on a block of stone. By his poAver over his abdominal mus- cles he could give himself different shapes, from the portly alderman to the lean and haggard student, and he Avas even accredited Avith assuming the shape of a " living skeleton." Quatrefages, the celebrated French scientist, examined him, and said that he could shut off the blood from the right side and then from the left side of the body, which feat he ascribed to unilateral muscular action. In 1893 there appeared in Washington, giving exhibitions at the colleges there and at the Emergency Hospital, a man named Fitzgerald, claiming to reside in Harrisburg, Pa., Avho made his living by exhibiting at medical colleges over the country. He simulated all the dislocations, claiming that they Avere complete, using manual force to produce and reduce them. He ex- hibited a thorough knowledge of the pathology of dislocations and of the anatomy of the articulations. He produced the different forms of talipes, as avcII as all the major hip-dislocations. AVhen interrogated as to the cause of his enormous saphenous veins, Avliich stood out like huge tAvisted cords under the skin and Avere associated with venous Aaricosity on the leg, he said he presumed they Avere caused by his constantly compressing the saphenous vein at the hip in giving his exhibitions, Avhich in some large cities Avere repeated several times a day. Endurance of Pain.—The question of the endurance of pain is, necessarily, one of comparison. There is little doubt that in the lower classes the sensa- tion of pain is felt in a much less degree than in those of a highly intellectual and nervous temperament. If we eliminate the element of fear, which always predominates in the loAver classes, the result of general hospital observation will shoAv this distinction. There are many circumstances Avhich have a marked influence on pain. Patriotism, enthusiasm, and general excitement, together with pride and natural obstinacy, prove the poAver of the mind over the body. The tortures endured by prisoners of Avar, religious martyrs and victims, exemplify the poAver of a strong Avill excited by deep' emotion over the sensation of pain. The flagellants, persons who expiated their sins by voluntarily flaying themselves to the point of exhaustion, are modern ex- amples of persons avIio in religious enthusiasm inflict pain on themselves. In 476 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. the ancient times in India the frenzied zealots struggled for positions from which thcv could throAV themselves under the car of the Juggernaut, and their intense emotions turned the pains of their Avounds into a pleasure. According to the reports of her Majesty's surgeons, there are at the present time in India native Brahmins avIio hang themselves on sharp hooks placed in the flesh betAveen the scapuhe, and remain in this position without the least visible show of pain. In a similar manner they pierce the lips and cheeks Avith long pins and bore the tongue Avith a hot iron. From a reliable source the authors have an account of a man in Northern India avIio as a means of self-inflicted penance held his arm aloft for the greater part of each day, bending the fingers tightly on the palms. After a considerable time the nails had groAvn or been forced through the palms of the hands, making their exit on the dorsal surfaces. There are manv savage rites and ceremonies calling for the severe infliction of pain on the participants which have been described from time to time by travelers. The Aztecs Avillingly sacrificed even their lives in the Avorship of their Sun-god. By means of singing and dancing the Aissaoui, in the Algerian toAvn of Constantine, throw themselves into an ecstatic state in AA'hich their bodies seem to be insensible even to severe Avounds. Helhvald says they run sharp-pointed irons into their heads, eyes, necks, and breasts Avithout apparent pain or injury to themselves. Some observers claim they are rendered insensible to pain by self-induced hypnotism. An account by Carpenter of the Algerian Aissaoui contained the folloAV- ing lucid description of the performances of these people :— "The center of the court aaus given up to the Aissaoui. These Avere 12 holloAV-cheeked men, some old and some young, avIio sat cross-legged in an irregular semicircle on the floor. Six of them had immense flat drums or tam- bours, Avhich they presently began to beat noisily. In front of them a charcoal fire burned in a brazier, and into it one of them from time to time threAv bits of some sort of incense, Avhich gradually filled the place Avith a thin smoke and a mildly pungent odor. " For a long time—it seemed a long time—this Avent on AA'ith nothing to break the silence but the rhythmical beat of the drums. Gradually, hoAvever, this had become quicker, and noAV grew Avild and almost deafening, and the men began a monotonous chant Avhich soon Avas increased to shouting. Sud- denly one of the men threAv himself AA'ith a IioaaI to the ground, AA'hen he Avas seized by another, Avho stripped him of part of his garments and led him in front of the fire. Here, Avhile the pounding of the drums and the shouts of the men became more and more frantic, he stood sAvaving his body backward and forward, almost touching the ground in his fearful contortions, and Avag- ging his head until it seemed as if he must dislocate it from his shoulders. All at once he dreAv from the fire a red-hot bar of iron, and AA'ith a yell of horror, Avhich sent a shiver down one's back, held it up before his eyes. ENDURANCE OF PAIN. 477 More violently than eATer he swayed his body and Avagged his head until he had Avorkcd himself up to a climax of excitement, Avhen he passed the ' the highly cultured. It would seem obA7iously preferable to have recourse to music of a lively and cheerful character." Idiosyncrasies of the visual organs are generally quite rare. It is well- known that among some of the loAver animals, e. g., the turkey-cocks, buffaloes, and elephants, the color red is unendurable. Buchnera and Tissot1' mention a young boy Avho had a paroxysm if he vieAved anything red. Certain in- dividuals become nauseated AA'hen they look for a long time on irregular lines or curves, as, for examples, in caricatures. Many of the older examples of idiosyncrasies of color are nothing more than instances of color-blindness, Avhich in those times Avas unrecognized. Prochaskac kneAV a woman Avho in her youth became unconscious at the sight of beet-root, although in her later years she managed to conquer this antipathy, but Avas neA'er able to eat the vegetable in question. One of the most remarkable forms of idiosyncrasy on record is that of a student Avho Avas deprh'ed of his senses by the very sight of an old Avoman. On one occasion he Avas carried out from a party in a dying state, caused, presumably, by the abhorred aspect of the chaperons. The Count of Cavlusd Avas ahvays horror-stricken at the sight of a Capuchin friar. He cured himself by a Avooden image dressed in the costume of this order placed in his room and constantly before his vieAV. It is common to see persons Avho faint at the sight of blood. Analogous are the individuals avIio feel nausea in an hospital Avard. All Robert Boyle's philosophy could not make him endure the sight of a spider, although he had no such aversion to toads, venomous snakes, etc. Pare mentions a man avIio fainted at the sight of an eel, and another Avho had convulsions at the sight of a carp. There is a record of a young lady a''Derachitide perfects' 1754. b "Del'epilepsie." c "Anuot. Acad." d302,xxiii. 488 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. in France avIio fainted on secil > "The Untoward Effect of Drugs." Detroit, 1884. c 704, 1881, No. 42. <* 720, ccii., 38. 32 498 PHYSIOLOGLC AND FUNCTIONAL ANOMALIES. ment of '1\ per cent, solution of boric acid in Avashing out a dilated stomach. The symptoms Avere quite similar to those mentioned by MolodenkoAV. In recent years the medical profession has become Avell aAvare that in its application to wounds it is possible for carbolic acid or phenol to exercise exceedingly deleterious and eA'en fatal consequences. In the earlier days of antisepsis, Avhen operators and patients Avere exposed for some time to an atmosphere saturated with carbolic spray, toxic symptoms Avere occasionally noticed. Von Langenbeck a spoke of severe carbolic-acid intoxication in a boy in Avhom carbolic paste had been used in the treatment of abscesses. The same author reports tAvo instances of death folloAving the employment of dry carbolized dressings after slight operations. K older b mentions the death of a man suffering from scabies Avho had applied externally a solution containing about a half ounce of phenol. Rose spoke of gangrene of the finger after the application of carbolized cotton to a wound thereon. In some cases phenol acts Avith a rapidity equal to any poison. Taylor speaks of a man who fell unconscious ten seconds after an ounce of phenol had been in- gested, and in three minutes Avas dead. There is recorded an account of a man of sixty-four who Avas killed by a solution containing slightly over a dram of phenol. A half ounce has frequently caused death ; smaller quantities have been folloAved by distressing symptoms, such as intoxication (Avhich Olshausen has noticed to follow irrigation of the uterus), delirium, singultus, nausea, rigors, cephalalgia, tinnitus aurium, and anasarca. Hind c mentions recoArery after the ingestion of nearly six ounces of crude phenol of 14 per cent, strength. There was a case at the Lh'erpool Northern Hospitald in which recovery took place after the ingestion with suicidal intent of four ounces of crude carbolic acid. Quoted by LeAvin, Busch accurately describes a case which may be mentioned as characteristic of the symptoms of carbol- ism. A boy, suffering from abscess under the trochanter, Avas operated on for its relief. During the feAV minutes occupied by the operation he Avas kept under a two per cent, carbolic spray, and the Avound AAas afterA\rard dressed with carbolic gauze. The day folloAving the operation he AAas seized Avith vomiting, AA'hich AAras attributed to the chloroform used as an anesthetic. On the folloAving morning the bandages were removed under the carbolic spray; during the day there was nausea, in the evening there AAras collapse, and car- bolic acid AA'as detected in the urine. The pulse became small and frequent and the temperature sank to 35.5° C. The frequent Aomiting made it im- possible to administer remedies by the stomach, and, in spite of hypodermic injections and external application of analeptics, the boy died fifty hours after operation. Recovery has followed the ingestion of art ounce of officinal hydrochloric acid.e Black f mentions a man of thirty-nine who recovered after swallow- a 199, 1878, No. 48. b 720, civ., 276. c 476, 1884, i., 659. d 548, 1875, ii., 597. e 218, xv. f 476, 1886, ii., 14. ANTIMONY. 499 ing 1J ounces of commercial hydrochloric acid. Johnson* reports a case of poisoning from a dram of hydrochloric acid. Tracheotomy was performed, but death resulted. Burmanb mentions recovery after the ingestion of a dram of dilute hydrocyanic acid of Scheele's strength (2.4 gm. of the acid). In this instance insensibility did not ensue until two minutes after taking the poison, the retarded digestion being the means of saAdng life. Quoting Taafe, in 1862 Taylor speaks of the case of a man who swallowed the greater part of a solution containing an ounce of potassium cyanid. In a few minutes the man was found insensible in the street, breathing ster- torously, and in ten minutes after the ingestion of the drug the stomach-pump Avas applied. In two hours vomiting began, and thereafter recovery Avas rapid. Mitscherlich speaks of erosion of the gums and tongue AA'ith hemorrhage at the slightest provocation, folloAving the long administration of dilute nitric acid. This Avas possibly due to the local action. According to Taylor, the smallest quantity of oxalic acid causing death is one dram. Ellis c describes a woman of fifty Avho swallowed an ounce of oxalic acid in beer. In thirty minutes she complained of a burning pain in the stomach and Avas rolling about in agony. Chalk and water was immediately given to her and she recovered. AVoodman d reports recovery after taking ^ ounce of oxalic acid. Salicylic acid in medicinal doses frequently causes untoward symptoms, such as dizziness, transient delirium, diminution of vision, headache, and profuse perspiration ; petechial eruptions and intense gastric symptoms have also been noticed. Sulphuric acid causes death from its corrosh'e action, and Avhen taken in excessive quantities it produces great gastric disturbance; hoAvever, there are persons addicted to taking oil of A'itriol Avithout any apparent untoward effect. There is mentioned a boot-maker e Avho constantly took \ ounce of the strong acid in a tumbler of Avater, saying that it relieA'ed his dyspepsia and kept his bowels open. Antimony.—It is recorded that f grain of tartar emetic has caused death in a child and t\vo grains in an adult. Falotf reports three cases in Avhich after small doses of tartar emetic there occurred A'omiting, delirium, spasms, and such depression of A'itality that only the energetic use of stimu- lants saved life. Beau g mentions death following the administration of two doses of 1J gr. of tartar emetic. Preparations of antimony in an ointment applied locally haAre caused necrosis, particularly of the cranium, and Ilebra407 has long since denounced the use of tartar emetic ointment in affections of the scalp. Carpenter h mentions recovery after ingestion of Iavo a 224, 1871, i., 221. b 476, 1854, i., 39. c 476, 1864, 265. d 548, 1864, ii., 386. e 548, 1861, i., 295. f 789, 1852, 245. g 548, 1857, i., 320. b 491, 1893, 514. 500 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. drams of tartar emetic. Behrendsa describes a case of catalepsy with mania, in Avhich a dose of 40 gr. of tartar emetic Avas tolerated, and Mor- gagni speaks of a man who swallowed tAAro drams, immediately vomited, and recovered. Instances like the last, in AArhich an excessive amount of a poison by its sudden emetic action induces Aromiting before there is absorp- tion of a sufficient quantity to cause death, are sometimes noticed. McCreery b mentions a case of accidental poisoning Avith half an ounce of tartar emetic successfully treated Avith green tea and tannin. Mason0 reports recovery after taking 80 gr. of tartar emetic. Arsenic.—The sources of arsenical poisoning are so curious as to de- serve mention. Confectionery, wall-paper, dyes, and the like arc examples. In other cases Ave note money-counting,*1 the colored candles of a Christmas tree,e paper collars/ ball-Avreaths of artificial floAvers,g ball-dresses made of green tarlatan,h playing cards,1 hat-lining, J and fly-papers.k Bazin has reported a case in Avhich erythematous pustules appeared after the exhibition during fifteen days of the -| gr. of arsenic. Macnal1 speaks of an eruption similar to that of measles in a patient to whom he had given but three drops of FoAvler's solution for the short period of three days. Pareira says that in a gouty patient for whom he prescribed i gr. of potassium arseniate daily, on the third day there appeared a bright red eruption of the face, neck, upper part of the trunk and flexor surfaces of the joints, and an edematous condition of the eyelids. The symptoms Avere preceded by rest- lessness, headache, and heat of the skin, and subsided gradually after the second or third day, desquamation continuing for nearly two months. After they had subsided entirely, the exhibition of arsenic again aroused them, and this time they were accompanied by salivation. Charcot and other French authors haAre noticed the frequent occurrence of suspension of the sexual instinct during the administration of Fowler's solution. Jacksonm speaks of recovery after the ingestion of two ounces of arsenic by the early employ- ment of an emetic. AValshn reports a case in which 600 gr. of arsenic were taken Avithout injury. The remarkable tolerance of arsenic eaters is Avell knoAvn. Taylor asserts that the smallest lethal dose of arsenic has been tAvo gr., but Tardieu mentions an instance in Avhich ten cgm. (1J gr.) has caused death. Mackenzie ° speaks of a man who SAvallowed a large quantity of arsenic in lumps, and received no treatment for sixteen hours, but recovered. It is added that from tAvo masses passed by the anus 105 gr. of arsenic were obtained. In speaking of the tolerance of belladonna, in 1859 Fuller mentioned a a 587, ix., 199. b 124, 1853. c 224, 1877, i., 674. d 491, 1883, 526. e 536, 1SS9. i., 287. f 224, 1880, ii., 240. g 548, 1862, i., 137. h 476, 1875, ii., 758. i 224, 1879, ii., 630. J 224, 1*79, ii., "46. k 476, 1884, i., 408. 1548,1868. m 124, July, 1858. n Annalist, N. Y., 1849, 136. o 435, 1872. BELLADONNA. 501 child of fourteen who in eighteen days took 37 grains of atropin; a child of ten Avho took seven grains of extract of belladonna daily, or more than two ounces in twenty-six days ; and a man who took 64 grains of the extract of belladonna daily, and from Avhose urine enough atropin Avas extracted to kill two .white mice and to narcotize two others. Bader has observed grave symptoms folloAving the employment of a A'aginal suppository containing three grains of the extract of belladonna. The dermal manifestations, such as urticaria and eruptions resembling the exanthem of scarlatina, are too well knoAvn to need mention here. An enema containing 80 grains of belladonna root has been folloAved in five hours by death, and Taylor757 has mentioned recovery after the ingestion of three drams of belladonna. In 1864 Chambers reported to the Lancet the recovery of a child of four years avIio took a solution containing | grain of the alkaloid. In some cases the idiosyn- crasy to belladonna is so marked that violent symptoms follow the application of the ordinary belladonna plaster. Maddox a describes a case of poisoning in a music teacher by the belladonna plaster of a reputable maker. She had obscure eye-symptoms, and her color-sensations were abnormal. Locomotor equilibration Avas also affected. Golden b mentions tAA-o cases in Avhich the application of belladonna ointment to the breasts caused suppression of the secretion of milk. Goochvin c relates the history of a case in Avhich an in- fant aaiis poisoned by a belladonna plaster applied to its mother's breast and died Avithin tAventy-four hours after the first application of the plaster. In 1881 Betancourt spoke of an instance of inherited susceptibility to belladonna, in Avhich the external application of the ointment produced all the symptoms of belladonna poisoning. Cooper d mentions the symptoms of poisoning fol- loAving the application of extract of belladonna to the scrotum. Davison reports poisoning by the application of belladonna liniment. Jenner and Lyman also record belladonna poisoning from external applications. Rosenthale reports a rare case of poisoning in a child eighteen months old Avho had SAvalloAved about a teaspoonful of benzin. Fifteen minutes later the child became unconscious. The stomach-contents, which were promptly removed, contained flakes of bloody mucus. At the end of an hour the radial pulse AA'as scarcely perceptible, respiration AAas someAvhat increased in fre- quency and accompanied Avith a rasping sound. The breath smelt of benzin. The child lay in quiet narcosis, occasionally throAving itself about as if in pain. The pulse gradually improved, profuse perspiration occurred, and normal sleep intervened. Six hours after the poisoning the child Avas still stupefied. The urine Avas free from albumin and sugar, and the next morning the little one had perfectly reco\Tered. There is an instance mentionedf of a robust youth of twenty who by a mistake took a half ounce of cantharides. He Avas almost immediately a 124, 1893. b 476, 1856. c 545, 1871, 346. d224, 1877, i., 164. e Therap. Gaz., July 16, 1894. f 476, 1825, 233. 502 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. seized Avith \7iolent heat in the throat and stomach, pain in the head, and intense burning on urination. These symptoms progressively increased, were folloAved by intense sickness and almost continual vomiting. In the evening he passed great quantities of blood from the urethra Avith excessive pain in the urinary tract. On the third day all the symptoms Avere less violent and the A'omiting had ceased. Recovery Avas complete on the fifteenth day. Digitalis has been frequently obserA'ed to produce dizziness, fainting, disturbances of vision, A'omiting, diarrhea, Aveakness of the pulse, and depres- sion of temperature. These phenomena, lioAveA'er, are generally noticed after continued administration in repeated doses, the result being doubtless due to cumulative action caused by abnormally sIoav elimination by the kid- neys. Traubea observed the presence of skin-affection after the use of digi- talis in a ease of pericarditis. Tardieu has seen a fluid-dram of the tincture of digitalis cause alarming symptoms in a young Avoman avIio Avas pregnant. He also quotes cases of death on the tenth day from ingestion of 20 grains of the extract, and on the fifth day from 2| grams of the infusion. Kohnhorn b mentions a death from Avhat might be called chronic digitalis poisoning. There is a deleterious practice of some of the Irish peasantry connected Avith their belief in fairies, AA'hich consists of giving a cachetic or rachitic child large doses of a preparation of fox-glove (Irish—luss-more, or great herb), to drhre out or kill the fairy in the child. It Avas supposed to kill an unhal- loAvcd child and cure a halloAved one. In the Hebrides, likeAvise, there were many cases of similar poisoning. Epidemics of ergotism have been recorded from time to time since the days of Galen, and Avere due to poverty, Avretchedness, and famine, resulting in the feeding upon ergotized bread. According to AVood,829 gangrenous er- gotism, or " Ignis Sacer" of the Middle Ages, killed 40,000 persons in Southwestern France in 922 A. D., and in 1128-29, in Paris alone, 14,000 persons perished from this malady. It is described as commencing Avith itchings and formications in the feet, severe pain in the back, contractions in the muscles, nausea, giddiness, apathy, with abortion in pregnant Avomen, in suckling Avomen drying of milk, and in maidens with amenorrhea. After some time, deep, heavy aching in the limbs, intense feeling of coldness, Avith real coldness of the surfaces, profound apathy, and a sense of utter Aveari- ness develop ; then a dark spot appears on the nose or one of the extremi- ties, all sensibility is lost in the affected part, the skin assumes a livid red hue, and adynamic symptoms in scwere cases deepen as the gangrene spreads, until finally death ensues. Very generally the appetite and digestion are preserved to the last, and not rarely there is a most ferocious hunger. AVood also mentions a species of ergotism characterized by epileptic paroxysms, Avhich he calls " spasmodic ergotism." Prentissc mentions a brunette of forty- two, under the influence of ergot, Avho exhibited a peculiar depression of a 263, i., 622. b 476, 1876, i., 583. c 450, 1889, No. 26, 912. LEAD-POISONING. 503 spirits Avith hysteric phenomena, although deriving much benefit from the administration of the drug from the hemorrhage caused by uterine fibroids. After taking ergot for three days she felt like crying all the time, became irritable, and stayed in bed, being all day in tears. The natural disposition of the patient Avas entirely opposed to these manifestations, as she was even- tempered and exceptionally pleasant. In addition to the instance of the fatal ingestion of a dose of Epsom salts already quoted, Lang a mentions a woman of thirty-five who took four ounces of this purge. She experienced burning pain in the stomach and boAvels, together with a sense of asphyxiation. There was no purging or vomiting, but she became paralyzed and entered a state of coma, dying fifteen minutes after ingestion. Iodin Preparations.—The eruptions folloAving the administration of small doses of potassium iodid are frequently noticed (Fig. 189), and at the same time large quantities of albumin haA'e been seen in the urine. Potassium iodid, al- though generally spoken of as a poisonous drug, by gradually in- creasing the dose can be given in such enormous quantities as to be almost beyond the bounds of credence, several drams being given at a dose. On the other hand, eight grains ha\Te produced alarming symptoms.13 In the extensive use of iodoform as a dressing instances of untoAvard effects, and eAren fatal ones, have been noticed, the majority of them being due to careless and injudicious application. In a French journalc there is mentioned the history of a man of twenty-five, suspected of urethral ulcer- ation, avIio submitted to the local application of one gram of iodoform. Deep narcosis and anesthesia were induced, and tAvo hours after aAvakening his breath smelled strongly of iodoform. There are tAvo similar instances recorded in England.*1 Popee mentions two fatal cases of lead-poisoning from diachylon plaster, self-administered for the purpose of producing abortion. Lead Avater-pipes, the use of cosmetics and hair-dyes, coloring matter in confectionery and' in pastry, habitual biting of silk threads, imperfectly burnt pottery, and cooking bread Avith painted Avoodf have been mentioned as causes of chronic lead- poisoning. Fig. 189.—A somewhat rare form of eruption from the in- gestion of iodin compounds (after J. C McGuire). a 476, 1891. d 476, May 31, 1879. b 133, xxvi., 197. e 224, 1893. c Le Practicien, Mar. 17, 1879. f 653, 1877, 349. 504 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Mercury.—Armstrong3 mentions recovery after ingestion of 1^ drains of corrosh'e sublimate, and Lodge b speaks of recovery after a dose contain- ing 100 grains of the salt. It is saidc that a man sAA'allowed 80 grains of mercuric chlorid in Avhiskey and Avater, and A'omited A'iolently about ten minutes afterward. A mixture of albumin and milk Avas given to him, and in about tAventy-fhre minutes a bolus of gold-leaf and reduced iron; in eight days he perfectly recovered. Severe and even fatal poisoning mav result from the external application of mercury. Meeres d mentions a case in Avhich a solution (tAvo grains to the fluid-ounce) applied to the head of a child of nine for the relief of tinea tonsurans caused diarrhea, profuse salivation, marked prostration, and finally death. AVashing out the A'agina with a solu- tion of corrosive sublimate, 1 : 2000, has caused severe and even fatal poison- ing.6 Bonet216 mentions death after the inunction of a mercurial ointment, and instances of distressing salivation from such medication are quite common. There are various dermal affections Avhich sometimes follow the exhibition of mercury and assume an erythematous type. The susceptibility of some per- sons to calomel, the slightest dose causing profuse salivation and painful oral symptoms, is so common that feAV physicians administer mercury to their patients Avithout some knoAvledge of their susceptibility to this drug. Blun- delf relates a curious case occurring in the times AA'hen mercury AA'as given in great quantities, in AA'hich to relieA'e obstinate constipation a half ounce of crude mercury Avas administered and repeated in tAveh'e hours. Scores of globules of mercury soon appeared OA'er a A'esicated surface, the result of a preAdous blister applied to the epigastric region. Blundel, not satisfied Avith the actuality of the phenomena, submitted his case to Dr. Lister, who, after careful examination, pronounced the globules metallic. Oils.—MauA'ezin g tells of the ingestion of three drams of croton oil by a child of six, folloAved by A'omiting and rapid recovery. There was no diar- rhea in this case. AVood quotes CoAvan in mentioning the case of a child of four, avIio in two days recoArered from a teaspoonful of croton oil taken on a full stomach. Adams saw recovery in an adult after ingestion of the same amount. There is recordedh an instance of a Avoman avIio took about an ounce, and, emesis being produced three-quarters of an hour afterAvard by mustard, she finally recovered. There is a record in Avhich so small a dose as three minims is supposed to haA'e killed a child of thirteen months.1 According to AVood, Giacomini mentions a case in Avhich 24 grains of the drug proved fatal in as many hours. Castor oil is usually considered a harmless drug, but the castor bean, from which it is derived, contains a poisonous acrid principle, three such beans having sufficed to produce death .in a man. Doubtless some of the in- a 491, 1887, 120. b 224, 1888. ii., 720. c 124, 1863, 340. d476, Sept. 16, 1871. e 261, 1887, No. 47. f 476, 1830, 767. g 363, 1869, 290. b 218, 1868, i., 294. i 548, 1870, i. OPIUM. 505 stances in which castor oil has produced symptoms similar to cholera are the results of the administration of contaminated oil. The untoward effects of opium and its derivatives are quite numerous. Gaubius treated an old Avoman in whom, after three days, a single grain of opium produced a general desquamation of the epidermis ; this peculiarity Avas not accidental, as it Avas verified on several other occasions. Hardens452 speaks of a Avoman in Avhom the slightest bit of opium in any form produced considerable salh'ation. Gastric disturbances are quite common, severe vomiting being produced by minimum doses; not infrequently, intense mental confusion, vertigo, and headache, lasting hours and even days, some- times referable to the frontal region and sometimes to the occipital, are seen in certain nervous individuals after a dose of from \ to |- gr. of opium. These symptoms Avere familiar to the ancient physicians, and, according to LeAvin, Tralles reports an obserAation Avith reference to this in a man, and says regarding it in rather unclassical Latin : " . . . per multos dies pon- derosissimum caput circumgestasse." Convulsions are said to be observed after medicinal doses of opium. Albers a states that twitching in the tendons, tremors of the hands, and eA'en paralysis, haA'e been noticed after the inges- tion of opium in eA^en ordinary doses. The " pruritus opii," so familiar to physicians, is spoken of in the older Avritings. Dioscorides, Paulus Aegineta, and nearly all the writers of the last century describe this symptom as an annoying and unbearable affection. In some instances the ingestion of opium provokes an eruption in the form of small, isolated red spots, which, in their general character, resemble roseola. Rieken b remarks that when these spots spread over all the body they present a scarlatiniform appearance, and he adds that even the mucous membranes of the mouth and throat may be attacked Avith erethematous inflammation. Behrendc obserA'ed an opium exanthem, Avhich Avas attended by intolerable itching, after the exhibition of a quarter of a grain. It Avas seen on the chest, on the inner surfaces of the arms, on the flexor surfaces of the forearms and Avrists, on the thighs, and posterior and inner surfaces of the legs, terminating at the ankles in a stripe- like discoloration about the breadth of three fingers. It consisted of closely disposed papules of the size of a pin-head, and several days after the dis- appearance of the eruption a fine, bran-like desquamation of the epidermis ensued. Brand d has also seen an eruption on the trunk and flexor surfaces, accompanied -with feA7er, from the ingestion of opium. Billroth e mentions the case of a lady in Avhom appeared a feeling of anxiety, nausea, and vomit- ing after ingestion of a small fraction of a grain of opium ; she would rather endure her intense pain than suffer the untoward action of the drug. According to Lewin, Brochin f reported a case in which the idiosyn- crasy to morphin Avas so great that -A% of a grain of the drug administered a 161, xxvi., 225. b 720, cvii., 22. c 199, 1879, 626. d 199, 1879, 718. e 611, 1868, 763. f 363, 1877, 226. 506 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. hypodermically caused irregularity of the respiration, suspension of the heart-beat, and profound narcosis. According to the same authority, AVernich has called attention to paresthesia of the sense of taste after the employment of morphin, Avhich, according to his observation, is particularly prone to supervene in patients who are much reduced and in persons otherAvise healthy who have suffered from prolonged inanition. These effects are prob- ably due to a central excitation of a similar nature to that produced by san- tonin. Persons thus attacked complain, shortly after the injection, of an intensely sour or bitter taste, which for the most part ceases after elimination of the morphin. Von Graefe and Sommerfrodt speak of a spasm of accom- modation occurring after ingestion of medicinal doses of morphin. There are several cases on record a in which death has been produced in an adult by the use of ^ to ^ grain of morphin. According to AVood, the maximum doses from Avhich recoA'cry has occurred without emesis are 55 grains of solid opium, and six ounces of laudanum. According to the same authority, in 1854 there was a case in AA'hich a babe one day old was killed by one minim of laudanum, and in another case a feAV drops of paregoric proved fatal to a child of nine months. Doubtful instances of death from opium are given, one in an adult female b after 30 grains of Dover's poAvder gh'en in divided doses, and another c after a dose of 4; grain of morphin. Yavorskid cites a rather remarkable instance of morphin-poisoning Avith recovery : a female took 30 grains of acetate of morphin, and as it did not act quickly enough she took an additional dose of J ounce of laudanum. After this she slept a feAV hours, and aAvoke complaining of being ill. Yavorski saAV her about an hour later, and by producing emesis, and giving coffee, atropin, and tincture of musk, he saA'ed her life. Pyle e describes a pugilist of twenty-two Avho, in a fit of despondency after a debauch (in Avhich he had taken repeated doses of morphin sulphate), took Avith suicidal intent three teaspoonfuls of morphin ; after rigorous treatment he revh'ed and Avas discharged on the next day per- fectly Avell. Potassium permanganate was used in this case. Chaffeef speaks of recovery after the ingestion of 18 grains of morphin Avithout A'omiting. In chronic opium eating the amount of this drug Avhich can be ingested Avith safety assumes astounding proportions. In his " Confessions " De Quincey remarks : " Strange as it may sound, I had a little before this time descended suddenly and Avithout considerable effort from 320 grains of opium (8000 drops of laudanum) per day to 40 grains, or % part. Instantaneously, and as if by magic, the cloud of profoundest melancholy Avhich rested on my brain, like some black vapors that I have seen roll away from the summits of the mountains, dreAV off in one day,—passed off Avith its murky banners as simul- taneously as a ship that has been stranded and is floated off by a spring-tide— ' That moveth altogether, if it move at all.' a 829, 168. b 269, July, 1882. c 218, Jan. 3, 1885. a 812, 1885. e 533, May 12, 1894. t 545, 1882, xlvii., 697. CHRONIC OPIUM EATING. 507 Now, then, I Avas again happy ; I took only a thousand drops of laudanum per day, and Avhat Avas that ? A latter spring had come to close up the sea- son of youth ; my brain performed its functions as healthily as ever before ; I read Kant again, and again I understood him, or fancied that I did." There have been many authors who, in condemning De Quincey for unjustly throAving about the opium habit a halo of literary beauty Avhich has tempted many to destruction, absolutely deny the truth of his statements. No one has any stable reason on which to found denial of De Quincey's statements as to the magnitude of the doses he was able to take ; and his frankness and truth- fulness is equal to that of any of his detractors. AVilliam Rosse Cobbe, in a volume entitled " Dr. Judas, or Portrayal of the Opium Habit," gives Avith great frankness of confession and considerable purity of diction a record of his OAvn experiences aa ith the drug. One entire chapter of Mr. Cobbe's book and several portions of other chapters are deA'oted to shoAving that De Quincey Avas Avrong in some of his statements, but notAvithstanding his criticism of De Quincey, Mr. Cobbe seems to haA'e experienced the same adventures in his dreams, shoAving, after all, that De Quincey knew the effects of opium, even if he seemed to idealize it. According to Mr. Cobbe, there are in the United States upward of two millions of A'ictims of enslaving drugs entirely exclusive of alcohol. Cobbe mentions several instances in Avhich De Quincey's dose of 320 grains of opium daily has been surpassed. One man, a resident of Southern Illinois, consumed 1072 grains a day; another in the same State contented himself Avith 1685 grains daily ; and still another is gh'en Avhose daily consumption amounted to 2345 grains per day. In all cases of laudanum-takers it is probable that analysis of the commercial laudanum taken would show the amount of opium to be greatly beloAv that of the offici- nal proportion, and little faith can be put in the records of large amounts of opium taken when the deduction has been made from the laudanum used. Dealers soon begin to knoAV opium victims, and find them ready dupes for adulteration. According to LeAvin, Samter mentions a ease of morphin-habit which AA'as continued for three years, during which, in a period of about three hundred and tAventy-three days, upAvard of 2|^ ounces of morphin Avas taken daily. According to the same authority, Eder reports still larger doses. In the case observed by him the patient took laudanum for six years in increasing doses up to one ounce per day ; for eighteen months, pure opium, commencing with 15 grains and increasing to 2\ drams daily; and for eighteen months morphin, in commencing quantities of six grains, Avhich Avere later increased to 40 grains a day. AVhen deprived of their accustomed dose of morphin the sufferings Avhich these patients experience are terrific, and they pursue all sorts of deceptions to enable them to get their enslaving drug. Patients haA'e been knoAvn to conceal tubes in their mouths, and even sAvallow them, and the authors knoAV of a fatal instance in which a tube of hypodermic tablets of the drug was found concealed in the rectum. 508 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. The administration of such an inert substance as the infusion of orange- peel has been sufficient to invariably produce nervous excitement in a patient afflicted Avith carcinoma. Sonnenschein refers to a case of an infant of five Aveeks avIio died from the effects of one phosphorous match head containing only y^ grain of phosphorus. There are certain people avIio by reason of a special suscepti- bility cannot tolerate phosphorus, and the exhibition of it causes in them nausea, oppression, and a feeling of pain in the epigastric region, tormina and tenesmus, accompanied AA'ith diarrhea, and in rare cases jaundice, sometimes lasting several months. In such persons -^ grain is capable of causing the foregoing symptoms. In 1882 a man Avas admitted to Guy's Hospital, Lon- don, after he had taken half of a sixpenny pot of phosphorous paste in avIus- key, and Avas subsequently discharged completely recovered. A peculiar feature of phosphorus-poisoning is necrosis of the jaAV. This affection was first noticed in 1838, soon after the introduction of the manu- facture of phosphorous matches. In late years, owing to the introduction of precautions in their manufacture, the disease has become much less common. The tipping of the match sticks is accomplished by dipping their ends in a Avarm solution of a composition of phosphorus, chlorate of potassium, Avith particles of ground flint to assist friction, sonic coloring agent, and Irish glue. From the contents of the dipping-pans fumes constantly arise into the faces of the Avorkmen and dippers, and in cutting the sticks and packing the matches the hands are constantly in contact with phosphorus. The region chiefly affected in this poisoning is the jaAV-bone, but the inflammation may spread to the adjoining bones and involve the vomer, the zygoma, the body of the sphenoid bone, and the basilar process of the occipital bone. It is supposed that conditions in Avhich the periosteum is exposed are firvorable to the progress of the disease, and, according to Hirt, workmen Avith diseased teeth are affected three times as readily as those Avith healthy teeth, and are therefore carefully excluded from some of the factories in America. Prentiss of AVashington, D. C, in 1881a reported a remarkable case of pilocarpin idiosyncrasy in a blonde of twenty-fh^e. He Avas consulted by the patient for constipation. Later on symptoms of cystitis developed, and an ultimate diagnosis of pyelitis of the right kidney Avas made. Uremic symptoms Avere avoided by the constant use of pilocarpin. BetAveen Decem- ber 16, 1880, and February 22, 1881, the patient had 22 sAveats from pilo- carpin. The action usually lasted from two to six hours, and quite a large dose Avas at length necessary. The idiosyncrasy noted was found in the hair, which at first Avas quite light, afterAvard chestnut-broAvn, and May 1, 1881, almost pure black. The groAvth of the hair became more vigorous and thicker than formerly, and as its color darkened it became coarser in propor- tion. In March, 1889, Prentiss saw his patient, and at that time her hair was a 547, July 2, 1881. QUININ. 509 dark brown, having returned to that color from black. Prentiss also reported the following casea as adding another to the evidence that jaborandi will produce the effect mentioned under favorable circumstances : Mrs. L., aged seventy-two years, was suffering from Bright's disease (contracted kidney). Her hair and eyebrows had been snoAV-white for twenty years. She suf- fered greatly from itching of the skin, due to the uremia of the kidney- disease ; the skin was harsh and dry. For this symptom fluid extract of jaborandi Avas prescribed with the effect of relieving the itching. It was taken in doses of 20 or 30 drops several times a day, from October, 1886, to February, 1888. During the fall of 1887 it was noticed by the nurse that the eyebroAvs Avere growing darker, and that the hair of the head was darker in patches. These patches and the eyebrows continued to become darker, until at the time of her death they were quite black, the black tufts on the head presenting a very curious appearance among the silver-Avhite hairs sur- rounding them. Quinin being such a universally used drug, numerous instances of idio- syncrasy and intolerance have been recorded. Chevalierb mentions that through contact of the drug Avorkmen in the manufacture of quinin are liable to an affection of the skin which manifests itself in a vesicular, papular, or pustular eruption on different parts of the body. Vepan c mentions a lady who took 1J grains and afterward 2 J grains of quinin for neuralgia, and two days afterward her body Avas covered Avith purpuric spots, Avhich disappeared in the course of nine days but reappeared after the administration of the drug was resumed. Lewin says that in this case the severity of the eruption Avas in accordance with the size of the dose, and during its existence there was bleeding at the gums; he adds that Gouchet also noticed an eruption of this kind in a lady who after taking quinin expectorated blood. The pe- techia? were profusely spread over the entire body, and they disappeared after the suspension of the drug. Daubceuf, GarraAvay,d Hemming,e Skinner/ and Cobner g mention roseola and scarlatiniform erythema after minute doses of quinin. In nearly all these cases the accompanying symptoms Avere differ- ent. Heusinger h speaks of a lady Avho, after taking J grain of quinin, ex- perienced headache, nausea, intense burning, and edema, together Avith nodular erythema on the eyelids, cheeks, and portion of the forehead. At another time 1^ grains of the drug gave rise to herpetic A-esicles on the cheeks, fol- loAved by branny desquamation on elimination of the drug. In other patients intense itching is experienced after the ingestion of quinin. Peters1 cites an instance of a woman of sixty-five Avho, after taking one grain of quinin, invariably exhibited after an hour a temperature of from 104° to 105° F., accelerated pulse, rigors, slight delirium, thirst, and all the appearances of a 727, Oct. 3, 1890. '1 224, 1869, ii., 388. g 199, 1S77, 305. bl41, 1851, T. lxviii., 5. e 224, 1869, ii., 533. h 199, 1877, 361. c 369, 1865. f 224, 1870, i., 103. i 476, 1889, ii., 727. 510 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. ill-defined fever, which Avould pass off in from tAvelve to tAvent\'-four hours. Peters Avitnessed this idiosyncrasy several times and believed it to be perma- nent. The most unpleasant of the untoward symptoms of quinin exhibition are the disturbances of the organs of special sense. Photophobia, and eA'en transient amblyopia, haA'e been observed to folloAV small doses. In the ex- amination of cases of the untoAvard effects of quinin upon the eye, Knapp of Ncav York found the poAver of sight diminished in various degrees, and rarely amaurosis and immobility of the pupils. According to LcAvin, the perceptions of color and light are ahvavs diminished, and although the disorder may last for some time the prognosis is favorable. The varieties of the disturb- ances of the functions of the ear range from tinnitus aurium tocongestion causing complete deafness. The gastro-intestinal and genito-urinary tracts are espe- cially disposed to untoAvard action by quinin. There is a case recorded in Avhich, after the slightest dose of quinin, tingling and burning at the meatus urina- rius Avere experienced. According to Lewin, there is mentioned in the case reported by Gauchet a symptom quite unique in the literature of quinin, viz., hemoptysis. Simon de Ronchard a first noted the occurrence of seAreral cases of hemoptysis following the administration of doses of eight grains daily. In the persons thus attacked the lungs and heart were healthy. Hemoptysis promptly ceased Avith the suspension of the drug. When it Avas reneAved, blood again appeared in the sputa. Taussig b mentions a curious mistake, in Avhich an ounce of quinin sulphate Avas administered to a patient atone dose; the only symptoms noticed Avere a stuporous condition and complete deaf- ness. No antidote Avas gh'en, and the patient perfectly recoA^ered in a Aveek. In malarious countries, and particularly in the malarial fevers of the late Avar, enormous quantities of quinin were frequently given. In fact, at the present day in some parts of the South quinin is constantly kept on the table as a prophylactic constituent of the diet. Skinnerc noticed the occurrence of a scarlatiniform eruption in a Avoman after the dose of ylg- grain of strychnin, AA'hich, however, disappeared with the discontinuance of the drug. There Avas a man in London in 1865 dAvho died in twenty minutes after the ingestion of J grain of strychnin. AVood speaks of a case in which the administration of -j-^j- grain killed a child three and one-half months old. Gray e speaks of a man who took 22 grains and avus not seen for about an hour. He had vomited some of it immediately after taking the dose, and was successfully treated Avith chloral hydrate. A curious case is mentioned in which three mustard plasters, one on the throat, one on the back of the neck, and another on the left shoulder of a Avoman, produced symptoms similar to strychnin poisoning. They remained in posi- tion for about thirty minutes, and about thirty hours afterward a painful stinging sensation commenced in the back of the neck, followed by violent a 363, Jan., 1861. b 543, 1864, i., 461. c 224. 1870. i., 303. d 392, 1865, xi., 208. e 224, 1880, i., 476. IDIOSYNCRASIES IN COITUS. 511 twitching of the muscles of the face, arms, and legs, Avhich continued in regular succession through the Avhole of the night, but after tAvelve hours yielded to hot fomentations of poppy-heads applied to the back of the neck. It could not be ascertained whether any medicine containing strychnin had been taken, but surely, from the symptoms, such must have been the case. Tobacco.—O'Neilla gives the history of a farmer's wife, aged forty, Avho Avounded her leg against a seAving-machine, and by lay advice applied a hand- ful of chopped Avet tobacco to it, from which procedure, strange to say, serious nicotin-poisoning ensued. The pupils were dilated, there were dimness of vision, confusion of thought, and extreme prostration. The pulse was scarcely apparent, the skin Avas Avhite and wet with clammy perspiration. Happily, strychnin Avas given in time to effect recovery, and Avithout early medical assistance she would undoubtedly have succumbed. There are several similar cases on record. Although not immediately related to the subject of idiosyncrasy, the fol- loAving case may be mentioned here : Ramadge b speaks of a young French- man, suffering from an obstinate case of gonorrhea, who was said to have been completely cured by hving in a newly painted house in which he inhaled the odors or vapors of turpentine. Whitec speaks of a case of exanthematous eruption similar to that of ivy- poison in mother and child, Avhich Avas apparently caused by playing Avith and burning the toy called " Pharaoh's serpent egg.'' The idiosyncrasies noticed in some persons during coitus are quite interesting. The Ephemerides mentions a person in whom coitus habitually caused vomiting, and another in whom excessive sexual indulgence provoked singultus. Sometimes exaggerated tremors or compulsions, particularly at the moment of orgasm, are noticed. Females especially are subject to this phenomenon, and it is seen sometimes in birds. Winn d reports the case of a man Avho, AA'hen prompted to indulge in sexual intercourse, was immediately prior to the act seized Avith a fit of sneezing. Even the thought of sexual pleasure Avith a female was sufficient to provoke this peculiar idiosyncrasy. SulliA'ane mentions a bride of four weeks, who called at the doctor's office, saying that in coitus her partner had no difficulty until the point of culmination or orgasm, AA'hen he AA'as seized Avith complete numbness and lost all pleasurable sensation in the penis. The numbness was followed by a sensation of pain, Avhich AA'as intensified on the slightest motion, and Avhich was at times so excruciating as to forbid separation for upAvard of an hour, or until the penis had become flaccid. The woman asked for advice for her unfortunate husband's relief, and the case Avas reported as a means of obtain- ing suggestions from the physicians over the country. In response, one a 476, 1879, i., 296. b 476, 1829-30, i., 415. c 331, 1867. d 703, 1873, x., 318. e 569, 1879, ii., 225. 512 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. theory Avas advanced that this man had been in the habit of masturbating and had a stricture of the membranous portion of the urethra, associated Avith an ulcer of the prostate involving the ejaculatory ducts, or an inflamma- tory condition of all the tissues compressed by the ejaculatory muscles. Hendrichsena quotes a ease in Avhich a spasmodic contraction of the levator ani occurred during coitus, and the penis could not be AvithdraAvn while this condition lasted; and in support of this circumstance Hendrich- sen mentions that Marion Sims, Beigel, and Budin describe spasmodic con- tractions of the levator ani, constricting the \Tagina ; he also cites an instance under his personal observation in which this spasm was excited by both vaginal and rectal examination, although on the following day no such con- dition could be produced. In this connection, among the older Avriters, Bor- ellus841 gives the history of a man who before coitus rubbed his virile member with musk, and, similar to the connection of a dog and bitch, Avas held fast in his wife's vagina ; it Avas only after the injection of great quanti- ties of water to soften the parts that separation Avas obtained. Diemerbroeck304 confirms this singular property of musk by an analogous observation, in which the ludicrous method of throwing cold water on the persons was prac- tised. Schurig also relates the history of a similar instance. Among the peculiar effects of coitus is its deteriorating effect on the healing process of Avounds. Boerhaave, Pare, and Fabricius Hildanus all speak of this untoward effect of venery, and in modern times Poncet has made observations at a hospital in Lyons which prove that during the pro- cess of healing wounds are unduly and harmfully influenced by coitus, and cites confirmatory instances. Poncet also remarks that he found on nine occasions, by placing a thermometer in the rectum, that the temperature was about 1 ° F. loAver just before than after coitus, and that during the act the temperature gradually rose above normal. There are many associate conditions which, under the exciting influence of coitus, provoke harmful effects and even a fatal issue. Deguise b mentions a man avIio had coitus 18 times in ten hours with most disastrous effects. Cabrolius245 speaks of a man who took a potion of aphrodisiac properties, in Avhich, among other things, he put an enormous dose of cantharides. The anticipation of the effect of his dose, that is, the mental influence, in addition to the actual therapeutic effect, greatly distressed and excited him. Almost beyond belief, it is said that he approached his Avife eighty-seven times during the night, spilling much sperm on the sleeping-bed. Cabrolius Avas called to see this man in the morning, and found him in a most exhausted condition, but still having the supposed consecutive ejaculations. Exhaustion progressed rapidly, and death soon terminated this erotic crisis. Lawson is accredited Avith saying that among the Marquesan tribe he kneAV of a Avoman Avho dur- ing a single night had intercourse with 103 men. a 839, Band xxiii., Heft i. b 664, T. vii., 113. SUSPENDED ANIMATION 513 Among the older writers there are instances reported in which erection and ejaculation took place Avithout the slightest pleasurable sensation. Clau- dius exemplifies this fact in his report of a Venetian merchant who had vig- orous erections and ejaculations of thick and abundant semen without either tingling or pleasure. Attila, King of the Huns, and one of the most celebrated leaders of the German hosts Avhich overran the Roman Empire in its decline, and whose enormous army and name inspired such terror that he Avas called the " Scourge of God," was supposed to have died in coitus. Apoplexy, organic heart dis- orders, aneurysms, and other like disorders are in such cases generally the direct cause of death, coitus causing the death indirectly by the excitement and exertion accompanying the act. Bartholinus, Benedictus, Borellus, Pliny, Morgagni, Plater, a Castro, Forestus, Marcellus Donatus, Schurig, Sinibaldus, Schenck, the Ephemerides, and many others mention death during coitus; the older writers in some cases attributed the fatal issue to excessive sexual indulgence, not considering the possibility of the associate direct cause, which most likely Avould have been foimd in case of a necropsy. Suspended Animation.—Various opinions have been expressed as to the length of time compatible Avith life during Avhich a person can stay under Avater. Recoveries from drowning furnish interesting examples of the sus- pension of animation for a protracted period, but are hardly ever reliable, as the subject at short intervals almost im'ariably rises to the surface of the Avater, alloAving occasional respiration. Taylor757 mentions a child of two avIio recovered after ten minutes' submersion ; in another case a man recovered after fourteen minutes' submersion. There is a case reported in this country a of a woman avIio Avas said to have been submerged twenty minutes. Guerard b quotes a case happening in 1774, in Avhich there Avas submersion for an hour with subsequent recovery ; but there hardly seems sufficient evidence of this. Greenc mentions submersion for fifteen minutes ; Donglass,d for fourteen minutes ; Laub,e for fifteen minutes ; PoATallf gives a description of three persons avIio recovered after a submersion of twenty-fh'e minutes. There is a case in French literature,g apparently Avell authenticated, in Avhich submer- sion for six minutes was folloAved by subsequent recovery. There have been indh'iduals who gave exhibitions of prolonged submer- sion in large glass aquariums, placed in full vieAV of the audience. Taylor remarks that the person knoAvn some years ago in London as " Lurline" could stay under Avater for three minutes. There have been several exhibi- tionists of this sort. Some of the more enterprising seat themseWes on an artificial coral, and surrounded by fishes of divers hues complacently eat a meal Avhile thus submerged. It is said that quite recently in Detroit there a 124, 1853, 348. b 141, 1850, ii., 306. c 629, 1732-44. d 490, 1842, L, 448. e 425, 1868. f 819, 1828. 8 789, 1871, 3 a xii., 293. 33 514 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. AA'as a performer avIio accomplished the feat of remaining under water four minutes and eight seconds in full vieAV of the audience. Miss Lurline swam about in her aquarium, Avhich Avas brilliantly illuminated, ate, reclined, and appeared to be taking a short nap during her short immersion. In Paris, some years since, there avus exhibited a creature called " l'homme-poisson," who performed feats similar to Lurline, including the smoking of a cigarette held entirely in his mouth. In all these exhibitions all sorts of artificial means are used to make the submersion appear long. Great ceremony, music, and the counting of the seconds in a loud voice from the stage, all tend to make the time appear much longer than it really is. HoAvever, James Finney in London, April 7, 1886, stayed under AA'ater four minutes, tAventy-nine and one-fourth seconds, and one of his feats Avas to pick up 70 or 80 gold-plated half-pennies Avith his mouth, his hands being securely tied behind his back, and never emerging from his tank until his feat Avas fully accomplished. In company AA'ith his sister he played a game of " nap " under AA'ater, using porce- lain cards and turning them to the vieAV of the audience. " Professor Enochs" recently stayed under Avater at Lowell, Mass., for four minutes, forty-six and one-fifth seconds. The best previous record was four minutes, thirty-five seconds, made by " Professor Beaumont" at Melbourne on Decem- ber 16, 1893. For the most satisfactory examples of prolonged submersion avc must look to the divers, particularly the nath'es Avho trade in coral, and the pearl fishers. Diving is an ancient custom, and even legendary exploits of this nature are recorded. Homer compares the fall of Hector's chariot to the action of a dhrer; and specially trained men Avere employed at the Siege of Syracuse, their mission being to laboriously scuttle the enemy's \'essels. Many of the old historians mention diving, and Herodotus speaks of a diver by the name of Scyllias avIio Avas engaged by Xerxes to recover some articles of A'alue AA'hich had been sunk on some Persian vessels in a tempest. Egyptian divers are mentioned by Plutarch, Avho says that Anthony Avas deceived by Cleopatra in a fishing contest by securing expert divers to place the fish upon the hooks. There Avas a historical or rather legendary character by the name of Didion, avIio AAas noted for his exploits in the rhTer Meuse. He had the ability to stay under AA'ater a considerable length of time, and eA'en to catch fish Avhile submerged. There Avas a famous dh'er in Sicily at the end of the fifteenth century Avhose feats are recorded in the Avritings of Alexander ab Alexandra, Pon- tanus, and Father Kircher, the Jesuit saA'ant. This man's name Avas Nicolas, born of poor parents at Catania. From, his infancy he shoAved an extraordi- nary poAver of diving and SAvimming, and from his compatriots soon acquired A'arious names indicative of his capacity. He became A'ery well knoAvn throughout Sicily, and for his patron had Frederick, King of Naples. In the present day, the sponge-fishers and pearl-fishers in the AVest Indies, the DIVERS. 515 Mediterranean, the Indian Seas, and the Gulf of Mexico invite the attention of those interested in the anomalies of suspended animation. There are many marvelous tales of their ability to remain under AA'ater for long periods. It is probable that none remain submerged over tAvo minutes, but, Avhat is more remarkable, they are supposed to dive to extraordinary depths, some as much as 150 to 200 feet. Ordinarily they remain under Avater from a minute to one and a half minutes. Remaining longer, the face becomes congested, the eyes injected, the sputum bloody, due to rupture of some of the minute vessels in the lung. It is said by those Avho have observed them carefully that feAV of these divers live to an advanced age. Many of them suffer apoplectic attacks, and some of them become blind from congestion of the ocular vessels. The Syrian divers are supposed to carry weights of considerable size in their hands in order to facilitate the depth and duration of submersion. It is also said that the divers of Oceanica use heavy stones. According to Guyot- Daubes,'594 in the Philippine Isles the native pearl-fishers teach their children to dive to the depth of 25 meters. The Tahitians, who excited the admiration of Cook, are noted for their extraordinary diving. Speaking of the inhabi- tants of the island of Fakaraya, near Tahiti, de la Quesnerie says that the pearl-fishers do not hesitate to dive to the depth ca-cii of 100 feet after their C0Areted prizes. On the Ceylon coast the mother-of-pearl fishers are under the direction of the English Government, AA'hich limits the duration and the prac- tice of this occupation. These divers are generally Cingalese, Avho practise the exercise from infancy. As many as 500 small boats can be seen about the field of operation, each equipped AA'ith dh'ers. A single dh7er makes about ten A'oyages under the Avater, and then rests in the bottom of the boat, Avhen his comrade takes his place. Among other native divers are the Arabs of Algeria and some of the inhabitants of the Mexican coast. It might be Avell to mention here the divers Avho Avork by means of appa- ratus. The ancients had knoAvledge of contrh'anoes whereby they could stay under AA'ater some time. Aristotle speaks of an instrument by Avhich divers could rest under Avater in communication AA'ith the air, and compares it Avith the trunk of an elephant Avading a stream deeper than his height. In the presence of Charles V. diving bells Avere used by the Greeks in 1540. In 1660 some of the cannon of the sunken ships of the Spanish Armada were raised by divers in dh'ing bells. Since then A'arious improATements in sub- marine armor have been made, gradually evoh'ing into the present perfected diving apparatus of to-day, by which men work in the holds of A'essels sunk in from 120 to 200 feet of AA'ater. The enormous pressure of the Avater at these great depths makes it necessary to have suits strong enough to resist it. Lambert, a celebrated English diver, recovered £90,000 in specie from the steamer Alphonso NIL, a Spanish mail boat belonging to the Lopez line, which sank off Point Gando, Grand Canary, in 26J fathoms of Avater. For nearly six months the salvage party, despatched by the undervvriters in May, 516 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. 1885, persevered in the operations; tAvo divers lost their lives, the golden bait being in the treasure-room beneath the three decks, but Lambert finished the task successfully. Deep-sea divers only acquire proficiency after long training. It is said that as a rule divers are indisposed to taking apprentices, as they are afraid of their vocation being croAvded and their present ample remuneration dimin- ished. At present there are several schools. At Chatham, England, there is a school of submarine mining, in Avhich men are trained to lay torpedoes and complete harbor defense. Most of these dh-ers can Avork six hours at a time in from 35 to 50 feet of Avater. Divers for the Royal Navy are trained at Sheerness. When sufficiently trained to Avork at the depth of 150 feet seamen-divers are fully qualified, and are drafted to the various ships. They arc connected Avith an air-pump in charge of trustworthy men ; they signal for their tools and material, as avcII as air, by means of a special line for this pur- pose. At some distance below the Avater the extraordinary Aveight of the suits cannot be felt, and the divers Avork as Avell in armor as in ordinary laboring clothes. One famous diver says that the only unpleasant experience he cAer had in his career as a diver, not excepting the occasion of his first dive, Avas a drumming in the ears, as a consequence of Avhich, after remaining under Avater at a certain Avork for nine hours, he completely lost the use of one ear for three months, during Avhich time he suffered agony AA'ith the earache. These men exhibit absolute indifference to the dangers attached to their calling, and some have been knoAvn to sleep many fathoms beneath the surface. Both by means of their signal lines and by Avriting on a slate they keep their asso- ciates informed of the progress of their Avork. Suspension of the Pulse.—In some cases the pulse is not apparent for many days before actual death, and there haA'e been instances in which, al- though the pulse ceased for an extended period, the patient made an ultimate recovery. In reA'iewing the older literature we find that Ballonius185 men- tions an instance in Avhich the pulse avus not apparent for fourteen days before complete asphyxia. Ramazzini660 describes a case of cessation of the pulse four days before death. Schenck718 details the history of a case in which the pulse ceased for three days and asphyxia Avas almost total, but the patient eA'entually recovered. There is a noteworthy observationa in which there was cessation of the pulse for nine days Avithout a fatal issue. Some persons seem to have a preternatural control over their circulatory system, apparently enabling them to produce suspension of cardiac move- ment at will. Cheyne speaks of a Colonel ToAvnshend Avho appeared to possess the poAver of dying, as it Avere, at will,—that is, so suspending the heart's action that no pulsation could be detected. After lying in this state of lifelessness for a short period, life would become slowly established Avith- out any consciousness or volition on the man's part. The longest period in a 282, 1732, 287. HUMAN HIBERNATION 517 which he remained in this death-like condition was about thirty minutes. A postmortem examination of this person Avas awaited Avith great interest; but after his death nothing was found to explain the power he possessed over his heart. Saint Augustin kneAV of a priest named Rutilut who had the power of voluntarily simulating death. Both the pulsation and respiration Avas appar- ently abolished when he avus in his lifeless condition. Burning and pricking left visible effects on the skin after his recovery, but had no apparent effect on his lethargy. Chaille a reports an instance of voluntary suspension of the pulse. Relative to hibernation, it is well-knoAvn that mice, snakes, and some rep- tiles, as well as bees, sometimes seem to entirely suspend animation for an ex- tended period, and especially in the cold weather. In Russia fish are trans- ported frozen stiff, but return to life after being plunged into cold water. A curious tale is told by Harley, from Sir John Lubbock, of a snail brought from Egypt and thought to be dead. It was placed on a card and put in position on a shelf in the British Museum in March, 1845. In March, 1850, after having been gummed to a label for five years, it Avas noticed to have an apparent growth on its mouth and Avas taken out and placed in water, when it soon shoAved signs of life and ate cabbage leaves offered to it. It has been said, Ave think Avith credible evidence, that cereal seeds found in the tombs with mummies have groAvn when planted, and Harley quotes an instance of a gentleman who took some berries, possibly the remnants of Pharaoh's daughter's last meal, coming as they did from her mummified stomach after lying dormant in an Egyptian tomb many centuries, and planted them in his garden, Avhere they soon greAV, and he shortly had a bush as flourishing as any of those emanating from fresh seeds. Human hibernation is an extremely rare anomaly. Only the fakirs of India seem to have developed this power, and eA'en the gifted ones there are seldom seen. Many theories have been advanced to explain this ability of the fakirs, and many persons have discredited all the stories relative to their poAvers ; on the other hand, all Avho have Avitnessed their exhibitions are con- vinced of their genuineness. Furthermore, these persons are extremely scarce and are indifferent to money; none has been enticed out of his own country to give exhibitions. AVhen one dies in a community, his place is never filled—proving that he had no accomplices Avho kneAV any fraudulent secret practices, otherAvise the accomplice would soon step out to take his place. These men have undoubtedly some extraordinary mode of sending themselves into a long trance, during Avhich the functions of life are almost entirely suspended. AVe can readily believe in their ability to fast during their periods of burial, as we have already related authentic instances of fasting for a great length of time, during which the individual exercised his normal functions. a 593, xvi., 388. 518 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. To the fakir, Avho neither visibly breathes nor shows circulatory movements, and who nevTer moves from his place of confinement, fasting should be com- paratively easy, when Ave consider the number of men Avhose minds Avere ac- tively at Avork during their fasts, and avIio also exercised much physical poAver. Harley a says that the fakirs begin their performances by taking a large dose of the poAverfully stupefying " bang," thus becoming narcotized. In this state they are loAvered into a cool, quiet tomb, Avhich still further favors the prolongation of the artificially induced A'ital lethargy ; in this condition they rest for from six to eight Aveeks. AVhen resurrected they are only by degrees restored to life, and present a Avan, haggard, debilitated, and wasted appearance. Braid b is credited; on the authority of Sir Claude AVade, AA'ith stating that a fakir Avas buried in an unconscious state at Lahore in 1837, and Avhen dug up, six Aveeks later, he presented all the appearances of a dead person. The legs and arms Avere shrunken and stiff, and the head reclined on the shoulder in a manner frequently seen in a corpse. There Avas no pul- sation of the heart or arteries of the arm or temple—in fact, no really visible signs of life. By degrees this person wras restored to life. EA'ery precaution had been taken in this case to preA'ent the possibility of fraud, and during the period of interment the grave was guarded night and day by soldiers of the regiment stationed at Lahore. Honigberger,0 a German physician in the employ of Runjcet Singh, has an account of a fakir of Punjaub who allowed himself to be buried in a well- secured vault for such a long time that grain soavii in the soil above the A'ault sprouted into leaf before he Avas exhumed. Honigberger affirms that the time of burial Avas over 40 days, and that on being submitted to certain pro- cesses the man recovered and lived many years after. Sir Henry LaAv- rence verified the foregoing statements. The chest in which the fakir was buried AA'as sealed Avith the Runjeet stamp on it, and Avhen the man was brought up he Avas cold and apparently lifeless. Honigberger also states that this man, whose name AA'as Haridas, was four months in a grave in the mountains; to prove the absolute suspension of animation, the chin was shaved before burial, and at exhumation this part AAas as smooth as on the day of interment. This latter statement naturally calls forth comment Avhen we consider the instances that are on record of the growth of beard and hair after death. There is another account of a person of the same class Avho had the power of suspending animation,4 and who Avould not alloAv his coffin to touch the earth for fear of worms and insects, from Avhich he is said to have suffered at a previous burial. It has been stated that the fakirs are either eunuchs or hermaphrodites, a 548, 1881. ii., 733. b "Treatise on Human Hibernation," 1850. c 548, 1870, i., 21. d Calcutta Med. Jour., 1835. RECOVERY AFTER HANGING. 519 social outcasts, having nothing in common with the AA'omen or men of their neighborhood; but Honigberger mentions one Avho disproved this ridiculous theory by eloping to the mountains Avith his neighbor's Avife. Instances of recovery after asphyxia from hanging are to be found, particularly among the older references of a time when hanging was more common than it is to-day. Bartholinus,189 Blegny,215 Camerarius,247 Mor- gagni,576 Pechlin,621 Schenck,718 Stoll,751 and AVepfera all mention recovery after hanging. Forestus348 describes a case in Avhich a man Avas rescued by provoking A'omiting Avith A'inegar, pepper, and mustard seed. There is a case on recordb in Avhich a person Avas sirved after hanging nineteen minutes. There Avas a case of a man brought into theHopital Saint-Louisc asphyxiated by strangulation, having been hung for some time. His rectal temperature Avas only 93.3° F., but six hours after it rose to 101.6° F., and he sub- sequently recovered. Taylor d cites the instance of a stout Avoman of forty- four avIio recovered from hanging. AVhen the Avoman Avas found by her hus- band she Avas hanging from the top of a door, having been driven to suicide on account of his abuse and intemperance. AVhen first seen by Taylor she was comatose, her mouth Avas surrounded by Avhite froth, and the SAVollen tongue protruded from it. Her face was bloated, her lips of a darkened hue, and her neck of a broAvn parchment-color. About the level of the larynx, the epidermis Avas distinctly abraded-, indicating Avhere the rope had been. The conjuncth-a was insensible and there Avas no contractile response of the pupil to the light of a candle. The reflexes of the soles of the feet Avere tested, but were quite in abeyance. There was no respiratory movement and only slight cardiac pulsation. After vigorous measures the AA'oman ultimately recovered. Recovery is quite rare when the asphyxiation has gone so far, the patients generally succumbing shortly after being cut down or on the folloAV- ing day. Chevers266 mentions a most curious case, in Avhich cerebral con- gestion from the asphyxiation of strangling Avas accidentally relieved by an additional cut across the throat. The patient was a man Avho was set upon by a band of Thugs in India, who, pursuant to their usual custom, strangled him and his fellow-traveler. Not being satisfied that he Avas quite dead, one of the band returned and made several gashes across his throat. This latter action effectually relieved the congestion caused by the strangulation and un- doubtedly saved his life, Avhile his unmutilated companion Avas found dead. After the wounds in his throat had healed this victim of the Thugs gave such a good description of the murderous band that their apprehension and execu- tion soon folloAved. Premature Burial.—In some instances simulation of death has been so exact that it has led to premature interment. There are many such cases on record, and it is a popular superstition of the laity that all the gruesome tales a " Exercit. in Apoplex.," 181: b 200, x., 242. c 476, 1870, i., 446. d 381, 1880, ii., 387. 520 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. are true of persons buried alive and returning to life, only to find themselves hopelessly lost in a narrow coffin many feet beloAv the surface of the earth. Among the lower classes the dread of being buried before life is extinct is quite generally felt, and for generations the medical profession have been de- nounced for their inability to discover an infallible sign of death. Most of the instances on record, and particularly those from lay journals, are vivid exaggerations, draAvn from possibly such a trivial sign as a corpse found Avith the fist tightly clenched or the face distorted, which are the inspiration of the horrible details of the dying struggles of the person in the coffin. In the works of Fontenelle there are 46 cases recorded of the premature interment of the living, in Avhich apparent has been mistaken for real death. None of these cases, hoAvever, are sufficiently authentic to be reliable. MoreoA'er, in all modern methods of burial, even if life were not extinct, there could be no possibility of consciousness or of struggling. Absolute asphyxiation would soon follow the closing of the coffin lid. AVe must admit, however, that the mistake has been made, particularly in instances of catalepsy or trance, and during epidemics of malignant fevers or plagues, in Avhich there is an absolute necessity of hasty burial for the pre- vention of contagion. In a feAV instances on the battle-field sudden syncope, or apparent death, has possibly led to premature interment; but in the present day this is surely a very rare occurrence. There is also a danger of mistake from cases of asphyxiation, drowning, and similar sudden suspensions of the vital functions. It is said that in the eighty-fourth Olympiad,Empedocles restored to life a woman Avho was about to be buried, and that this circumstance induced the Greeks, for the future protection of the supposed dead, to establish laws which enacted that no person should be interred until the sixth or seventh day. But eA7en this extension of time did not give satisfaction, and Ave read that when Hephestion, at whose funeral obsequies Alexander the Great was present, was to be buried his funeral was delayed until the tenth day. There is also a legend that Avhen Acilius AA'iola fell a victim to disease he Avas burned alive, and although he cried out, it was too late to save him, as the fire had become so widespread before life returned. AVhile returning to his country house Asclepiades, a physician denominated the " God of Physic," and said to have been a descendant of iEsculapius, saAV during the time of Pompey the Great a crowd of mourners about to start a fire on a funeral pile. It is said that by his superior knowledge he per- ceived indications of life in the corpse and ordered the pile destroyed, subse- quently restoring the supposed deceased to life. These examples and several others of a similar nature induced the Romans to delay their funeral rites, and laws Avere enacted to prevent haste in burning, as well as in interment. It was not until the eighth day that the final rites Avere performed, the days im- mediately subsequent to death having their own special ceremonies. The PREMATURE BURIAL. 521 Turks were also fearful of premature interment and subjected the defunct to every test; among others, one was to examine the contractility of the sphincter ani, Avhich sIioavs their keen observation of a Avell-knoAvn modern medical fact. According to the Memoirs of Amelot de la Houssaye, Cardinal Espinola, Prime Minister to Philip II., put his hand to the embalmer's knife Avith which he Avas about to be opened. It is said that Vesalius, sometimes called the " Father of Anatomy," having been sent for to perform an autopsy on a woman subject to hysteric convulsions, and who Avas supposed to be dead, on making the first incision perceived by her motion and cries that she Avas still alive. This circumstance, becoming knoAvn, rendered him so odious that he had to leave the community in Avhich he practised, and it is believed that he never entirely recovered from the shock it gave him. The Abbe Prevost, so Avell knoAvn by his Avorks and the singularities of his life, Avas seized by apoplexy in the Forest of Chantilly on October 23, 1763. His body Avas carried to the nearest village, and the officers of justice proceeded to open it, Avhen a cry he sent forth frightened all the assistants and convinced the sur- geon in charge that the Abbe Avas not dead ; but it Avas too late to save him, as he had already received a mortal Avound. Massien speaks of a Avoman living in Cologne in 1571 Avho was interred living, but was not aAvakened from her lethargy until a grave-digger opened her grave to steal a valuable ring which she Avore. This instance has been cited in nearly every language. There is another more recent instance, com- ing from Poitiers, of the Avife of a goldsmith named Mernache who Avas buried Avith all her jeAvels. During the night a beggar attempted to steal her jewelry, and made such exertion in extracting one ring that the woman re- covered and was saved. After this resurrection she is said to have had sev- eral children. This case is also often quoted. Zacchias 83° mentions an in- stance Avhich, from all appearances, is authentic. It was that of a voung man, pest-stricken and thought to be dead, avIio was placed Avith the other dead for burial. He exhibited signs of life, and Avas taken back to the pest- hospital. Tavo days later he entered a lethargic condition simulating death, and was again on his way to the sepulcher, AA'hen he once more recoA^ered. It is said that AA'hen the body of AVilliam, Earl of Pembroke,* Avho died April 10, 1630, Avas opened to be embalmed, the hand raised Avhen the first incision Avas made. There is a story of an occurrence which happened on a return A'oyage from India.5 The wife of one of the passengers, an officer in the army, to all appearances died. They Avere about to resort to sea-burial, Avhen, through the interposition of the husband, Avho was anxious to take her home, the ship-carpenters started to construct a coffin suitable for a long voy- age, a process Avhich took several days, during AA'hich time she lay in her berth, sAvathed in robes and ready for interment. AVhen the coffin Avas at last ready the husband Avent to take his last fareAvell, and removed the Aved- a 536, 1887, L, 586. b 548, 1866, i., 287. 522 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. ding-ring, aa hich was quite tightly on her finger. In the effort to do this she AA'as aroused, recovered, and arrh'ed in England perfectly avcII. It is said that Avhen a daughter of Henry Laurens, the first President of the American Congress, died of small-pox, she Avas laid out as dead, and the Avindows of the room were opened for ventilation. While left alone in this manner she recovered. This circumstance so impressed her illustrious father that he left explicit directions that in case of his death he should be burned.a The same journal also contains the case of a maid-servant avIio recovered thrice on her Avay to the grave, and avIio, Avhen really dead, Avas kept a pre- posterous length of time before burial. The literature on this subject is A'ery exhaustive, volumes having been written on the uncertainty of the signs of death, with hundreds of examples cited illustrative of the danger of premature interment. The foregoing in- stances haA'e been given as indicative of the general style of narration ; for further information the reader is referred to the plethora of material on this subject. Postmortem Anomalies.—Among the older Avriters startling move- ments of a corpse have given rise to much discussion, and possibly often led to suspicion of premature burial. Bartholinus190 describes motion in a cadaver. Barlow b says that movements were noticed after death in the vic- tims of Asiatic cholera. The bodies Avere cold and expressions were death- like, but there were movements simulating natural life. The most common avus flexion of the right leg, which would also be drawn up toward the body and resting on the left leg. In some cases the hand Avas moAred, and in one or two instances a substance was grasped as if by reflex action. Some observers have stated that reflex movements of the face were quite noticeable. These movements continued sometimes for upward of an hour, occurring mostly in muscular subjects who died very suddenly, and in whom the mus- cular irritability or nervous stimulus or both had not become exhausted at the moment of dissolution. Richardson173 doubts the existence of postmortem movements of respiration. SnoAv is accredited c with haA'ing seen a girl in Soho avIio, dying of scarlet fever, turned dark at the moment of death, but in a few hours presented such a life-like appearance and color as to almost denote the return of life. The center of the cheeks became colored in a natural fashion, and the rest of the body resumed the natural flesh color. The parents refused to believe that death had ensued. Richardson remarks that he had seen tAvo similar cases, and states that he believes the change is due to oxidation of the blood sur- charged Avith carbon dioxid. The moist tissues suffuse carbonized blood, and there occurs an osmotic interchange between the carbon dioxid and the oxygen of the air resulting in an oxygenation of the blood, and modification of the color from dark venous to arterial red. a 548, 1866, i., 287. b 173, 1889, 5. c Richardson, 173, 1889. POSTMORTEM ANOMALIES. 523 A peculiar postmortem anomaly is erection of the penis. The Ephem- erides and Morgagni576 discuss postmortem erection, and Guyon mentions that on one occasion, he saAV 14 negroes hanged, and states that at the moment of suspension erection of the penis occurred in each ; in nine of these blacks traces of this erectile state were perceived an hour after death. Cadaveric perspiration has been observed and described by several authors, and Paullini620 has stated that he has seen tears Aoav from the eyes of a corpse. The retardation of putrefaction of the body after death sometimes presents interesting changes. Petrifaction or mummification of the body are quite Avell known, and not being in the province of this vvork, aa^II be referred to collateral books on this subject; but sometimes an unaccountable preservation takes place. In a tomb recently opened at Canterbury Cathedral, a for the purpose of discovering what Archbishop's body it contained, the corpse was of an extremely offensive and sickening odor, unmistakably that of putre- faction. The body Avas that of Hubert Walter, Avho died in 1204 A. D., and the decomposition had been retarded, and was actually still in progress, several hundred years after burial. Retardation of the putrefactive process has been noticed in bodies some years under water. K5nig of Hermannstadt mentions a man who, forty years previous to the time of report, had fallen under the waters of Echo- schacht, and who was found in a complete state of preserA'ation. Postmortem Growth of Hair and Nails.—The hair and beard may grow after death, and even change color. Bartholinus recalls a case of a man who had short, black hair and beard at the time of interment, but who, some time after death, was found to possess long and yelloAvish hair. Aristotle discusses postmortem growth of the hair, and Garmanus cites an instance in which the beard and hair Avere cut several times from the cadaA'er. AVe occasionally see evidences of this in the dissecting-rooms. Cakhvellb men- tions a body buried four years, the hair from AA'hich protruded at the points where the joints of the coffin had gh'en away. The hair of the head measured 18 inches, that of the beard eight inches, and that on the breast from four to six inches. Rosse of AVashington mentions an instance in Avhich after burial the hair turned from dark broAA'n to red, and also cites a case in a Washington cemetery of a girl, tAvelve or thirteen years old, avIio when exhumed AA'as found to have a new groAA-th of hair all over her body. The Ephemerides contains an account of hair suddenly turning gray after death. Nails sometimes grow several inches after death, and there is on record the account of an idiot who had an idiosyncrasy for long nails, and after death the nails Avere found to have groAvn to such an extent that they curled up under the palms and soles. The untoward effects of the emotions on the vital functions are » 476, 1890, i., 1105. b 538, 1877. 524 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. quite Avell exemplified in medical literature. There is an abundance of cases reported in which joy, fear, pride, and grief have produced a fatal issue. In history avc haA'e the old story of the Lacedemonian Avoman who for some time had believed her son Avas dead, and avIio from the sudden joy occasioned by see- ing him alive, herself fell lifeless. There is a similar instance in Roman history. Aristotle, Pliny, Livy, Cicero, and others cite instances of death from sudden or excessive joy. Fouquet died of excessive joy on being released from prison. A niece of the celebrated Leibnitz immediately fell dead on seeing a casket of gold left to her by her deceased uncle. Galen mentions death from joy, and in comment upon it he says that the emotion of joy is much more dangerous than that of anger. In discussing this subject, Haller says that the blood is probably sent Avith such violence to the brain as to cause apoplexy. There is one case on record in which after a death from sudden joy the pericardium AAas found full of blood.a The Ephemerides, Marcellus Donatus,306 Martini, and Struthius all mention death from joy. Death from violent laughter has been recorded, but in this instance it is A'ery probable that death was not due to the emotion itself, but to the ex- treme convulsion and exertion used in the laughter. The Ephemerides men- tions a death from laughter, and also describes the death of a pregnant Avoman from violent mirth. Roy,b SAvinger,c and Camerarius247 have recorded in- stances of death from laughter. Strange as it may seem, Saint-Foix'1 says that the Moravian brothers, a sect of Anabaptists haA'ing great horror of bloodshed, executed their condemned brethren by tickling them to death. PoAverfully depressing emotions, Avhich are called by Kant "asthenic," such as great and sudden sorrow, grief, or fright, have a pronounced effect on the A'ital functions, at times even causing death. Throughout literature and history avc have examples of this anomaly. In Shakespeare's " Pericles," Thaisa, the daughter to Simonides and wife of Pericles, frightened Avhen pregnant by a threatened shipAvreck, dies in premature childbirth. In Scott's " Guy Mannering," Mrs. Bertram, on suddenly learning of the death of her little boy, is throAvn into premature labor, folloAved by death. Various theories are advanced in explanation of this anomaly. A very plausible one is, that the cardiac palsy is caused by energetic and persistent excitement of the inhibitory cardiac nerves. Strande is accredited Avith saying that agony of the mmd produces rupture of the heart. It is quite common to hear the expression, " Died of a broken heart;" and, strange to say, in some cases postmortem examination has proved the actual truth of the saying. Bartholinus, Fabricius Hildanus, Pliny, Rhodius, Schenck, Marcellus Dona- tus, Riedlin, and Garengeot speak of death from fright and fear, and the a "Anecdotes de Medecine,'' 117. b 462, 1812, Oct., 199. c "Theatre vitae human," 2656. d "Essais historiques sur Paris," T. v., 54. e "Treatise on the Physical Cause of the Death of Christ." DEATH FROM FEAR. 525 Ephemerides describes a death the direct cause of which was intense shame. Deleau,ri a celebrated doctor of Paris, while embracing his favorite daughter, avIio Avas in the last throes of consumption, was so overcome by intense grief that he fell over her corpse and died, and both were buried together. The fear of child-birth has been frequently cited as a cause of death. McClintock quotes a case from Travers of a young lady, happily married, Avho entertained a fear of death in child-birth ; although she had been safely delivered, she suddenly and without apparent cause died in six hours. Every region of the body avus examined with minutest care by an eminent physician, but no signs indicative of the cause of death were found. Mor- dret cites a similar instance of death from fear of labor. Morgagni576 men- tions a woman who died from the disappointment of bearing a girl baby AA'hen she was extremely desirous of a boy. The following case, quoted from Lauder Brunton,b shoAvs the extent of shock which may be produced by fear : Many years ago a janitor of a college had rendered himself obnoxious to the students, and they determined to punish him. Accordingly they prepared a block and an axe, which they conveyed to a lonely place, and having appropriately dressed themselves, some of them prepared to act as judges, and sent others of their company to bring him be- fore them. He first affected to treat the Avhole affair as a joke, but was solemnly assured by the students that they meant it in real earnest. He was told to prepare for immediate death. The trembling janitor looked all around in the vain hope of seeing some indication that nothing Avas really meant, but stern looks met him everywhere. He was blindfolded, and made to kneel before the block. The executioner's axe Avas raised, but, instead of the sharp edge, a Avet towel Avas brought sharply doAvn on the back of the neck. The bandage Avas now removed from the culprit's eyes, but to the horror and astonishment of the students they found that he was dead. Such a case may be due to heart-failure from fear or excitement. It is not uncommon that death ensues from the shock alone following blows that cause no visible injury, but administered to vital parts. This is particularly true of Ihoavs about the external genital region, or epigastrium, Avhere the solar plexus is an active factor in inhibition. lA'anhoff of Bulgaria in 1886 speaks of a man of forty-five who was dealt a bloAv on the testicle in a violent street fight, and staggering, he fell insensible. Despite A'igorous medical efforts he never regained consciousness and died in forty- five minutes. Postmortem examination revealed eA'erything normal, and death must have been caused by syncope following violent pain. AVatkins c cites an instance occurrmg in South Africa. A native shearing sheep for a farmer provoked his master's ire by calling him by some nickname. AVhile the man Avas in a squatting posture the farmer struck him in the epigastrium. He followed this up by a kick in the side and a blow on the head, neither of a 224, 1878, ii., 381. b 846, 292. c 476, 1884, i., 916. 526 PHYSIOLOGIC AND FUNCTIONAL ANOMALIES. Avhich, however, was as severe as the first bloAv. The man fell unconscious and died. At the autopsy there Avere no signs indicative of death, Avhich must have been due to the shock folloAving the blow on the epigastrium. As illustrative of the sensitiveness of the epigastric region, Vincent relates the folloAving case : " A man received a bloAV by a stick upon the epigastrium. He had an anxious expression and suffered from oppression. Irregular heart- action and shivering Avere symptoms that gradually disappeared during the day. In the evening his appetite returned and he felt Avell; during the night he died Avithout a struggle, and at the autopsy there was absolutely nothing abnormal to be found." BIoavs upon the neck often produce sudden collapse. Prize-fighters are avcII aAvare of the effects of a bloAV on the jugular vein. Maschka, quoted by AVarren,846 reports the case of a boy of tAvelve, avIio Avas struck on the anterior portion of the larynx by a stone. • He fell lifeless to the ground, and at autopsy no local lesion was found nor any lesion elseAvhere. The sudden death may be attributed in this case partly to shock and partly to cerebral anemia. Soldiers have been seen to drop lifeless on the battle-field Avithout apparent injury or organic derangement; in the olden times this death was attributed to fear and fright, and later was supposed to be caused by what is called " the wmd of a cannon-ball." Tolifree a has written an article on this cause of sudden death and others have discussed it. By some it is maintained that the momentum acquired by a cannon-ball generates enough force in the neigh- boring air to prostrate a person in the immediate vicinity of its path of flight. a 187, 1834, ii., 151. CHAPTER X. SUEGICAL ANOMALIES OF THE HEAD AND NECK. Injuries of such a delicate organ as the eye, in which the slightest acci- dent can produce such disastrous consequences, naturally elicit the interest of all. Examples of exophthalmos, or protrusion of the eye from the orbit from bizarre causes, are of particular interest. Among the older writers Ave find Fickera and the Ephemerides giving instances of exophthalmos from vomiting. Fabricius Hildanusb mentions a similar instance. Salmuth,706 Verduc,799 and others mention extrusion of the eyeball from the socket, due to excessive coughing. Ab Heers409 and Sennert732 mention instances in which after replacement the sight Avas uninjured. Tyler relates the case of a man Avho, after arising in the morning, bleAv his nose violently, and to his horror his left eye extruded from the orbit. AVith the assistance of his wife it Avas immediately replaced and a bandage placed over it. AVhen Tyler saAV him the upper lid Avas slightly swollen and discolored, but there Avas no hemorrhage. Hutchinson c describes extrusion of the eyeball from the orbit caused by a thrust Avith a stick. There Avas paraphymotic strangulation of the globe, entirely preventing replacement and necessitating excision. Reyssie d speaks of a patient Avho, during a fire, Avas struck in the right eye by a stream of water from a hose, violently thrusting the eye backward. Contracting under the double influence of shock and cold, the surrounding tissues forced the eyeball from the orbit, and an hour later Reyssie saAV the patient with the eye hanging by the optic nerve and muscles. Its reduction was easy, and after some minor treatment A'ision Avas perfectly restored in the injured organ. Thirty months after the accident the patient had perfect A'ision, and the eye had never in the slightest Avay discommoded him. Bodkine mentions the case of a woman of sixty Avho fell on the key in a door and completely avulsed her eye. In von Graefe's Archiv there is a record of a man of seventy-five who suffered complete aAmlsion of the eye by a cart- wheel passing over his head. Verhaeghe recordsf complete avulsion of the eye caused by a man falling against the ring of a sharp-Avorn key. Hamill s a 452, 1809, xi., 63. ' b 334, cent, i., obs. i. c 693, 1866. d 363, 1859, No. 65. e 312, 1854. f 145, xxvi., 99. g 224, 1878, i., 894. 527 528 SURGICAL ANOMALLES OF THE HEAD AND NECK. describes the case of a young girl AA'hose conjunctiva Avas pierced by one of the rests of an ordinary gas-bracket. Being hooked at one of its extremities the iron became entangled in either the inferior oblique or external rectus muscles, and completely avulsed the eyeball upon the cheek. The real dam- age could not be estimated, as the patient never returned after the muscle was clipped off close to its conjuncth'al insertion. Calhoun a mentions an instance of a little Esquimaux dog AA'hose head Avas seized betAveen the jaws of a large XeAvfbundland with such force as to press the left eyeball from the socket. The ball rested on the cheek, held by the taut optic nerve; the cornea was opaque. The ball Avas carefully and gently replaced, and sight soon returned to the eye. In former days there Avas an old-fashioned manner of fighting called "gouging." In this brutal contest the combatant was successful who could, Avith his thumb, press his opponent's eyeball out. Strange to say, little serious or permanently bad results followed such inhuman treatment of the eye. Von Langenbeck of Berlin mentions an instance of fracture of the superior maxilla, in which the eyeball Avas so much displaced as to lodge in the antrum of Highmore. Von Becker of Heidelberg reports the history of a case in which a bloAV from the horn of a coav dislocated the eye so far back in the orbit as to present the appearance of enucleation. The conjunctiva hid the organ from A'iew, but when it was pulled aside the eyeball was exposed, and in its remote position still possessed the power of vision. In some cases in Avhich exophthalmos has been seemingly spontaneous, extreme laxity of the lids may serve as an explanation. There is an instance on record in Avhich a Polish Jew appeared in a Continental hospital, saying that while turning in bed, without any apparent cause, his eyeball was completely extruded. There have been people who prided themselves on their ability to produce partial exophthalmos. Rupture of the Eyeball.—Jessop mentions the case of a child of eight aaIio suffered a blow on the eye from a fall against a bedpost, followed by compound rupture of the organ. The wound in the sclerotic was three or four lines in length, and the rent in the conjunctiva was so large that it required three sutures. The chief interest in this case was the rapid and complete recovery of vision. Adlerb reports a case of fracture of the superior maxillary in which the dislocated bone-fragment of the lower orbital border, through pressure on the inferior maxillary and counter pressure on the skull, caused rupture of the conjunctiva of the left eye. Serious Sequelae of Orbital Injuries.—In some instances injuries pri- marily to the orbit either by extension or implication of the cerebral contents provoke the most serious issues. Pointed instruments thrust into the orbital caA'ity may by this route reach the brain. There is a record0 of death a 176, 1876. b wien. Med. Woch., No. 6, 1895. c 476, 1831. GUNSHOT INJURIES OF THE ORBIT. 529 caused by a Avound of a cavernous sinus through the orbit by the stem of a tobacco-pipe. BoAvera saw a Avoman at the Gloucester Infirmary Avho had been stabbed in the eye by the end of an umbrella. There Avas profuse hemorrhage from the nostrils and left eye, but no signs indicative of its origin. Death shortly ensued, and at the necropsy a fracture through the roof of the orbit Avas re\Tealed, the umbrella point having completely severed the optic nerve and divided the ophthalmic artery. The internal carotid artery was AA'ounded in one-half of its circumference at its bend, just before it passes up betAveen the anterior clinoid process and the optic nerve. The cavernous sinus Avas also opened. In this rare injury, although there avus a considerable quantity of clotted blood at the base of the brain, there was no wound to the eyeball nor to the brain itself. Pepper records a case in which a knife Avas thrust through the sphenoidal fissure, Avounding a large meningeal vein, causing death from intracranial hemorrhage. Xelaton describes an instance in which the point of an umbrella wounded the cavernous sinus and internal carotid artery of the opposite side, causing the formation of an arteriovenous aneurysm which ultimately burst, and death ensued. Polaillon b suav a boy of eighteen avIio avus found in a state of coma. It was stated that an umbrella stick had been thrust up through the roof of the orbit and had been AvithdraAvn AA'ith much difficulty. The anterior lobe of the brain AA'as evidently much wounded ; an incision Avas made in the forehead and a portion of the frontal bone chiseled aAvaA'; en- trance being thus effected, the dura was incised, and some blood and cerebro- spinal fluid escaped. Five splinters Avere removed and a portion of the damaged brain-substance, and a small artery was tied with catgut. The debris of the eyeball Avas enucleated and a drain was placed in the frontal Avound, coming out through the orbit. The patient soon regained conscious- ness and experienced no bad symptoms afterward. The drains were gradu- ally withdrawn, the process of healing advanced rapidly, and recovery soon ensued. Annandalec mentions an instance in which a knitting-needle penetrated the brain through the orbit. HeAvettd speaks of perforation of the roof of the orbit and injury to the brain by a lead-pencil. Gunshot Injuries of the Orbit.—Barkan e recites the case in which a leaden ball j^j- inch in diameter was throAvn from a sling into the left orbital cavity, penetrating betAveen the eyeball and osseous Avail of the orbit Avithout rupturing the tunics of the eye or breaking the bony Avail of the cavity. It remained lodged tAvo AA'eeks Avithout causing any pain or symptoms, and sub- sequently Avorked itself forward, contained in a perfect conjunctiA'al sac, in Avhich it AA'as freely moA'able. Buchanan f recites the case of a private in the army Avho was shot at a a 476, 1R79, i., 517. b 233, Aug., 1891. c 318, 1877, xii. d 779, 1848-50, i., 188. e 616, 1874-5, 444. f 545, 1862-3, ix., 274. 34 530 SURGICAL ANOMALIES OF THE HEAD AND NECK. distance of three feet aAvay, the ball entering the inner canthus of the right eye and lodging under the skin of the opposite side. The eye Avas not lost, and opacity of the loAver part of the cornea alone resulted. Cold Avater and purging constituted the treatment. It is said a that an old soldier of one of Napoleon's armies had a musket- ball removed from his left orbit after tAventy-four years' lodgment. He Avas struck in the orbit by a musket-ball, but as at the same time a companion fell dead at his side he inferred that the bullet rebounded from his orbit and killed his comrade. For twenty-four years he had suffered from cephalalgia and pains and partial exophthalmos of the left eye. After removal of the ball the eye partially atrophied. AVarren reports a case of a man of thirty-five Avhose eyeball was destroyed by the explosion of a gun, the breech-pin flying off and penetrating the head. The orbit was crushed; fourteen months afterAvard the man complained of soreness on the hard palate, and the Avhole breech-pin, AA'ith screw attached, was extracted. The removal of the pin was followed by fissure of the hard palate, which, however, Avas relieA'ed by operation. The following is an ex- tract b of a report by AVenyon of Fatshan, South China :— " Tang Shan, Chinese farmer, thirty-one years of age, Avas injured in the face by the bursting of a shot-gun. After being for upward of two months under the treatment of native practitioners, he came to me on December 4, 1891. I observed a cicatrix on the right side of his nose, and above this a sinus, still unhealed, the orifice of Avhich involved the inner canthus of the right eye, and extended downward and iiiAvard for about a centimeter. The sight of the right eye Avas entirely lost, and the anterior surface of the globe was so uniformly red that the cornea could hardly be distinguished from the surrounding conjunctiva. There was no perceptible enlargement or protrusion of the eyeball, and it did not appear to haA'e sustained any mechanical injury or loss of tissue. The ophthalmia and keratitis Avere possibly caused by the irritating substances applied to the Avound by the Chinese doctors. The sinus on the side of the nose gaA'e exit to a continuous discharge of slightly putrid pus, and the patient complained of continuous headache and occasional dizziness, Avhich interfered AA'ith his work. The pain Avas referred to the right frontal and temporal regions, and the skin on this part of the head had a slight blush, but there Avas no superficial tenderness. The patient had been told by his native doctors, and he belieA'ed it himself, that there Avas no foreign body in the Avound ; but on probing it I easily recognized the loAver edge of a hard metallic substance at a depth of about one inch posteriorly from the orifice of the sinus. Being unable to obtain any reliable informa- tion as to the probable size or shape of the object, I cautiously made several attempts to remove it through a slightly enlarged opening, but Avithout success. I therefore continued the incision along the side of the nose to the nostril, a 222, 1846. b 224, Oct. 12, 1895. FOREIGN BODIES IN THE ORBIT. 531 thus laying open the right nasal cavity ; then, seizing the foreign body with a pair of strong forceps, I Avith difficulty removed the complete breech-pin of a Chinese gun. Its size and shape are accurately represented by the accompanying draAving (Fig. 190). The breech-pin measures a little over three inches in length, and weighs 2f ounces, or 75.6 grams. It had evidently lain at the back of the orbit, inclined upward and slightly backward from its point of entrance, at an angle of about 45 degrees. On its removal the headache was at once relieved and did not return. In ten davs the wound was perfectly healed and the patient Avent back to his work. A somewhat similar case, but Avhich terminated fatally, is recorded in the American Journal of the Medical Sciences of July, 1882." The extent of permanent injury done by foreign bodies in the orbit is variable. In some instances the most extensh'e wound is followed by the happiest result, while in others vision is entirely destroyed by a minor injury. Cartera reports a case in which a hat-peg 3t3q- inches long and about \ inch in diameter (upon one end of AA'hich was a knob nearly J inch in diame- ter) Avas impacted in the orbit for from ten to twenty days, and during this Fig. 190.—Breech-pin removed from the orbit. (Actual size.) time the patient Avas not aware of the fact. Recovery folloAved its extraction, the vision and movements of the eye being unimpaired. According to the Philosophical Transactions b a laborer thrust a long lath with great violence into the inner canthus of the left eye of his fellow work- man, EdAAard Roberts. The lath broke off short, leaving a piece two inches long, J inch wide, and \ inch thick, in situ. Roberts rode about a mile to the surgery of Mr. Justinian Morse, who extracted it Avith much difficulty ; recovery folloAved, together with restoration of the sight and muscular action. The lath was supposed to have passed behind the eyeball. Collettec speaks of an instance in Avhich 186 pieces of glass were extracted from the left orbit, the Avhole mass Aveighing 186 Belgian grains. They were blown in by a gust of Avind that broke a pane of glass ; after extraction no affection of the brain or eye occurred. AVatson d speaks of a case in Avhich a chip of steel f inch long AA'as imbedded in cellular tissue of the orbit for four days, and was re- moved Avithout injury to the eye. AVordsAVorthe reports a case in Avhich a foreign body Avas deeply imbedded in the orbit for six weeks, and was re- a Ophth. Rev., No. 4, p. 337. b 629, 1743, 945. c 145, 1850, 217. ^224, 1876, i., 506. e 548, 1861, ii., 452. 532 SURGICAL ANOMALIES OF THE HEAD AND NECK. moved Avith subsequent recovery. Chisholm* has seen a case in which for five weeks a fly Avas imbedded in the culdesac between the loAver lid and the eyeball. Foreign bodies are sometimes contained in the eyeball for many years. There is an instance on record b in which a wooden splinter, five mm. long and two mm. broad, remained in the eye forty-seven years. It Avas extracted, with the lens in which it Avas lodged, to relieve pain and other distressing symptoms. Snellc reports a case hi which a piece of steel Avas imbedded and encapsulated in the ciliary process twenty-nine years Avithout producing sym- pathetic irritation of its fellow, but causing such pain as to warrant enuclea- tion of this eye. Gunningd speaks of a piece of thorn £ inch long, im- bedded in the left eyeball of an old man for six years, causing total loss of vision ; he adds that, after its removal, some improvement was noticed. Williams mentions a stone-cutter Avhose left eye Avas put out by a piece of stone. Shortly after this his right eye Avas Avounded by a knife, causing traumatic cataract, which Avas extracted by Sir AVilliam Wilde, giving the man good sight for twelve years, after AA'hich iritis attacked the right eye and produced a false membrane over the pupil so that the man could not Avork. It Avas in this condition that he consulted Williams, fourteen years after the loss of the left eye. The eye Avas atrophied, and on examination a piece of stone Avas seen projecting from it directly between the lids. The visible portion was \ inch long, and the end in the shrunken eye Avas evi- dently longer than the end protruding. The sclera was incised, and, after fourteen years' duration in the eye, the stone Avas remoA'ed. Taylor e reports the removal of a piece of bone which had remained qui- escent in the eye for fourteen years ; after the removal of the eye the bone was found adherent to the inner tunics. It resembled the lens in size and shape. Williams f mentions continual tolerance of foreign bodies in the eye- ball for fifteen and twenty-two years ; and Chisholm 8 reports the lodgment of a fragment of metal in'the iris for twenty-three years. Liebreichh ex- tracted a piece of steel from the interior of the eye where it had been lodged twenty-two years. Barkar1 speaks of a piece of steel which penetrated through the cornea and lens, and Avhich, five months later, Avas successfully removed by the extraction of the cataractous lens. Critchett-" gives an in- stance of a foreign body being loose in the anterior chamber for sixteen years. Riderk speaks of the lodgment of a fragment of a copper percussion cap in the left eye, back of the inner ciliary margin of the iris, for thirty-five years ; and Bartholinus1 mentions a thorn in the canthus for thirty years. Jacob m re- ports a case in AA'hich a chip of iron remained.in the eyeball twenty-eight years a 186, 1870. b 548, 1880, i., 280. c 476, 1880, i., 749. d 476, 1880, i., 749. e 809, 1878. f 218, 1881, 84. S 476, April 3, 1880. b 224, 1873, ii., 651. i Archiv. of Opthal. and Otol., N. Y., 1874, iv., 231. J 693, 1857-8, i., 264. k 773, 1872, 160. 1188, iv., obs. 64. m 476, 1880, i., 667. RARE ACCIDENTS TO THE EYE. 533 without giving indications for removal. It Avas clearly visible, protruding into the anterior surface of the iris, and although it Avas rusted by its long lodgment, sight in the eye was fairly good, and there Avas no sign of irritation. Snella gives an instance in which a piece of steel AA'as imbedded close to the optic disc with retention of sight. It Avas plainly visible by the opthal- moscope eighteen months after the accident, AA'hen as yet no diminution of sight AA'as apparent. Smyly b speaks of a portion of a tobacco pipe which Avas successfully remoA'ed from the anterior chamber by an incision through the cornea. Clarkc mentions a case in which molten lead in the eye caused no permanent injury; and there are several cases mentioned in confirmation of the statement that the eye seems to be remarkably free from disastrous effects after this injury. AVilliamson d mentions eyelashes in the anterior chamber of the eye, the result of a stab AA'ound of this organ. Contusion of the eyeball may cause dislocation of the lens into the an- terior chamber, and several instances have been recorded. AVe regret our in- ability to give the reference or authority for a report that we haA'e seen, stating that by one kick of a horse the lenses of both eyes of a man AA'ere synchronously knocked through the eyeballs by the calkins of the horseshoe. Oliver mentions extraction of a lens by a thrust of a coav's horn. LoAve e speaks of rupture of the anterior capsule of the lens from violent sneezing, with subsequent absorption of the lenticular substance and restora- tion of vision. Trioenf mentions a curious case of expulsion of the crystalline lens from the eye in ophthalmia, through the formation of a corneal fissure. The authors haA'e personal knoAvledge of a case of spontaneous extrusion of the lens through a corneal ulcer, in a case of ophthalmia of the neAV-born. Injury of the Eyeball by Birds.—There are several instances in Avhich birds haA'e pierced the eyeball with their bills, completely destroying A'ision. Not long since a prominent taxidermist Avinged a crane, picked it up, and started to examine it, Avhen it made one thrust Avith its bill and totally de- stroyed his eyeball. In another instance a man AA'as going from the railroad station to his hotel in a gale of Avind, Avhen, as he turned the corner of the street, an English sparroAV Avas bloAvn into his face. Its bill penetrated his eyeball and completely ruined his sight. There are several instances on record in Avhich game foAvls have destroyed the eyes of their OAvners. In one case a game cock almost completed the enucleation of the eye of his handler, by striking him Avith his gaff while preparing in a cock-pit. Moorehead s explains a rare accident to an eye as folloAvs :— " Mr. S. B. A., Avhile attending to his bees, AA'as stung by one upon the right upper eyelid near its center. An employee, avIio Avas assisting in the work, immediately discovered the sting drh'en in the lid and cautiously ex- a 693, ix., part iii. b 310, 1876, 181. c 591, 1852, 303. d 476, 1882, ii., 448. e 476, 1861, i., 530.' t 784, 98. S 533, May 27, 1893. 534 SURGICAL ANOMALIES OF THE HEAD AND NECK. traded it, stating that he made sufficient traction to lift the lid Avell aAvay from the globe. In a feAV hours the lid became much swollen, but the pain experienced at first had disappeared. Before retiring for the night he began gentle massage of the lid, stroking it horizontally Avith his finger. The edematous condition Avas by this means much reduced in a short time. AVhile thus engaged in stroking the lid he suddenly experienced intense pain in the eye as if it had been pierced by a sharp instrument. The suffering Avas very severe, and he passed a Avretched night, constantly feeling ' something in his eye.' " The next morning, the trouble continuing, he came to me for relief. Upon examination of the lid, no opening could be made out Avhere the sting had penetrated, and a minute inspection of the conjunctival surface AA'ith a good glass failed to reveal any foreign substance. Cleansing the lid thoroughly, and carefully inspecting with a lens under strong light, a minute dark point Avas made out about the center of the lid. Feeling that this might be the point of the sting, I had recourse to several expedients for its removal, but without success. Finally, with a fine knife, I succeeded in cutting doAvn by the side of the body and tilting it out. Examination with a ^ inch objective confirmed my opinion that it Avas the point of the bee-sting. " The barbed formation of the point explains how, under the stroking with the finger, it was forced through the dense tarsal cartilage and against the cornea of the eye." There is a story told in La M6decine Moderne a of a seamstress of Berlin Avho Avas in the habit of allowing her dog to lick her face. She was attacked with a severe inflammation of the right eye, Avhich had to be enucleated, and was found full of tenia echinococcus, evidently derived from the dog's tongue. Gabb b mentions a case of epistaxis in which the blood Avelled up through the lacrimal ducts and suffused into the eye so that it Avas constantly neces- sary to wipe the lower eyelid, and the discharge ceased only when the nose stopped bleeding. A brief editorial note on epistaxis through the eyes, referring to a case in the Medical News of November 30, 1895, provoked further reports from numerous correspondents. Among others, the follow- ing:— " Dr. T. L. AVilson of Bell wood, Pa., relates the case of an old lady of seventy-eight Avhom he found Avith the blood gushing from the nostrils. After plugging the nares thoroughly with absorbent cotton dusted with tannic acid he was surprised to see the blood ooze out around the eyelids and trickle doAvn the cheeks. This oozing continued for the greater part of an hour, being controlled by applications of ice to both sides of the nose." " Dr. F. L. Donlon of NeAV York City reports the case of a married Avoman, about fifty years old, in Avhom epistaxis set in suddenly at 11 P. M., and had continued for several hours, when the anterior nares were plugged. a 545, June 6, 1896. * b 224, 1883, i., 715. LATE RESTORATION OF SIGHT. 535 In a short time the Avoman complained that she could scarcely see, owing to the Avelling up of blood in the eyes and trickling down her face. The bleeding only ceased when the posterior nares also were plugged." " Dr. T. G. AV right of Plain ville, Conn., narrates the ease of a young man Avhom he found in the night, bleeding profusely, and having already lost a large amount of blood. Shortly after plugging both anterior and pos- terior nares the blood found its way through the lacrimal ducts to the eyes and trickled doAvn the cheeks." " Dr. Charles W. Crumb cites the case of a man, sixty-five years old, with chronic nephritis, in whom a slight bruise of the nose was folloAved by epis- taxis lasting tAventy-four hours. AVhen the nares were plugged blood escaped freely from the eyes. A cone-shaped bit of sponge, saturated with ferrous sulphate, was passed into each anterior naris, and another piece of sponge, similarly medicated, into either posterior naris. The patient had been taking various preparations of potassium, and it was thought that his blood contained a deficiency of fibrin. Upon removal of the nasal plugs a catarrhal inflam- mation developed Avhich lasted a long time and was attended with considerable purulent discharge." Late Restoration of Sight.—There are some marvelous cases on record in which, after many years of blindness, the surgeon has been able, by opera- tion, to restore the sight. McKeown a gives the history of a blind fiddler of sixty-three, who, when one and a half years old, had lost the sight of both eyes after an attack of small-pox. Iridectomy Avas performed, and after over sixty years of total blindness his sight was restored ; color-perception was good. Berncastlo b mentions a case of extraction of double cataract and double iri- dectomy for occluded pupils, which, after thirty years of blindness, resulted in the recovery of good sight. The patient was a blind beggar of Sydney. To those interested in this subject, Jauffretc has a most interesting de- scription of a man by the name of Garin, who was born blind, Avho talked at eight or nine months, shoAved great intelligence, and who was educated at a blind asylum. At the age of tAventy-four he entered the hospital of For- lenzc, to be operated upon by that famous oculist. Garin had never seen, but could distinguish night or darkness by one eye only, and recognized orange and red when placed close to that eye. He could tell at once the sex and age of a person approximately by the voice and tread, and formed his conclusions more rapidly in regard to females than males. Forlenze diagnosed cataract, and, in the presence of a distinguished gathering, operated with the happiest result. The description that folloAvs, which is quoted by Fournierd and is readily accessible to any one, is well worth reading, as it contains an account of the first sensations of light, objects, distance, etc., and minor analogous a 476, 1888, i., 14. b 179, Oct. 15, 1869. c " Experience metaphysique ou Developpement de la lumiere et des sensations." d 302, iv. 536 SURGICAL ANOMALIES OF THE HEAD AND NECK. thoughts, of an educated and matured mind experiencing its first sensations of sight. Hansell and Clark 843 say that the perplexities of learning to see after twenty-six years of blindness from congenital disease, as described by a patient of Franke, remind one of the experience of Shelley's Frankenstein. Franke's patient AA'as successfully operated on for congenital double cataract, at tAventy-six years of age. The author describes a the difficulties the patient had of recognizing by means of vision the objects he had hitherto knoAvn through his other senses, and his slowness in learning to estimate distances and the comparative size of objects. Sight is popularly supposed to be occasionally restored without the aid of art, after long years of blindness. Benjamin Rush saAV a man of forty-five avIio, twelve years before, became blind Avithout ascertainable cause, and recoA'ered his sight equally without reason. St. Clair mentions Marshal Vivian, who at the age of one hundred regained sight that for nearly forty years had gradually been failing almost to blindness, and preserved this new sight to the time of his death. There are many superstitions preA'alent among uneducated people as to " second sight," recoA'ery of vision, etc., which render their reports of such things untrustAvorthy. The real explanations of such cases are too varied for discussion here. Nyctalopia etymologically means night-blindness, but the general usage, making the term mean night-\'ision, is so strongly intrenched that it is useless and confusing to attempt any reinstatement of the old significance. The con- dition in Avhich one sees better by night, relatively speaking, than by day is due to some lesion of the macular region, rendering it blind. At night the pupil dilates more than in the day-time, and hence A'ision AA'ith the extramac- ular or peripheral portions of the retina is correspondingly better. It is, therefore, a symptom of serious retinal disease. All night-prowling animals haA'e AA'idely dilatable pupils, and in addition to this they have in the retina a special organ called the tapetum lucidum, the function of Avhich is to reflect to a focus in front of them the relatively few rays of light that enter the widely-dilated pupil and thus enable them the better to see their Avay. Hence the luminous appearance of the eyes of such animals in the dark. Hemeralopia (etymologically day-blindness, but by common usage mean- ing day-vision or night-blindness) is a symptom of a peculiar degenerative disease of the retina, called retinitis pigmentosa. It also occurs in some cases of extreme denutrition, numerous cases haA'ing been reported among those Avho make the prolonged fasts customary in the Russian church. In retinitis pig- mentosa the peripheral or extramacular portions of the retina are subject to a pigmentary degeneration that renders them insensitive to light, and patients so afflicted are consequently incapable of seeing at night as well as others. They stumble and run against objects easily seen by the normal eye. a Beit, zur Augenh., Heft xvi., 1894. INJURIES TO THE EAR. 537 Snow-blindness occurs from prolonged exposure of the eyes to snow upon which the sun is shining. Some years ago, some seventy laborers, who were clearing away snow-drifts in the Caucasus, were seized, and thirty of them could not find their Avay home, so great was the photophobia, conjunctivitis, and lacrimation. Graddy a reports six cases, and many others are constantly occurring. Other forms of retinal injury from too great or too prolonged exposure to light are " moon-blindness," due to sleeping Avith the eyes exposed to bright moonlight, and that due to lightning—a case, e.g., being reported by Knies.b Silexc also reports such a case and reviews the reported cases, 25 in number, in ten of which cataract ensued. In the Annual of the Universal Medical Sciences, 1888, there is a report of seven cases of retmal injury Avith central scotoma, amblyopia, etc., in Japanese medical students, caused by observation of the sun in eclipse. In discussing the question of electric-light injuries of the eyes Gould d reviews the literature of the subject and epitomizes the cases reported up to that time. They numbered 23. No patient was seriously or permanently injured, and none was in a person who used the electric light in a proper manner as an illuminant. All Avere in scientific investigators or Avorkmen about the light, Avho approached it too closely or gazed at it too long and Avithout the colored protecting spectacles now found necessary by such workers. Injuries to the Ear.—The folly of the practice of boxing children's ears, and the possible disastrous results subsequent to this punishment, are Avell exemplified throughout medical literature. Stewarte quotes four cases of rupture of the tympanum from boxing the cars, and there is an instance f of a boy of eight, who was boxed on the ear at school, in Avhom subsequent brain-disease developed early, and death folloAved. Roosa of New York mentions the loss of hearing following a kiss on the ear.s Dalby,b in a paper citing many different causes of rupture of the tympanic membrane, mentions the folloAving : A bloAV in sparring ; A'iolent sneezing; bloAving the nose ; forcible dilatation of the Eustachian canal; a thorn or twig of a tree accidentally thrust into the head ; picking the ear Avith a toothpick. In time of battle soldiers sometimes have their tympanums ruptured by the concussion caused by the firing of cannon. Dalby mentions an instance of an officer Avho Avas discharged for deafness acquired in this manner during the Crimean AVar. He Avas standing beside a mortar AA'hich, unexpectedly to him, AAas fired, causing rupture of the tympanic membrane, folloAved by hemorrhage from the ear. Similar cases Avere reported in the recent naA'al engagements between the Chinese and Japanese. Wilson1 reports tAvo a 124, 1887. b Graefe's Archiv, 1887. c Arch. f. Augenheilk., 1887. d 533, Dec. 8, 1888. e 476, 1889, i., 574. f 476, 1879, i., 23. g Archives of Otology, 1880, ix., 16. b 476,1875, i., 752. i 533, xii., 173. 538 SURGICAL ANOMALIES OF THE HEAD AND NECK. cases of rupture of the membrana tympani caused by diving. Roosaa divides the causes into traumatic, hemorrhagic, and inflammatory, and primary lesions of the labyrinth, exemplifying each by numerous instances. Under traumatic causes he mentions severe falls, bloAvs about the head or face, con- stant listening to a telegraphic instrument, cannonading, and finally eight cases of boiler-makers' deafness. Roosa cites a curious case of sudden and pro- found deafness in a young man in perfect health, AA'hile calling upon the parents of his lady-love to ask her hand in marriage. Strange to say that after he had had a favorable reply he gradually recovered his hearing ! In the same paper there is an instance of a case of deafness due to the sudden cessation of perspiration, and an instance of tinnitus due to the excessive use of tobacco; Roosa also mentions a case of deafness due to excessive mental employment. Perforation of the Tympanum.—Kealy b relates an instance in Avhich a pin was introduced into the left ear to relieve an intolerable itching. It perforated the tympanum, and before the expiration of twenty-four hours Avas coughed up from the throat AA'ith a small quantity of blood. The pin Avas bent at an angle of about 120 degrees. Another similar case c was that of a girl of twenty-tAvo who, while pricking her ear with a hair-pin, Avas jerked or struck on the arm by a child, and the pin forced into the ear; great pain and deafness followed, together with the loss of taste on the same side of the tongue ; after treatment both of the disturbed senses were restored. A man of twentyd was pricked in the ear by a needle entering the meatus. He uttered a cry, fell senseless, and so continued until the fourth day when he died. The whole auditory meatus Avas destroyed by suppuration. Gamgee e tells of a constable who was stabbed in the left ear, seAering the middle meningeal artery, death ensuing. In this instance, after digital compression, ligature of the common carotid was practised as a last resort. There is an accountf of a provision-dealer's agent who fell asleep at a public house at Tottenham. In sport an attendant tickled his ear with a wooden article used as a pipe light. A quick, unconscious movement forced the wooden point through the tympanum, causing cerebral inflammation and subsequent death. There is a record8 of death, in a child of nine, caused by the passage of a knitting-needle into the auditory meatus. Kauffmann h reports a case of what he calls objective tinnitus aurium, in Avhich the noise originating in the patient's ears was distinctly audible by others. The patient Avas a boy of fourteen, who had fallen on the back of his head and had remained unconscious for nearly two weeks. The noises were bilateral, but more distinct on the left than on the right side. The sounds Avere described as crackling, and seemed to depend on movements of a 124, Oct., 1874, 376. b 548, 1859, 602. c 476, 1889, i., 574. d566, Jan. 20, 1829. e 476, 1875, i., 535. f 476, 1895, ii., 222. g 224, 1869, ii., 470. h Deutsche Med. Zeitung, Jan. 6, 1896. FOREIGN BODIES IN THE EAR. 539 the arch of the palate. Kauffmann expresses the opinion that the noises Avere due to clonic spasm of the tensor velum palati, and states that under appro- priate treatment the tinnitus gradually subsided. The introduction of foreign bodies in the ear is usually accidental, although in children we often find it as a result of sport or curiosity. There is an instance on record of a man who Avas accustomed to catch flies and put them in his ear, deriving from them a pleasurable sensation from the tickling which ensued. There have been cases in which children, and even adults, have held grasshoppers, crickets, or lady-birds to their ears in order to more atten- tively listen to the noise, and while in this position the insects have escaped and penetrated the auditory canal. Insects often enter the ears of persons re- posing in the fields with the ear to the ground. Fabricius Hildanus speaks of a cricket penetrating the ear during sleep. Calhoun a mentions an instance of disease of the ear Avhich he found was due to the presence of several living maggots in the interior of the ear. The patient had been sleeping in a horse stall in which were found maggots similar to those extracted from his ear. An analogous instance was seen in a negro in the Emergency Hospital, Wash- ington, D. C, in the summer of 1894 ; and many others are recorded. The insects are frequently removed only after a prolonged lodgment. D'Aguanno b gives an account of two instances of living larvae of the musca sarcophaga in the ears of children. In one of the cases the larvae entered the drum-cavity through a rupture in the tympanic membrane. In both cases the maggots were removed by forceps. Haug c has observed a tic (ixodes ricinus) in the ear of a lad of seventeen. The creature avus killed by a mercuric-chlorid solution, and removed Avith a probe. There is a common superstition that centipedes have the faculty of entering the ear and penetrating the brain, causing death. The authors have knowl- edge of an instance in Avhich three small centipedes Avere taken from the ear of a policeman after remaining there three days ; during this time they caused excruciating pain, but there was no permanent injury. The Ephemerides con- tains instances in which, while yet living, worms, crickets, ants, and beetles have all been taken from the ear. In one case the entrance of a cricket in the auditory canal was the cause of death. Martin d gives an instance in which larvae were deposited in the ear. Stalpart van der AViel750 relates an instance of the lodgment of a lh'ing spider in the ear. Far more common than insects are inanimate objects as foreign bodies in the ear, and numerous examples are to be found in literature. Fabricius Hildanus 334 tells of a glass ball introduced into the auditory canal of a girl of ten, followed by headache, numbness on the left side, and after four or five years epileptic seizures, and atrophy of the arm. He extracted it and the symptoms immediately ceased. Sabatier speaks of an abscess of the brain caused by a ball of paper in the ear; and it is quite common for persons in a 176, 1873, x., 665. b 843, 836. c Ibid. d 462, T. xxxi., 179. 540 SURGICAL ANOMALIES OF THE HEAD AND NECK. the habit of using a tampon of cotton in the meatus to mistake the deep entrance of this substance for functional derangement, and many cases of temporary deafness are simply due to forgetfulness of the cause. A strange case is reported in a girl of fourteen, Avho lost her tympanum from a profuse otorrhea, and Avho substituted an artificial tympanum Avhich Avas, in its turn, lost by deep penetration, causing augmentation of the symptoms, of the cause of which the patient herself seemed unaAvare." Sometimes artificial otoliths are produced by the insufflation of various poAvders which become agglutinated, and are veritable foreign bodies. Holman b tells of a negro, aged thirty-five, Avhose Avife poured molten peAvter in his ear while asleep. It Avas removed, but total deafness Avas the result. Alleyc mentions a New Orleans Avharf laborer, in Avhose ear avus poured some molten lead ; seventeen months afterward the lead Avas still occupying the external auditory meatus. It is quite remarkable that the lead should have remained such a length of time Avithout causing meningeal inflammation. There Avas deafness and palsy of that side of the face. A fungous groAvth occupied the external portion of the ear; the man suffered pain and discharge from the ear, and had also great difficulty in closing his right eyelid. Mor- rison d mentions an alcoholic patient of forty who, on June 6, 1833, had nitric acid poured in her right ear. There were no headache, febrile symptoms, stupor, or vertigo. Debility alone was present. Two Aveeks after the injury paralysis began on the right side, and six weeks from the injury the patient died. This case is interesting from the noA'el mode of death, the perfect par- alysis of the arm, paralysis agitans of the body (occurring as hemorrhage from the ear came on, and subsiding Avith it), and extensive caries of the petrous bone, Avithout sensation of pain or any indicative symptoms. There is an instance in a young girl in which a piece of pencil remained in the right ear for seven years.e Haug speaks of two beads lying in the auditory canal for tAventy-eight years Avithout causing any harm. A boy of six introduced a carob-nut kernel into each ear. On the next day incompetent persons attempted to extract the kernel from the left side, but only caused pain and hemorrhage. The nut issued spontaneously from the right side. In the afternoon the auditory canal was found excoriated and red, and deep in the meatus the kernel Avas found, covered AA'ith blood. The patient had been so excited and pained by the bungling attempts at extraction that the employment of instruments Avas impossible ; prolonged employment of injections Avas substituted. Discharge from the ear commenced, intense fever and delirium ensued, and the patient had to be chloroformed to facili- tate the operation of extraction. The nut, when taken out, was found to have a consistency much larger than originally, caused by the agglutination of wax and blood. Unfortunately the symptoms of meningitis increased ; three days a 720, 1877, 210. b 744) 188a c 124) Ap^ 1852) 377. d 310, 1836, ix., 99. e 554, 1842. No. 32. FOREIGN BODIES IN THE EAR. 541 after the operation coma followed, and on the next day death ensued.3 In 75 cases collected by Mayer, and cited by Poulet641 (whose work on " Foreign Bodies " is the most extensive in existence), death as a consequence of menin- gitis Avas found in three. Fleury de Clermontb mentions a woman of twenty-five who consulted him for removal of a pin AA'hich was in her right ear. Vain attempts by some of her lay-friends to extract the pin had only made matters Avorse. The pin Avas directed transversely, and its middle part touched the membrana tym- panum. The mere touching of the pin caused the Avoman intense pain; even after etherization it Avas necessary to construct a special instrument to extract it. She suffered intense cephalalgia and other signs of meningitis ; despite vigorous treatment she lost consciousness and died shortly after the operation. Winterbothamc reports an instance in which a cherry-stone Avas removed from the meatus auditorius after lodgment of upward of sixty years. Mar- chal de Calvi mentions intermittent deafness for forty years, caused by the lodgment of a small foreign body in the auditory canal. There is an instance in Avhich a carious molar tooth has been tolerated in the same location for forty years.d Albucasius, Fabricius Hildanus, Pare, and others, have mentioned the fact that seeds and beans have been frequently seen to increase in A'olume while lodged in the auditory canal. Tulpius 842 speaks of an infant, playing Avith his comrades, Avho put a cherry-seed in his ear AA'hich he Avas not able to extract. The seed increased in volume to such an extent that it avus only by surgical interference that it could be extracted, and then such serious consequences folloAved that death resulted. Alberse reports an instance in Avhich a pin introduced into the ear issued from the pharynx. Confusion of diagnosis is occasionally noticed in terrified or hysteric per- sons. Lowenberg Avas called to see a child of five Avho had introduced a button into his left ear. AVhen he saAV the child it complained of all the pain in the right ear, and he naturally examined this ear first but found nothing to indicate the presence of a foreign body. He examined the ear supposed to be healthy and there found the button lying against the tympanum. This Avas explained by the fact that the child Avas so pained and terrified by the previous explorations of the affected ear that rather than undergo them again he presented the Avell ear for examination. In the British Medical Journal for 1877 is an account of an unjustified exploration of an ear for a foreign body by an incompetent physician, Avho spent a half hour in exploration and manipulation, and Avhose efforts resulted in the extraction of several pieces of bone. The child died in one and a half hours afterAvard from extreme hemor- rhage, and the medical bungler Avas compelled to appear before a coroner's jury in explanation of his ignorance. In the external ear of a child Tansley observed a diamond which he a 720, 1800, 230. b 363, 1870, 58. c 548, 1866, ii., 496. d641, 695. e 456, i., 151. 542 SURGICAL ANOMALIES OF THE HEAD AND NECK. removed under chloroform." The mother of the child had pushed the bodv further imvard in her endeavors to remove it and had AA'ounded the canal. SchmiegeloAV b reports a foreign body forced into the drum-cavity, folloAved by rough extraction, great irritation, tetanus, and death ; and there are on record several cases of fatal meningitis, induced by rough endeavors to extract a body from the external ear. In the Therapeutic Gazette, August 15, 1896, there is a translation of the report of a case by A^oss, in Avhich a child of fh'e pushed a dry pea in his ear. Four doctors spent several days endeavoring to extract it, but only succeeded in pushing it in further. It Avas removed by operation on the fifth day, but suppuration of the tympanic cavity caused death on the ninth day. Barclay0 reports a rare case of ensnared aural foreign body in a lady, aged about forty years, AA'ho, Avhile " picking" her left ear Avith a so-called " inA'isible hair-pin " seA'eral hours before the consultation, had heard a sudden " twang " in the ear, as if the hair-pin had broken. And so, indeed, it had ; for on the instant she had attempted to jerk it quickly from the ear the sharp extremity of the inner portion of its lower prong sprang away from its fellow, penetrated the soft tissues of the floor of the external auditory canal, and re- mained imbedded there, the separated end of this prong only coming away in her grasp. EA'ery attempt on her part to remove the hair-pin by traction on its projecting prong—she durst not force it inward for fear of Avounding the drumhead—had served but to bury the point of the broken prong more deeply into the flesh of the canal, thereby increasing her suffering. Advised by her family physician not to delay, she forthwith sought advice and aid. On examination, it Avas found that the loAver prong of the " invisible hair-pin " had broken at the outer end of its AvaA'y portion, and seemed firmly im- bedded in the floor of the auditory canal, now quite inflamed, at a point about one-third of its depth from the outlet of the canal. The loop or turn of the hair-pin avus about ^ inch from the flaccid portion of the drumhead, and, to- gether Avith the unbroken prong, it lay closely against the roof of the canal. Projecting from the meatus there Avas enough of this prong to be easily grasped between one's thumb and finger. Removal of the hair-pin was effected by first inserting within the meatus a Gruber speculum, encircling the unbroken projecting prong, and then raising the end of the broken one with a long-shanked aural hook, when the hair-pin was readily Avithdrawn. The wound of the canal-floor promptly healed. In the seATerest forms of scalp-injuries, such as avulsion of the scalp from the entangling of the hair in machinery, skin-grafting or replantation is of particular value. Aslihurstd reports a case Avhich he considers the severest case of scalp-Avound that he had ever seen, followed by recovery. The patient Avas a girl of fifteen, an operative in a cotton-mill, Avho aa as caught by a 165, Aug., 1894. b 843, 836. c 533, Jan. llf 1896. d 174, 324. SCALP-INJURIES. 543 her hair between two rollers which were revolving in opposite directions ; her scalp being thus, as it were, squeezed off from her head, forming a large horse- shoe flap. The linear extent of the wound was 14 inches, the distance be- tween the two extremities being but four inches. This large flap was thrown backAvard, like the lid of a box, the skull being denuded of its pericranium for the space of 1\ by one inch in extent. The anterior temporal artery was divided and bled profusely, and when admitted to the hospital the patient was extremely depressed by shock and hemorrhage. A ligature was applied to the bleeding vessel, and after it had been gently but carefully cleansed the flap was replaced and held in place with gauze and collodion dressing. A large compress soaked in warm olive oil was then placed over the scalp, covered with oiled silk and with a recurrent bandage. A consid- erable portion of the wound healed by adhesions, and the patient was dis- charged, cured, in fifty-four days. No exfoliation of bone occurred. Rever- din, a relative of the discoverer of transplantation of skin,a reported the case of a girl of twenty-one whose entire scalp was detached by her hair being caught in machinery, leaving a Avound measuring 35 cm. from the root of the nose to the nape of the neck, 28 cm. from one ear to the other, and 57 cm. in cir- cumference. Grafts from the rabbit and dog failed, and the skin from the amputated stump of a boy was employed, and the patient was able to leave the hospital in seven months. CoAvley b speaks of a girl of fourteen Avhose hair was caught in the revolving shaft of a steam-engine, which resulted in the tearing off of her whole scalp. A triangular portion of the skin was hanging over her face, the apex of the triangle containing short hair, from Avhich the long hair had been detached. Both ears were hanging doAvn the neck, having been detached above. The right pinna was entire, and the upper half of the left pinna had disappeared. The whole of the head and back of the neck Avas denuded of skin. One of the temporal arteries was ligated, and the scalp cleansed and reapplied. The hanging ears and the skin of the forehead Avere successfully restored to their proper position. The patient had no bad symp- toms and little pain, and the shock was slight. Where the periosteum had sloughed the bone Avas granulating, and at the time of the report skin-grafting Avas shortly to be tried. Schaeffer c has presented quite an extensh'-e article on scalp-injuries in which grafting and transplantation has been used, and besides reporting his OAvn he mentions several other cases. One Avas that of a young lady of twenty- four. While at Avork under a reA'oh'ing shaft in a laundry the wind bleAV her hair and it Avas caught in the shaft. The entire skull Avas laid bare from the margin of the eyelids to the neck. The nasal bones were uncovered and broken, exposing the superior nasal meatus. The skin of the eyelids was re- moved from Avithin three mm. of their edges. The lower margin of the wound a Deutsche Zeitschrift fur Chirurg., Feb , 1876. b 476, 1879, ii., 421. c 782, 1887, iii., 166 et seq. 544 SURGICAL ANOMALIES OF THE HEAD AND NECK. Avas traceable from the lower portion of the left external process of the frontal bone, doAvnward and backAvard beloAv the left ear (Avhich Avas entirely removed), thence across the neck, five cm. beloAv the superior curved line of the occipi- tal bone, and forward through the lower one-third of the right auricle to the right external angular process of the frontal bone and margin of the right upper eyelid, across the lid, nose, and left eyelid, to the point of commencement. Every vessel and nerve supplying the scalp Avas destroyed, and the pericranium AA'as torn off in three places, one of the denuded spots measuring five by seven cm. and another five by six cm. The neck flap of the Avound fell aAvay from the muscular structures beneath it, exposing the trapezius muscle almost one- half the distance to the shoulder blade. The right ear Avas torn across in its loAver third, and hung by the side of the neck by a piece of skin less than five mm. Avide. The exposed surface of the Avound measured 40 cm. from before back, and 34 cm. in Avidth near the temporal portion. The cranial sutures Avere distinctly seen in several places, and only a few muscular fibers of the temporal were left on each side. Hemorrhage was profuse from the temporal, occipital, and posterior auricular arteries, Avhich were tied. The patient was seen three-quarters of an hour after the injury, and the mangled scalp AA'as thoroughly Avashed in Avarm carbolized Avater, and stitched back in position, after the hair Avas cut from the outer surface. Six weeks after the injury suppuration Avas still free, and skin-grafting was commenced. In all, 4800 grafts were used, the patient supplying at different times 1800 small grafts. Her own skin invariably did better than foreign grafts. In ten months she had almost completely recovered, and sight and hearing had returned. Figure 191 shows the extent of the injury, and the ultimate results of the treatment. Schaeffer also reports the case of a woman working in a button factory at Union City, Conn., in 1871, who placed her head under a sAviftly turning shaft to pick up a button, when her hair caught in the shaft, taking off her scalp from the nape of the neck to the eyebrows. The scalp was cleansed by her physician, Dr. Bartlett, and placed on her head about two hours after the ac- cident, but it did not stay in position. Then the head was covered tAvice by skin-grafts, but each time the grafts Avere lost; but the third time a successful grafting Avas performed and she was enabled to work after a period of two years. The same authority also quotes Wilson and AAray of Bristol, Conn., in an account of a complete avulsion of the scalp, together with tearing of the eyelid and ear. The result of the skin-grafting was not given. PoAvell of Ciiicago gh'es an account of a girl of nineteen Avho lost her scalp while Avorking in the Elgin AVatch Factory at Elgin, Illinois. The Avound extended across the forehead above the eyebroAvs, but the ears were untouched. Skin- grafting Avas tried in this case but with no result, and the Avoman afterward lost an eye by exposure, from retraction of the eyelid. In some cases extensive wounds of the scalp heal without artificial CEREBRAL INJURIES. 545 aid by simply cicatrizing over. Gross387 mentions such a case in a young lady, Avho, in 1869, lost her scalp in a factory. There is reporteda an account of a conductor on the Union Pacific Railroad, Avho, near Cheyenne, in 1869, AAas scalped by Sioux Indians. He suffered an elliptic Avound, ten by eight cm., a portion of the outer table of the cranium being removed, yet the wound healed OA'er. Cerebral Injuries.—The recent advances in brain-surgery have, in a measure, diminished the interest and wonder of some of the older instances of Fig. 191.—Scalp-injury and skin-graft (Schaeffer). major injuries of the cerebral contents Avith unimportant after-results, and in revieAving the older cases Ave must remember that the recoA'cries were made under the most unfavorable conditions, and without the slightest knoAvledge of all important asepsis and antisepsis. Penetration or even complete transfixion of the brain is not ahvays attended Avith serious symptoms. Dubrisayb is accredited with the descrip- tion of a man of forty-four, Avho, Avith suicidal intent, drove a dagger ten cm. long and one cm. Avide into his brain. He had deliberately held the dagger a 544, surgical portion, part i., 315. b 476, 1881, ii., 845, 35 546 SURGICAL ANOMALIES OF THE HEAD AND NECK. in his left hand, and Avith a mallet in his right hand struck the steel several bloAvs. AVhen seen tAvo hours later he claimed that he experienced no pain, and the dagger Avas sticking out of his head. For half an hour efforts at extraction Avere made, but with no aA'ail. He Avas placed on the ground and held by tAvo persons Avhile traction Avas made AA'ith carpenter's pliers. This failing, he AA-as taken to a coppersmith's, Avhere he AAas fastened by rings to the ground, and strong pinchers Avere placed over the dagger and attached to a chain AA'hich Avas fastened to a cylinder revolved by steam force. At the second turn of the cylinder the dagger came out. During all the efforts at extraction the patient remained perfectly cool and complained of no pain. A feAV drops of blood escaped from the Avound after the removal of the dagger, and in a few minutes the man walked to a hospital Avhere he remained a few days Avithout feA'er or pain. The wound healed, and he soon returned to Avork. By experiments on the cadaver Dubrisay found that the difficulty in extrac- tion Avas due to rust on the steel, and by the serrated edges of the wound in the bone. AVarren describes a case of epilepsy of seven months' standing, from de- pression of the skull caused by a red hot poker thrown at the subject's head. Striking the frontal bone just above the orbit, it entered three inches into the cerebral substance. Kesteven a reports the history of a boy of thirteen avIio, Avhile holding a fork in his hand, fell from the top of a load of straw. One of the prongs entered the head one inch behind and on a line with the lobe of the left ear and passed upward and slightly backward to almost its entire length. With some difficulty it was withdrawn by a fellow workman; the point AA'as bent on itself to the extent of two inches. The patient lived nine days. Abel and Colman b have reported a case of puncture of the brain with loss of memory, of which the following extract is an epitome : " A railway- fireman, thirty-six years old, while carrying an oil-feeder in his hand, slipped and fell fonvard, the spout of the can being driven forcibly into his face. There was transitory loss of consciousness, followed by tAvitching and jerking movements of the limbs, most marked on the left side, the legs being draAvn up and the body bent forward. There was no hemorrhage from mouth, nose, or ears. The metallic spout of the oil-can was firmly fixed in the base of the skull, and Avas only removed from the grasp of the bone by firm traction Avith forceps. It had passed upward and toward the middle line, Avith its concavity directed from the middle line. Its end was firmly plugged by bone from the base of the skull. No hemorrhage followed its removal. The wound was cleansed and a simple iodoform-dressing applied. The violent jerking move- ments were replaced by a few occasional tAvitchings. It Avas now found that the left side of the face and the left arm were paralyzed, Avith inability to close the left eye completely. The man became droAvsy and confused, and Avas unable to give replies to any but the simplest questions. The temperature a 779, xxv., 13. b 224, No. 1781, 356. PENETRA TION OF THE BRAIN 547 rose to 102° ; the pupils became contracted, the right in a greater degree than the left; both reacted to light. The left leg began to lose poAver. There Avas complete anesthesia of the right eyebroAV and of both eyelids and of the right cheek for an uncertain distance beloAv the lower eyelid. The con- junctiva of the right eye became congested, and a small ulcer formed on the right cornea, Avhich healed Avithout much trouble. In the course of a few days power began to return, first in the left leg and afterward, though to a much less extent, in the left arm. For two weeks there was droAvsiness, and the man slept considerably. He Avas apathetic, and for many days passed urine in bed. He could not recognize his Avife or old comrades, and had also difficulty in recognizing common objects and their uses. The most remarkable feature Avas the loss of all memory of his life for twenty years before the accident. As time Avent on, the period included in this loss of memory Avas reduced to five years preceding the accident. The hemi- B____,_ Fig. 192.—Diagram indicating the probable course of the spout; the direction was not vertical, but inclined backward (Abel and Colman). Fig. 193.—Exact outline of spout after re- moval ; the dotted line represents position of cheek-wound; from A to B, natural size, meas- ured 6% inches. plegia persisted, although the man was able to get about. Sensibility was lost to all forms of stimuli in the right upper eyelid, forehead, and anterior part of the scalp, corresponding Avith the distribution of the supraorbital and nasal nerves. The cornea Avas completely anesthetic, and the right cheek, an inch and a half external to the angle of the nose, presented a small patch of anesthesia. There Avas undue emotional mobility, the patient laughing or crying on slight provocation. The condition of mind-blindness remained. It is believed that the spout of the oil-can must have passed under the zygoma to the base of the skull, perforating the great wing of the sphenoid bone and penetrating 548 SURGICAL ANOMALIES OF THE HEAD AND NECK. the centrum OA'ale, injuring the anterior fibers of the motor tract in the internal capsule near the genu." Figures 192 and 19-*3 sIioav the outline and probable course of the spout. Beaumonta reports the history of an injury in a man of forty-five, avIio standing but 12 yards aAvay, Avas struck in the orbit by a rocket, Avhich penetrated through the sphenoidal fissure into the middle and posterior lobes of the left hemisphere. He did not fall at the time he Avas struck, and fifteen minutes after the stick Avas remoA'ed he arose Avithout help and Avalked aAvav. Apparently no extensive cerebral lesion had been caused, and the man suffered no subsequent cerebral symptoms except, three years afterAvard, impairment of memory. There is an account given by Cheliusb of an extraordinary Avound caused by a ramrod. The rod Avas accidentally discharged while being employed in loading, and struck a person a few paces aAvay. It entered the head near the root of the zygomatic arch, about a finger's breadth from the outer corner of the right eye, passed through the head, emerging at the posterior superior angle of the parietal bone, a finger's breadth from the sagittal suture, and about the same distance above the superior angle of the occipital bone. The Avounded man attempted to pull the ramrod out, but all his efforts Avere ineffectual. After the tolerance of this foreign body for some time, one of his companions managed to extract it, and AA'hen it Avas brought out it Avas as straight as the day it left the maker's shop. Little blood Avas lost, and the Avound healed raj)idly and completely ; in spite of this major injury the patient recovered. Carpenter0 reports the curious case of an insane man who deliberately bored holes through his skull, and at different times, at a point above the ear, he inserted into his brain five pieces of No. 20 broom wire from 2^ to 6f inches in length, a fourpenny nail 1\ inches long, and a needle If inches long. Despite these desperate attempts at suicide he lived several months, finally accomplishing his purpose by taking an overdose of morphin. Mac- Queen d has given the history of a man of thirty-five, Avho drove one three- inch nail into his forehead, another close to his occiput, and a third into his vertex an inch in front and \ inch to the left of the middle line. He had used a hammer to effect complete penetration, hoping that death Avould result from his injuries. He failed in this, as about five Aveeks later he A\as dis- charged from the Princess Alice Hospital at Eastbourne, perfectly recovered. There is a record e of a man by the name of Bulkley Avho Avas found, by a police officer in Philadelphia, staggering along the streets, and Avas taken to the inebriate Avard of the Blockley Hospital, Avhere he subsequently sank and died, after having been transferred from Avard to Avard, his symptoms appear- ing inexplicable. A postmortem examination revealed the fact that an ordi- nary knife-blade had been driven into his brain on the right side, just above a 476, 1862, i., 626. b 265, i. c 124. 1*76. 426. d 476, 1890, ii., 721. e 547, Nov. 1, 1871. GUNSHOT INJURIES OF THE BRAIN. 549 the ear, and Avas completely hidden by the skin. It had evidently become loosened from the handle when the patient was stabbed, and had remained in the brain several days. No clue to the assailant Avas found. Thudicum a mentions the case of a man who walked from Strafford to NeAv- castle, and from NeAvcastle to London, Avhere he died, and in his brain Avas found the breech-pin of a gun. Neiman b describes a seA-ere gunshot wound of the frontal region, in Avhich the iron breech-block of an old-fashioned muzzle-loading gun Avas driven into the substance of the brain, requiring great force for its extraction. The patient, a young man of tAventy-eight, was unconscious but a short time, and happily made a good recovery. A few pieces of bone came away, and the wound healed with only a slight depression of the forehead. AVilsonc speaks of a child who fell on an upright copper paper-file, which penetrated the right side of the occipital bone, below the ex- ternal orifice of the ear, and entered the brain for more than three inches ; and yet the child made a speedy recovery. Baron Larrey kneAV of a man whose head was completely transfixed by a ramrod, which extended from the middle of the forehead to the left side of the nape of the neck ; despite this serious injury the man lived two days. Jewett d records the case of an Irish drayman who, without treatment, Avorked for forty-seven days after receiving a penetrating Avound of the skull \ inch in diameter and four inches deep. Recovery ensued in spite of the delay in treatment. Gunshot Injuries.—Svrain e mentions a patient who stood before a look- ing glass, and, turning his head far around to the left, fired a pistol shot into his brain behind the right ear. The bullet passed into his mouth, and he spat it out. Some bleeding occurred from both the internal and external wounds ; the man soon began to suffer AA'ith a troublesome cough, Avith bloody expecto- ration ; his tongue Avas coated and drawn to the right; he became slightly deaf in his right ear and dragged his left leg in Avalking. These symptoms, together with those of congestion of the lung, continued for about a Aveek, Avhen he died, apparently from his pulmonary trouble. Fordf quotes the case of a lad of fifteen Avho Avas shot in the head, £ inch anterior to the summit of the right ear, the ball escaping through the left os frontis, 14; inch above the center of the broAV. RecoA'ery ensued, with a cicatrix on the forehead, through Avhich the pulsations of the brain could be distinctly seen. The senses Avere not at all deteriorated. Richardson g tells of a soldier AA'ho Avas struck by a Minie ball on the left temporal bone ; the missile passed out through the left frontal bone J inch to the left of the middle of the forehead. He was only stunned, and twenty- four hours later his intellect AA'as undisturbed. There Avas no operation; free a 536. 1SS4, ii., 419. b 520, Oct. 20, 1891. c 224, 1SS7. ii., 278. dHosp. (raz.. London, 1879, 39. « 224, Feb. 7, 1891. f Monthly Jour. Med. Sciences, 1845, v., 653. g 593, 1866-67, xix., 52. 550 SURGICAL ANOMALIES OF THE HEAD ANI) NECK. suppuration with discharges of fragments of skull and broken-doAvn sub- stance ensued for four Aveeks, Avhen the Avounds closed kindly, and recovery folloAved. Angle a records the case of a cowboy avIio was shot by a comrade in mis- take. The ball entered the skull beneath the left mastoid process and passed out of the right eye. The man recovered. Riceb describes the case of a boy of fourteen who Avas shot in the head, the ball directly traversing the brain substance, some of Avhich protruded from the Avound. The boy recovered. The ball entered one inch above and in front of the right ear and made its exit through the lambdoidal suture posteriorly. Hall of Denver, Col.,c in an interesting study of gunshot wounds of the brain, Avrites as folloAvs :— " It is in regard to injuries involving the brain that the question of the production of immediate unconsciousness assumes the greatest interest. AVe may state broadly that if the medulla or the great centers at the base of the brain are wounded by a bullet, instant unconsciousness must result; with any other wounds involving the brain-substance it will, with very great probability, result. But there is a very broad area of uncertainty. Many instances have been recorded in which the entrance of a small bullet into the anterior part of the brain has not preA'ented the firing of a second shot on the part of the suicide. Personally, I have not observed such a case, however. But, aside from the injuries by the smallest missiles in the anterior parts of the brain, we may speak AA'ith almost absolute certainty Avith regard to the production of unconsciousness, for the jar to the brain from the blow of the bullet upon the skull would produce such a result eA'en if the damage to the brain were not sufficient to do so. " Many injuries to the brain from bullets of moderate size and low velocity do not cause more than a temporary loss of consciousness, and the subjects are seen by the surgeon, after the lapse of half an hour or more, apparently sound of mind. These are the cases in which the ball has lost its momentum in passing through the skull, and has consequently done little damage to the brain-substance, excepting to make a passage for itself for a short distance into the brain. It is apparently well established that, in the case of the rifle-bullet of high A'elocitv, and especially if fired from the modern military Avcapons using nitro-powders, and giA'ing an enormous initial velocity to the bullet, the transmission of the force from the displaced particles of brain (and this rule applies to any other of the soft organs as avcII) to the adjacent parts is such as to disorganize much of the tissue surrounding the original track of the missile. Under these circumstances a much slighter Avound Avould be necessary to pro- duce unconsciousness or death than in the case of a bullet of Ioav velocity, especially if it Avere light in Aveight. Thus I have recorded elseAvhere an a San Francisco Med. Jour., 1856, i., 10. b 218, 1849, 323, c 533, 1895, ii., 478. "AMERICAN CROW-BAR CASE. 551 instance of instant death in a grizzly bear, an animal certainly as tenacious of life as any avc have, from a mere furrow, less than a quarter of an inch in depth, through the cortex of the brain, Avithout injury of the skull excepting the removal of the bone necessary for the production of this furrow. The jar to the brain from a bullet of great velocity, as in this case, Avas alone suf- ficient to injure the organ irreparably. In a similar manner I have known a deer to be killed by the impact of a heavy rifle-ball against one horn, although there was no evidence of fracture of the skull. On the other hand, game animals often escape after such injuries not directly invohdng the brain, although temporarily rendered unconscious, as I haA'e observed in several instances, the diagnosis undoubtedly being concussion of the brain. " Slight injury to the brain, and especially if it be unilateral, then, may not produce unconsciousness. It is not A'ery uncommon for a missile from a heavy Aveapon to strike the skull, and be deflected without the production of such a state. Near the town in Avhich I formerly practised, the toAvn-marshal shot at a negro, who resisted arrest, at a distance of only a few feet, Avith a 44- caliber revolver, striking the culprit on the side of the head. The Avound showed that the ball struck the skull and ploAved along under the scalp for several inches before emerging, but it did not even knock the negro doAvn, and no unconsciousness folloAved later. I once examined an express-messenger who had been shot in the occipital region by a weapon of similar size, Avhile seated at his desk in the car. The blow was a very glancing one and did not produce unconsciousness, and probably, as in the case of the negro, because it did not strike Avith sufficient directness." Head Injuries with Loss of Cerebral Substance.—The brain and its membranes may be severely wounded, portions of the cranium or cerebral sub- stance destroyed or lost, and yet recovery ensue. Possibly the most noted injury of this class Avas that reported by Harlow a and commonly known as " Bige- low's Case " or the " American Crow-bar Case." Phineas P. Gage, aged hventy-nve, a foreman on the Rutland and Burlington Railroad, Avas employed September L>, LS47, in charging a hole Avith powder preparatory to blasting. A premature explosion drove a tamping-iron, three feet seven inches long, 14; inches in diameter, weighing 134; pounds, completely through the man's head. The iron was round and comparatively smooth; the pointed end entered first. The iron struck against the left side of the face, immediately anterior to the inferior maxillary and passed under the zygomatic arch, fracturing portions of the sphenoid bone and the floor of the left orbit; it then passed through the left anterior lobe of the cerebrum, and, in the median line, made its exit at the junction of the coronal and sagittal sutures, lacerating the longitudinal sinus, fracturing the parietal and frontal bones, and breaking up considerable of the brain ; the globe of the left eye protruded nearly one-half of its diameter. The patient Avas thrown backward and gave a few convulsive movements of a 218, 1848. 552 SURGICAL ANOMALIES OF THE HEAD AND NECK. the extremities. He avus taken to a hotel £ mile distant, and during the transportation seemed slightly dazed, but not at all unconscious. Upon arriv- ing at the hotel he dismounted from the conveyance, and Avithout assistance walked up a long flight of stairs to the hall Avhere his Avound avus to be dressed. HarloAv saw him at about six o'clock in the evening, and from his condition could hardly credit the story of his injury, although his person and his bed were drenched Avith blood. His scalp Avas shaved, the coagula and debris removed, and among other portions of bone Avas a piece of the anterior superior angle of each parietal bone and a semicircular piece of the frontal bone, leav- ing an opening 3^ inches in diameter. At 10 P. M. on the day of the injury Gage AA'as perfectly rational and asked about his Avork and after his friends. After a Avhile delirium set in for a feAV days, and on the eleventh day he lost the A'ision in the left eye. His convalescence Avas rapid and uneventful. It was said that he discharged pieces of bone and cerebral substance from his mouth for a few days. The iron when found Avas smeared AA'ith blood and cerebral substance. As AA'as most natural such a Avonderful case of cerebral injury attracted much notice. Not only Avas the case remarkable in the apparent innocuous loss of cerebral substance, but in the singular chance which exempted the brain from either concussion or compression, vand subsequent inflammation. Professor BigeloAV examined the patient in January, 1850, and made a most excellent report of the case,a and it is due to his efforts that the case attained world-Avide notoriety. BigeloAV found the patient quite recoA'ered in his facul- ties of body and mind, except that he had lost the sight of the injured eye. He exhibited a linear cicatrix one inch long near the angle of the ramus of the left lower jaAV. His left eyelid was involuntarily closed and he had no poAver to overcome his ptosis. Upon the head, avcII covered by the hair, Avas a large unequal depression and elevation. In order to ascertain Iioav far it might be possible for a bar of the size causing the injury to traverse the skull in the track assigned to it, Bigelow procured a common skull in Avhich the zygomatic arches were barely A'isible from above, and having entered a drill near the left angle of the inferior maxilla, he passed it obliquely upAvard to the median line of the cranium just in front of the junction of the sagittal and coronal sutures. This aperture was then enlarged until it alloAved the passage of the bar in question, and the loss of substance strikingly corresponded Avith the lesion said to have been received by the patient. From the coronoid pro- cess of the inferior maxilla there was remoA'ed a fragment measuring about f inch in length. This fragment, in the patient's case, might have been fractured and subsequently reunited. The iron bar, together Avith a cast of the patient's head, was placed in the Museum of the Massachusetts Medical College. Bigelow appends an engraving (Fig. 194) to his paper. In the illustration the parts are as follows :— a 124, July, 1850. LOSS OF BRAIN-SUBSTANCE. 553 (1) Lateral view of a prepared cranium representing the iron bar travers- ing its cavity. (2) Front vieAV of same. (:>) Plan of the base seen from within. In these three figures the optic foramina are seen to be intact and are occupied by small white rods. (4) Cast taken from the shaved head of the patient representing the appearance of the fracture in 1850, the anterior fragment being considerably elevated in the profile view. (5) The iron bar with length and diameter in proportion to the size of the other figures. Heaton a reports a case in which, by an explosion, a tamping-iron Avas driven through the chin of a man into the cerebrum. Although there Avas loss of brain-substance, the man recovered with his mental faculties unim- Fig. 194—Dr. Harlow's case of recovery after the passage of an iron bar through the head. paired. A second case was that of a man avIio, during an explosion, Avas Avounded in the skull. There avus A'isible a triangular depression, from Avhich, possibly, an ounce of brain-substance issued. This man also recovered. JeAvett mentions a case in Avhich an injury someAvhat similar to that in BigeloAv's case Avas produced by a gas-pipe. Among older Avriters, speaking of loss of brain-substance Avith subsequent recoA'ery, Brasavolus saw as much brain evacuated as Avould fill an egg shell; the patient afterAvard had an impediment of speech and greAV stupid. Fran- ciscus Arcasus gives the narrative of a Avorkman Avho Avas struck on the head by a stone Aveighing 24 pounds falling from a height. The skull Avas frac- tured ; fragments of bone Avere driven into the brain. For three days the patient Avas unconscious and almost lifeless. After the eighth day a cranial a Trans. Detroit Med. and Library Assoc, 1879, i., 4. 554 SURGICAL ANOMALIES OF THE HEAD AND NECK. abscess spontaneously opened, from the sinciput to the occiput, and a large quantity of " corruption" was evacuated. Speech returned soon after, the eyes opened, and in tAventy days the man could distinguish objects. In four months recovery Avas entire. Bontius relates a singular accident to a sailor, whose head Avas crushed between a ship and a small boat; the greater part of the occipital bone Avas taken aAvay in fragments, the injury extending almost to the foramen magnum. Bontius asserts that the patient Avas per- fectly cured by another surgeon and himself. Galen mentions an injury to a youth in Smyrna, in Avhom the brain Avas so seriously wounded that the anterior ventricles Avere opened ; and yet the patient recovered. Glandorp 380 mentions a case of fracture of the skull out of Avhich his father took large portions of brain and some fragments of bone. He adds that the man Avas afterward paralyzed on the opposite side and became singularly irritable. In his " Chirurgical Observations," Job ATan Meek'ren tells the story of a Russian nobleman AA'ho lost part of his skull, and a dog's skull Avas supplied in its place. The bigoted divines of the country excommunicated the man, and would not annul his sentence until he submitted to have the bit of foreign bone removed. Mendenhalla reports the history of an injury to a laborer nineteen years old. While sitting on a log a few feet from a comrade who was chopping wood, the axe glanced and, slipping from the woodman's grasp, struck him just above the ear, burying the "bit" of the axe in his skull. Two hours after- Avard he was seen almost pulseless, and his clothing drenched with blood Avhich avus still oozing from the wound with mixed brain-substance and fragments of bone. The cut Avas horizontal on a level Avith the orbit, 5 J inches long externally, and, oAving to the convex shape of the axe, a little less internally. Small spicules of bone Avere removed, and a cloth was placed on the battered skull to receive the discharges for the inspection of the surgeon, Avho on his arrival saAV at least two tablespoonfuls of cerebral substance on this cloth. Contrary to all expectation this man recovered, but, strangely, he had a marked and peculiar change of voice, and this was permanent. From the time of the reception of the injury his whole mental and moral nature had undergone a pronounced change. Before the injury, the patient was consid- ered a quiet, unassuming, and stupid boy, but universally regarded as honest. AfterAvard he became noisy, self-asserting, sharp, and seemingly devoid of moral sense or honesty. These neAV traits developed immediately, and more strikingly so soon as convalescence was established. Bergtoldb quotes a case reported in 1857 545 of extreme injury to the cra- nium and its contents. AVhile sleeping on the deck of a canal boat, a man at Highspire avus seriously injured by striking his head against a bridge. AVhen seen by the surgeon his hair was matted and his clothes saturated Avith blood. There Avas a terrible gap in the scalp from the superciliary ridge to the occip- a 124, 1869. b Medical Press of Western New York, ls88. 317. LOSS OF BRAIN-SUBSTANCE. 555 ital bone, and, though full of clots, the wound Avas still oozing. In a cloth on a bench opposite Avere rolled up a portion of the malar bone, some fragments of the os frontis, one entire right parietal bone, detached from its felloAV along the sagittal suture, and from the occipital along the lambdoidal suture, perhaps taking Avith it some of the occipital bone together Avith some of the squamous portion of the temporal bone. This bone was as clean of soft parts as if it had been removed from a dead subject with a scalpel and saAV. No sight of the membranes or of the substance of the brain Avas obtained. The piece of cranium removed Avas 6f inches in the longitudinal diameter, and 5f inches in the short oval diameter. The dressing occupied an hour, at the end of which the patient arose to his feet and changed his clothes as though nothing had happened. Twenty-six years after the accident there Avas slight unsteadi- ness of gait, and gradual paralysis of the left leg and arm and the opposite side of the face, but otherwise the man Avas in good condition. In place of the parietal bone the head presented a marked deficiency as though a slice of the skull were cut out (Fig. 195). The depressed area measured five by six inches. In 1887 the man left the hospital in Buffalo Avith the paralysis improved, but his mental equilibrium could be easily dis- turbed. He became hysteric and sobbed when scolded. Buchanan a mentions the history of a case in a Avoman of twenty-one, Avho, while work- ing in a mill, Avas struck by a bolt. Her skull Avas fractured and driven into the brain comminuted. Hanging from the wound Avas a bit of brain-substance, the size of a finger, composed of convolution as well as white matter. The Avound healed, there was no hernia, and at the time of report the girl Avas conscious of no disturbance, not even a headache. There AAas nothing indicative of the reception of the injury except a scar near the edge of the hair on the upper part of the right side of the forehead. Steele,b in a school-boy of eight, mentions a case of very severe injury to the bones of the face and head, with escape of cerebral substance, and recovery. The injury was caused by falling into machinery. There was a seaman aboard of the U. S. S. " Constellation,' c who fell through a hatcliAvay from the masthead, landing on the vertex of the head. There Avas copious bleeding from the ears, 50 to 60 fluid-ounces of blood oozing in a feAV hours, mingled with small fragments of brain-tissue. The next day the discharge became Avatery, and in it Avere found small pieces of true brain- » 381, 1879. b 476, 1889, i., 1083. c 124, April, 1859. Fig. 195.—Skull injury with extensive loss of cranial and cerebral substance. 556 SURGICAL ANOMALIES OF THE HEAD AND NECK. substance. In fh7e Aveeks the man returned to duty complaining only of giddiness and of a " stuffed-tip " head. In 1846 there is a record of a man of forty avIio fell from a scaffold, erected at a height of 20 feet, striking on his head. He Avas at first stunned, but on admission to the hospital recovered consciousness. A small Avound AA'as found over the right cycbroAv, protruding from which avus a portion of brain-substance. There Avas slight hemorrhage from the right nostril, and some pain in the head, but the pulse and respira- tion Avere undisturbed. On the folloAving day a fragment of the cerebral substance, about the size of a hazel-nut, together Avith some blood-clots, escaped from the right nostril. In this case the inner Avail of the frontal sinus Avas broken, affording exit for the lacerated brain. Cooke and Laycocka mention a case of intracranial injury Avith extensive destruction of brain- substance around the Rolandic area; there Avas recovery but Avith loss of the so-called mus- cular sense. The patient, a Avork- man of tAventy-nine, while cut- ting down a gum-tree, Avas struck by a branch as thick as a man's arm, Avhich fell from 100 feet overhead, inflicting a compound comminuted fracture of the cran- ium. The right ca'c Avas con- tused but the pupils equal; the vertex-AVOimd Avas full of brain- substance and pieces of bone, ten of Avhich avc re remoA'ed, leaA'ing an OA'al opening four by three inches. The base of the skull was fractured behind the orbits ; a fissure \ inch Avide Avas discernible, and the right frontal bone could be easily moved. The lacerated and contused brain-substance was removed. Con- sciousness returned six days after the operation. The accompanying illustra- tions (Figs. 196 and 197) show the extent of the injury. The loAver half of the ascending frontal convolution, the greater half of the sigmoid gyrus, the posterior third of the loAver and middle frontal convolutions, the base and pos- terior end of the upper convolution, and the base of the corresponding por- tion of the falciform lobe Avere involved. The sensory and motor functions of the arm were retained in a relative degree. There Avas poAver of simple movements, but complex movements Avere aAvkAvard. The tactile localization Avas almost lost. Fig. 100.—Skull injury with extensive destruction of brain- substance around the Rolandic area (Cooke and Laycock). a 180, July 13, 1893. LOSS OF BRAIN-SUBSTANCE. 557 Morton a mentions a patient of forty-seven, avIio was injured in a railroad accident near Phcenixville, Pa.; there was a compound comminuted fracture of the skull involving the left temporal, sphenoid, and superior maxillary bones. The side of the head and the ear Avere considerably lacerated; several teeth Avere broken, and besides this there Avas injury to the dura and cerebral substance. There Avas profound coma for ten days and paralysis of the 1st, 2d, 3d, 4th, 6th, and 7th cranial nerves, particularly affecting the left side of the face. There Avas scarcely enough blood-supply left to the orbit to maintain life in the globe. The man primarily recovered, but ninety-one days from the injury he died of cerebral abscess. There is the record b of a curious brain-injury in a man of tAventy-tAvo, avIio Avas struck on the skull by a circular saAV. The saw cut directly down into the brain, scA'ering the superior longitudinal sinus, besides tearing a branch of the meningeal artery. The wound avus filled Avith saAvdust left by the saAV Avhile it was tearing through the parts. After ordinary treatment the man recoA'ered. Birdc reports a compound com- minuted fracture of the left temporal region, Avith loss of bone, together Avith six drains of brain-substance, which, hoAvever, Avas followed by recovery. Tagertd gives an instance of compound depressed fracture of the skull, Avith loss of brain-substance, in AA'hich recovery Avas effected Avithout operative interfer- ence. Ballou,e Bartlett/ Buckner, Ca- pon^ Carmichael,h Corban/ Maunder, J and many others, cite instances of cranial fracture and loss of brain-substance, with subsequent recovery. Halstedk reports the history of a boy of seventeen, who, while out fowling, had the breech-pin of a shot-gun blown out, the sharp point striking the fore- head in the frontal suture, crushing the os frontis, destroying If inches of the longitudinal sinus, and causing seA'ere hemorrhage from both the longitudinal and frontal sinuses. The pin Avas pulled out by the boy, who Avashed his own face, and lay doAvn ; he soon became semi-comatose, in Avhich condition he remained for some days; but, after operation, he made complete recovery. Loss of Brain-substance from Cerebral Tumor.—Koser is accredited Avith reporting results of a postmortem held on a young man of tAventy who suffered from a cerebral tumor of considerable duration. It Avas stated that, although there Avas a cavity in the brain at least five inches Fig. 197.—Diagrammatic sketch of injury seen in figure 196. a 547, Oct. 3, 1874. e 29S, 1883. i 535, 1825. b 130, 1861, 165. e 124, 1865, 552. d 548, 1852, 268. f 647, 1878. g 548, 1879. h 312, 1841. j 548, 1870. k 703, 1870, 131. 558 SURGICAL ANOMALIES OF THE HEAD AND NECK. in length, the patient, almost up to the time of death, Avas possessed of the senses of touch, taste, hearing, and smell, shoAved considerable control over his locomotor muscles, and could talk. In fact, he Avas practically discommoded in no other Avay than by loss of vision, caused by pressure on the optic centers. It Avas also stated that the retention of mem- ory Avas remarkable, and, up to within tAvo weeks of his death, the patient AAas able to memorize poems. The amount of involvement discovered post- mortem in cases similar to the preceding is astonishing. At a recent patho- logic display in London619 several remarkable specimens Avere sIioavii. Extensive Fractures of the Skull.—Jenningsa mentions an instance of extensive fracture of the skull, 14 pieces of the cranium being found (Fig. 198). The patient lived five Aveeks and tAvo days after the injury, the immediate cause of death being edema of the lungs. His language was incoherent and full of oaths. Belloste, in his " Hospital Surgeon," states that he had under his care a most dreadful case of a girl of eleven or tAvelve years, Avho received 18 or 19 cut- lass wounds of the head, each so violent as to chip out pieces of bone; but, notAvithstanding her severe injuries, she made recovery. At the Emergency Hospital in Washington, D. C, there Avas received a negress with at least six gaping Avounds of the head, in some cases denuding the perios- teum and cutting the cranium. Fig. 198.-Cranial fracture (14 fragments) (Jennings). During a debauch the night be- fore she had been engaged in a quarrel with a negro with Avhom she lived, and was struck by him several times on the head Avith an axe. She lay all night unconscious, and was discovered the next morning with her hair and clothes and the floor on which she lay drenched with blood. The ambulance was summoned to take her to the morgue, but on the arrival of the police it was seen that feeble signs of life still existed. On admission to the hospital she was semi-comatose, almost pulseless, cold, and exhibiting all the signs of extreme hemorrhage and shock. Her head AAas cleaned up, but her condition Avould not permit of any other treatment than a corrosive-sublimate compress and a bandage of Scultetus. She Avas taken to the hospital ward, Avhere Avarmth and stimulants were applied, after Avhich she completely reacted. She progressed so well that it was not deemed advisable to remove the head-bandage until the fourth day, Avhen it Avas seen that the wounds had almost entirely healed and suppuration Avas A'irtually absent. The patient rapidly and completely recovered, and her neighbors, on » 124, May, 1891. FRACTURES OF THE BASE OF THE SKULL. 559 her return home, could hardly believe that she was the same woman Avhom, a feAV days before, they Avere preparing to take to the morgue. A serious injury, AA'hich is not at all infrequent, is that caused by diving into shallow water, or into a bath from which Avater has been AvithdraAvn. Currana mentions a British officer in India avIio, being overheated, stopped at a station bath in Avhich the previous night he had had a plunge, and Avithout examining, took a violent " header " into the tank, confidently expecting to strike from eight to ten feet of Avater. He dashed his head against the con- crete bottom 12 feet beloAv (the Avater two hours previously having been AvithdraAvn) and crushed his brain and skull into an indistinguishable mass. There are many cases on record in which an injury, particularly a gunshot wound of the skull, though showing no external wound, has caused death by producing a fracture of the internal table of the cranium. Pare618 gives details of the case of a nobleman whose head Avas guarded by a helmet and who was struck by a ball, leaving no external sign of injury, but it was sub- sequently found that there Avas an internal fracture of the cranium. Tulpius842 and Scultetus are among the older writers reporting somewhat similar instances, and there are several analogous cases reported as having occurred during the War of the Rebellion. Bolingb reports a case in which the internal table Avas splintered to a much greater extent than the external. Fracture of the base of the skull is ordinarily spoken of as a fatal in- jury, reported instances of recovery being extremely rare, but Battle,0 in a paper on this subject, has collected numerous statistics of nonfatal fracture of the base of the brain, A'iz.:— Male. Female. Anterior fossa, .............16 5 Middle fossa...............50 6 Posterior fossa,.............10 1 Middle and anterior fossae,........15 5 Middle and posterior fossae,........4 1 Anterior, middle, and posterior fossae, ... 1 96 18 Total, 114. In a paper on nonmortal fractures of the base of the skull, Lidelld gives an account of 135 cases. MacCormac e reports a case of a boy of nine Avho Avas run over by a carriage draAvn by a pair of horses. He suffered fracture of the base of the skull, of the bones of the face, and of the left ulna, and although suppuration at the points of fracture ensued, followed by an optic neuritis, an ultimate recovery Avas effected. Ball, an Irish surgeon, has collected several instances in Avhich the base of the skull has been driven in and the condyle of the jaAV impacted in the opening by force transmitted through the loAver maxilla. The tolerance of foreign bodies in the brain is most marvelous. In the ancient chronicles of Koenigsberg there is recorded the history of a man a 476, 1*86, ii., 579. b 817, 1844. c 476, 1890, ii , 1. d 124, lxxxi., 1881, 335. e 476, 1886, ii., 209. 560 SURGICAL ANOMALIES OF THE HEAD AND NECK. who for fourteen years carried in his head a piece of iron as large as his finger. After its long lodgment, during AA'hich the subject Avas little dis- commoded, it finally came out by the palatine arch. There is also an old record of a ball lodging near the sella turcica for over a year, the patient dying suddenly of an entirely different accident. Fabricius Hildanus:!:!4 re- lates the history of an injury, in Avhich, Avithout causing any uncomfortable symptoms, a ball rested between the skull and dura for six months. Amatus Lusitanus119 speaks of a drunken courtesan avIio avus Avounded in a fray with a long, sharp-pointed knife Avhich Avas driven into the head. No apparent injury resulted, and death from fever took place eight years after the reception of the injury. On opening the head a large piece of knife Avas found betAveen the skull and dura. It is said that Benedictus mentions a Greek Avho avus Avounded, at the siege of Colchis, in the right temple by a dart and taken captive by the Turks ; he lh'ed for tAventy years in slavery, the Avound having completely healed. Obtaining his liberty, he came to Sidon, and five years after, as he Avas Avashing his face, he Avas seized by a violent fit of sneezing, and discharged from one of his nostrils a piece of the dart having an iron point of considerable length. In about 1884 there died in the Arienna Hospital a a bookbinder of forty- five, Avho had always passed as an intelligent man, but Avho had at irregular intervals suffered from epileptic convulsions. An iron nail covered with rust Avas discovered in his brain ; from the history of his life and from the appear- ances of the nail it had evidently been lodged in the cerebrum since childhood. Slee b mentions a case in Avhich, after the death of a man from septic peri- tonitis folloAving a bullet-wound of the intestines, he found postmortem a knife- blade ^g- inch in width projecting into the brain to the depth of one inch. The blade was ensheathed in a strong fibrous capsule \ inch thick, and the adjacent brain-structure was apparently normal. The blade was black and corroded, and had evidently passed betAveen the sutures during boyhood as there Avas no depression or displacement of the cranial bones. The Aveapon had broken off just on a level AA'ith the skull, and had remained in situ until the time of death without causing any indicative symptoms. Slee does not state the man's age, but remarks that he Avas a married man and a father at the time of his death, and had enjoyed the best of health up to the time he AA'as shot in the abdomen. Callaghan, quoted in Erichsen's " Surgery," remarks that he knew of an officer Avho lh'ed seven years Avith a portion of a gun- breech Aveighing three ounces lodged in his brain. LaAvsonc mentions the impaction of a portion of a breech of a gun in the forehead of a man for twelve years, Avith subsequent removal and recovery. AValdon d speaks of a similar case in which a fragment of the breech Aveighing three ounces penetrated the cranium, and Avas lodged in the brain for two months previous to the death of the patient. a 545, Nov. 1, 1884. b 533, July 25, 1891. c 224, 1869. d 564, 1799. INJURIES OF THE NOSE. 561 Huppert a tells of the lodgment of a slate-pencil three inches long in the brain during lifetime, death ultimately being caused by a slight head-injury. Larry mentions a person avIio for some time carried a six ounce ball in the brain and ultimately recovered. Peterb removed a musket-ball from the frontal sinus after six years' lodgment, AA'ith successful issue. Mastin c has given an instance in AA'hich the blade of a pen-knife remained in the brain six months, recovery folloAving its removal. Camden d reports a case in which a ball received in a gunshot wound of the brain remained in situ for thirteen years ; Cronyn e mentions a similar case in Avhich a bullet rested in the brain for eight years. Doylef Successfully removed an ounce Minie ball from the brain after a fifteen years' lodgment. Pipe-stems, Avires, shot, and other foreign bodies, are from time to time recorded as remaining in the brain for some time. AVhartonS has compiled elaborate statistics on this subject, commenting on 316 cases in winch foreign bodies avc re lodged in the brain, and furnishing all the necessary information to persons interested in this sub- ject. Injuries of the nose, with marked deformity, are in a measure combated by devices invented for restor- ing the missing portions of the injured member. Taliacotius, the distinguished Italian surgeon of the sixteenth century, deA'ised an operation AA'hich now bears his name, and consists in fashioning a nose from the fleshy tissues of the arm. The arm is approximated to the head and held in this position by an apparatus or system of bandages for about ten days, at Avhich time it is supposed that it can be severed, and further trim- ming and paring of the nose is then practised. A column is subsequently made from the upper lip. In the olden days there was a humorous legend representing Taliacotius making noses for his patients from the gluteal regions of other persons, AA'hich statement, needless to say, is not founded on fact. Various modifications and improvements on the Taliacotian method have been made (Fig. 199); but in recent years the Indian method, introduced by Carpue into England in 1816, is generally preferred. Syme of Edinburgh, AVood, and Oilier haA'e deA'ised methods of restoring the nose, Avhich bear their names. Ohmann-Dumesnil h reports a case of rhinophyma in a man of seventy- tAvo, an alcoholic, who Avas originally affected Avith acne rosacea, on Avhom he performed a most successful operation for restoration. The accompanying Fig. 199.—Warren's appar- atus for resorting to the meth- od of Taliapotius. a 155, 1875. C681, 1873. e 230, 1871-2, xi., 194. 8 547, 1879, ix., 493. 36 b 133, 1870, ii. d Trans. Med. Soc. W. Va., 1877. f South. Med. Rec, Atlanta, 1878, 323. b International Med. Mag., Phila., Feb., 1894. 562 SURGHAL ANOMALIES OF THE HEAD AND NECK. illustration (Fig. 200) sIioavs the original deformity—a growth Aveighing tAvo pounds—and also pictures the appearance shortly after the operation. This case is illustrative of the possibilities of plastic surgery in the hands of a skilful and ingenious operator. About 1892 Dr. J. P. Parker then of Kansas City, Mo., restored the missing bridge of a patient's nose by laying the sunken part open in tAvo long flaps, denuding the distal extremity of the little finger of the patient's right hand of nail, flesh, tendons, etc., and binding it into the AA'ound of the nose until firm union had taken place. The finger avus then amputated at the second joint and the plastic operation completed, AA'ith a result pleasing both to patient and operator. There is a case quoted a of a young man who, when first seen by his medical attendant, had all the soft parts of the nose gone, except one-third of the left ala Fig. 200.—Case of rhinophyma hefore and after operation (Ohmann-Dimi. _il). and a thin flap of the septum Avhich avus lying on the upper lip. The missing member Avas ferreted out and cleansed, and after an hour's separation sutured on. The nostrils Avere daily syringed with a corrosive sublimate solution, and on the tenth day the dressing Avas removed ; the nose Avas found active and well, with the single exception of a triangular notch on the right side, which AA'as too greatly bruised by the violence of the bloAV to recover. AVhen Ave con- sider the A'aricosity of this organ avc can readily believe the possibility of the foregoing facts, and there is little doubt that more precaution in suturing severed portions of the nose Avould render the operation of nose-making a A'ery rare one. MaxAvellb mentions a curious case of attempted suicide in Avhich the ball, passing through the palatine process of the superior maxillary bone, crushing the vomer to the extent of its oavii diameter, fell back through the right nostril into the pharynx, Avas SAvalloAved, and discharged from the anus. a 536, 1890, ii., 240. b 246, 1869. FOREIGN BODIES IN THE NOSE. 563 Deformities of the nose causing enormous development, or the condition called " double-nose " by Bartholinus, Borellus, Bidault, and others, are ordi- narily results of a pathologic development of the sebaceous glands. In some cases tumors develop from the root of the nose, forming Avhat appears to be a second nose. In other cases monstrous A'egetations dh'idethe nose into many tumors. In the early portion of this century much avus heard about a man who was a dailv habitue of the Palais-Royal Gardens. His nose AA'as divided into un- equally sized tumors, covering nearly his entire face. Similar instances have been obsen'ed in recent years. Hey mentions a case in which the tumor ex- tended to the loAver part of the under lip, Avhich compressed the patient's mouth and nostrils to such an extent that while sleeping, in order to- insure sufficient respiration, he had to insert a tin-tube into one of his nostrils. Im- bert de Lannesa is quoted as operating on a former Mayor of Angouleme. This gentleman's nose Avas divided into fhre lobes by sarcomatous tumors weighing two pounds, occupying the external surface of the face, adherent to the buccinator muscles to which they extended, and coA'ering the chin. In the upright position the tumors sealed the nostrils and mouth, and the man had to bend his head before and after respiration. In eating, this unfortunate person had to lift his tumors aAvay from his mouth, and during sleep the monstrous growths Avere supported in a sling attached to his night-cap. He presented such a hideous aspect that he Avas A'irtually ostracized from society. The growth had been in progress for twelve years, but during twenty-two months' confinement in ReA'olutionary prisons the enlargement had been A'ery rapid. Fournier says that the most beautiful result folloAved the operation, which was considered quite hazardous. Foreign bodies in the nose present phenomena as interesting as wounds of this organ. Among the living objects which have been found in the nose may be mentioned flies, maggots, worms, leeches, centipedes, and even lizards. Zacutus Lusitanus tells of a person Avho died in tAvo days from the effects of a leech which Avas inadvertently introduced into the nasal fossa, and there is a somewhat similar case b of a military pharmacist, a member of the French army in Spain, avIio drank some Avater from a pitcher and exhibited, about a half hour afterAvard, a persistent hemorrhage from the nose. Emaciation pro- gressively continued, although his appetite was normal. Three doctors, called in consultation, prescribed bleeding, Avhich, hoAvever, proA'ed of no aA'ail. Three weeks afterAvard he carried in his nostril a tampon of lint, wet with an astrin- gent solution, and, on the next day, on bloAving his nose, there fell from the right nostril a body Avhich he recognized as a leech. Hcalev c gives the history of four cases in AA'hich medicinal leeches Avere remoA^ed from the mouth and pos- terior nares of persons avIio had, for some days previously, been drinking turbid water. Sinclair d mentions the removal of a leech from the posterior nares. a 302, iv., 209. b 662, 1st series, T. x., 406. c Trans. Med. and Phys. Soc, Calcutta, 1842. d 224, 1885, i., 1246. 564 SURGICAL ANOMALIES OF THE HEAD AND NECK. In some regions, more particularly tropical ones, there are certain flies that crawl into the nostrils of the inhabitants and deposit eggs in the cavi- ties. The larvse develop and multiply AA'ith great rapidity, and sometimes gain admission into the frontal sinus, causing intense cephalalgia, and even death. Dempster a reports an instance of the lodgment of numerous live maggots within the cavity of the nose, causing sloughing of the palate and other com- plications. Nicholson15 mentions a case of ulceration and abscess of the nostrils and face from Avhich maggots Avere discharged. Jaiwis c gives the history of a strange and repeated hemorrhage from the nose and adjacent parts that Avas found to be due to maggots from the ova of a fly, Avhich had been deposited in the nose Avhile the patient Avas asleep. Tomlinson d gives a case in Avhich maggots traversed the Eustachian tube, some being picked out of the nostrils, Avhile others Avere coughed up. Packarde records the acci- dental entrance of a centipede into the nostril. There is an accountf of a native avIio was admitted to the Madras General Hospital, saying that a small lizard had craAvled up his nose. The urine of these animals is very irrita- ting, blistering any surface it touches. Despite vigorous treatment the patient died in consequence of the entrance of this little creature. There have been instances among the older writers in Avhich a pea has remained in the nose for such a length of time as to present evidences of sprouting. The Ephemerides renders an instance of this kind, and Breschet cites the history of a young boy, avIio, in 1718, introduced a pea into his nos- tril ; in three days it had SAVollen to such an extent as to fill the whole pas- sage. It could not be extracted by an instrument, so tobacco snuff Avas used, Avhich excited sneezing, and the pea Avas ejected. Vidal and the Ephemerides report several instances of tolerance of for- eign bodies in the nasal cavities for from tAventy to tAventy-five years. AViesman, in 1893, reported a rhinolith, which was composed of a cherry- stone enveloped in chalk, that had been removed after a sojourn of sixty years, AA'ith intense ozena as a consequence of its lodgment. Waring g men- tions the case of a housemaid Avho carried a rhinolith, AA'ith a cherry-stone for a nucleus, Avhich had been introduced twenty-seven years before, and which for tAventy-five years had caused no symptoms. Grove h describes a necrosed inferior turbinated bone, to AA'hich Avas attached a coffee-grain Avhich had been retained in the nostril for tAventy years. Hickmani gives an instance of a steel ring Avhich for thirteen and a half years had been impacted in the naso- pharyngeal fossa of a child. It Avas detected by the rhinoscope and Avas re- moved. Parkerj speaks of a gunbreech bolt AA'hich Avas removed from the a 434, 1836, i., 449. b 500, 1842, iv., 345. c 594, 1S47. ix., 315. d272, 1872. e 545, xxix., 100. f 548, 1876, ii., 717. 8 224, 1893. b Trans. Path. Soc, Phila., 1874, 25. i 224, 1867, ii., 266. J 476, 1885, i., 378. INJURIES TO THE TONGUE. 565 nose after five years' lodgment. Major :l mentions the remo\Tal of a foreign body from the nose sca'cii years after its introduction. HoAvard b removed a large thimble from the posterior nares, although it had remained in its position for some time undetected. Eve reports a case in which a thimble Avas impacted in the right posterior nares. Gazdar c speaks of a case of persistent neuralgia of one-half of the face, caused by a foreign body in the nose. The obstruction Avas remoA'ed after seven years' lodgment, and the neuralgia disappeared. Molinierd has an observation on the extrac- tion of a fragment of a knife-blade Avhich had rested four years in the nasal fossa1, Avhere the blade had broken off during a quarrel. A peculiar habit, sometimes seen in nerA'ous individuals, is that of " swal- lowing the tongue." Cohen claims that in some cases of supposed laryn- geal spasm the tongue is sAvalloAved, occluding the larynx, and sometimes AA'ith fatal consequences. There are possibly a half score of cases recorded, but this anomaly is very rare, and Major e is possibly the only one Avho has to a certainty demonstrated the fact by a laryngoscopic examination. By the laryngoscope he Avas enabled to observe a paroxysm in a Avoman, in which the tongue retracted and impinged on the epiglottis, but quickly recovered its position. Pettit mentions suffocation from " tongue SAvallowing," both with and without section of the frenum. Schobingerf cites a similar instance, due to loosening of the frenum. Analogous to the foregoing phenomenon is the habit of " tongue suck- ing." Morris g mentions a young lady of fifteen AA'ho spontaneously dislo- cated her jaAV, OAving indirectly to this habit. Morris says that from infancy the patient Avas addicted to this habit, Avhich was so audible as to be heard in all parts of the room. The continued action of the pterygoid muscles had so preternaturally loosened the ligaments and muscular structures supporting the joint as to render them unable to resist the violent action of " tongue suck- ing " even during sleep. Injuries to the Tongue.—Hobbs h describes a man of twenty-three who, while working, had a habit of protruding his tongue. One day he was hit under the chin by the chain of a crane on a pier, his upper teeth inflicting a Avound tAvo inches deep, three inches from the tip, and dividing the entire structure of the tongue except the arteries. The edges of the wound were brought into apposition by sutures, and after the remoA'al of the latter perfect union and complete restoration of the sensation of taste ensued. Franck350 mentions regeneration of a severed tongue ; and Van AVy has seen union of almost entirely severed parts of the tongue. De Fuisseaux1 reports reunion of the tongue by suture after almost complete transverse division. a 252, xv. b 612, 1852-3, v., 215. ° 435, xviii., 341. d 662, 1854, xiv., 291. e 252, 1884-5, 611. f 401, v. g 224, 1872, ii., 242. b 536, 1887, 78. i Arch. Beiges de Med. Milt., 1851. 566 SURGICAL ANOMALIES OF THE HEAD AND NECK. There is an account a of a German soldier avIio, May 2, 1813, Avas Avounded at the battle of Gross-Gorschen by a musket ball AA'hich penetrated the left cheek, carrying aAvay the last four molars of the upper juav and passing through the tongue, making exit on the left side, and forcing out several teeth of the left loAver jaAV. To his surprise, thirty years afterAvard, one of the teeth was removed from an abscess of the tongue. Baker b speaks of a boy of thir- teen avIio AA'as shot at three yards distance. The bullet knocked out tAvo teeth and passed through the tongue, although it produced no wound of the pharynx, and AA'as passed from the anus on the sixth day. Stevenson c mentions a ease of an organist avIio fell forAvard AA'hen stooping AA'ith a pipe in his mouth, driv- ing its stem into the roof of the pharynx. He complained of a sore throat for several days, and, after explanation, Stevenson remoA'ed from the soft palate a piece of clay pipe nearly 1£ inches long. Herbert tells of a case resembling carcinoma of the tongue, Avhich Avas really due to the lodgment of a piece of tooth in that organ. Articulation Without the Tongue.—Total or partial destruction of the tongue does not necessarily make articulation impossible. Banon d mentions a man Avho had nothing in his mouth representing a tongue. When he Avas young, he was attacked by an ulceration destroying every vestige of this member. The epiglottis, larynx, and pharynx, in fact the surrounding struc- tures were normal, and articulation, Avhich avus at first lost, became fairly dis- tinct, and deglutition Avas neA'er interfered AA'ith. Pare gives a description of a man whose tongue Avas completely severed, in consequence of which he lost speech for three years, but was afterward able to make himself under- stood by an ingenious bit of mechanism. He inserted under the stump of the tongue a small piece of wood, in a most marvelous way replacing the missing member. Articulation Avith the absence of some constituent of the vocal apparatus has been spoken of on page 254. Hypertrophy of the Tongue.—It sometimes happens that the tongue is so large that it is rendered not only useless but a decided hindrance to the performance of the ordinary functions into which it ahvays enters. Ehrlich, Ficker, Klein,e Rodtorffer, and the Ephemerides, all record instances in Avhich a large tongue avus removed either by ligation or amputation. Von Sieboldf records an instance in which death was caused by the ligature of an abnor- mally sized tongue. There is a modern record of three cases of enormous tongues, the result of simple hypertrophy.8 In one case the tongue measured 6| inches from the angle of the mouth about the sides and tip to the opposite angle, necessitating amputation of the protruding portion. Carnochann reports a case in which hypertrophy of the tongue Avas reduced to nearly the normal size by first tying the external carotid, and a 476, 1846, i., 173. b 224, 1883, i., 457. c 224, 1890, ii., 205. d 312, 1864, iii., 60. e 735, i., 665. f 735, i., 651. g 548, 1853, i., 202. Um. Med. Gaz. and Jour. Health, N. Y., 1856, vii., 1. LIVING FISH IN THE PHARYNX. 567 disloca- enlarge- six weeks later the common carotid artery. Chalk a mentions partial tion of the lower jaAV from an enlarged tongue. Lyford b speaks of ment of the tongue causing death. The above conditions are known as macroglossia, which is a congenital hypertrophy of the tongue analogous to elephan- tiasis. It is of slow growth, and as the organ enlarges it interferes AA'ith deglutition and speech. It may protrude over the chin and reach even as far doAvn as the sternum (Fig. 201). The great enlargement may cause deformities of the teeth and lower jaAV, and even present itself as an enormous tumor in the neck (Fig. 202). The pro- truding tongue itself may ulcer- -Macroglossia in a girl eleven years old (after Humphrey). ate, possibly bleed, and there is con- stant dribbling of saliva. The dis- ease is probably due to congenital defect aggravated by frequent attacks of glossitis, and the treatment consists in the removal of the protruding por- tions by the knife, ligation, the cau- tery, or 6craseur. Living Fish in the Pharynx.— Probably the most interesting cases of foreign bodies are those in which living fish enter the pharynx and eso- phagus. Chevers266 has collected five cases in Avhich death Avas caused by living fish entering the mouth and occluding the air-passages. He has men- tioned a case in Avhich a large catfish jumped into the mouth of a Madras a 779, viii., 305. b 476, 1827-8, i., 16. Fig. 202.— Alacroglossia (Keen and White). 999 568 SURGICAL ANOMALIES OF THE HEAD AND NECK. bheestie. An operation on the esophagus Avas immediately commenced, but abandoned, and an attempt made to push the fish doAvn Avith a probang, Avhich was, in a measure, successful. HoAvever, the patient gave a convulsive struggle, and, to all appearances, died. The trachea Avas immediately opened, and respira- tion was restored. During the course of the night the man vomited up pieces of fish bone softened by decomposition. In 1863 AVhite mentions that the foregoing accident is not uncommon among the nath'es of India, avIio are in the habit of SAvimming Avith their mouths open in tanks abounding Avith fish. There is a casea in Avhich a fisherman, having both hands engaged in dniAv- ing a net, and seeing a sole-fish about eight inches long trying to escape through the meshes of the net, seized it Avith his teeth. A sudden convulsive effort of the fish enabled it to enter the fisherman's throat, and he Avas as- phyxiated before his boat reached the shore. After death the fish Avas found in the cardiac end of the stomach. There is another case of a man named Durand, Avho held a mullet between his teeth Avhile rebaiting his hook. The fish, in the convulsive struggles of death, slipped down the throat, and be- cause of the arrangement of its scales it could be pushed doAvn but not up; asphyxiation, however, ensued. SteAvartb has extensively described the case of a native " Puckally " of Ceylon Avho was the victim of the most distress- ing symptoms from the impaction of a living fish in his throat. The native had caught the fish, and in order to extract it placed its head betAveen his teeth, holding the body AA'ith the left hand and the hook AA'ith the right. He had hardly extracted the hook, Avhen the fish pricked his palm with his long and sharp dorsal fin, causing him suddenly to release his grasp on the fish and voluntarily open his mouth at the same time. The fish quickly bolted into his mouth, and, although he grasped the tail with his right hand, and squeezed his pharynx with his left, besides coughing violently, the fish found its Avay into the esophagus. Further attempts at extraction Avere dangerous and quite likely to fail; his symptoms were distressing, he could not hold his head erect Avithout the most agonizing pain and he was almost prostrated from fright and asphyxia; it was thought advisable to push the fish into the stomach, and after an impaction of sixteen hours the symptoms Avere relieved. The fish in this instance was the Anabas scandens or " walking perch " of Ceylon, which derives its name from its power of locomotion on land and its ability to live out of water for some time. It is from four to five inches long and has a dorsal fin as sharp as a knife and directed toAvard the tail, and pectoral fins following the same direction ; these would admit of entrance, but Avould interfere Avith extraction. MacLaurenc reports the history of a young man who, after catching a fish, placed it between his teeth. The fish, three inches long, by a sudden movement, entered the pharynx. Immedi- ately ensued suffocation, nausea, vomiting, together with the expectoration of blood and mucus. There Avas emphysema of the face, neck, and chest. The a 548, 1863, i., 333. b 476, Sept. 25, 1868. c 476, 1873. A LEECH IN THE PHARYNX. 569 fish could be easily felt impacted in the tissues, but, after sAA'allowing much water and vinegar, together with other efforts at extraction, the fins Avere loosened—about tAventy-four hours after the accident. By this time the em- physema had extended to the scrotum. There Avas much expectoration of mucopurulent fluid, and on the third day complete aphonia, but the symptoms gradually disappeared, and recovery Avas complete in eight days. Dantra is accredited a AA'ith describing asphyxiation, accompanied by great agony, in a man avIio, while swimming, had partially swallowed a live fish. The fish was about three inches in length and one in breadth, and was found lying on the dorsum of his tongue and, together with numerous clots of blood, filled his mouth. Futile attempts to extract the fish by forceps were made. Exami- nation shoAved that the fish had firmly grasped the patient's uvula, which it was induced to relinquish when its head was seized by the forceps and pressed from side to side. After this it was easily extracted and lived for some time. There Avas little hemorrhage after the removal of the offending object, and the blood had evidently come from the injuries to the sides of the mouth, caused by the fins. The uvula was bitten, not torn. There is an interesting account of a native of India, who, Avhile fishing in a stream, caught a flat eel-like fish from fifteen to sixteen inches long. After the fashion of his fel- Ioavs he attempted to kill the eel by bitting off its head; in the attempt the fish slipped into his gullet, and owing to its sharp fins could not be Avith- draAvn. The man died one hour later in the greatest agony ; so firmly was the eel impacted that even after death it could not be extracted, and the man was buried Avith it protruding from his mouth. A Leech in the Pharynx.—Granger, a surgeon in Her Majesty's Indian Servicc,b Avrites :—" Several days ago I received a note from the political sirdar, asking me if I would see a man who said he had a leech in his throat Avhich he was unable to get rid of. I was somewhat sceptical, and thought that possibly the man might be laboring under a delusion. On going outside the fort to see the case, I found an old Pathan graybeard wait- ing for me. On seeing me, he at once spat out a large quantity of dark, half-clotted blood to assure me of the serious nature of his complaint. His history—mostly made out with the aid of interpreters—was that eleven days ago he AAas drinking from a rain-water tank and felt something stick in his throat, Avhich he could not reject. He felt this thing moving, and it caused difficulty in SAvalloAving, and occasionally vomiting. On the following day he began to spit up blood, and this continued until he saw me. He stated that he once vomited blood, and that he frequently felt that he AA'as going to choke. On examining his throat, a large clot of blood was found to be adherent to the posterior Avail of the pharynx. On removing this clot of blood, no signs of the presence of a leech could be detected. However, on account of the symptoms complained of by the patient I introduced a polypus forceps a 548, 1878, ii., 504. b 224, 1895, ii., 695. 570 SURGICAL ANOMALIES OF THE HEAD AND NECK. into the lower part of the pharynx and toAAard the esophagus, where a body, distinctly moving, Avas felt. This body I seized Avith the forceps, and with considerable force managed to remove it. It Avas a leech betAveen 2| and three inches in length, and Avith a body of the size of a Lee-Motford bullet. Xo doubt during the eleA'en days it had remained in the man's throat the leech had increased in size. Nevertheless it must ha\'e been an animal of considerable size Avhen the man attempted to savuIIoav it. I send this case as a typical example of the carelessness of natives of the class from Avhich Ave enlist our Sepoys, as to the nature of the AA'ater they drink. This man had drunk the pea-soup like Avater of a tank dug in the side of the hill, rather than go a feAV hundred yards to a spring Avhere the AA'ater is perfectly clear and pure. Though I have not met with another case of leeches being taken Avith drink- ing Avater, I am assured that such cases are occasionally met Avith about Agm and other to avus in the Xorth-West Provinces. This great carelessness as to the purity or impurity of their drinking water sIioavs the difficulty medical officers must experience in their endeavors to prcA'ent the Sepoys of a regi- ment from drinking water from condemned or doubtful sources during a cholera or typhoid epidemic." Foreign Bodies in the Pharynx and Esophagus.—Aylesbury8 men- tions a boy who swalloAved a fish-hook Avhile eating gooseberries. He tried to pull it up, but it was firmly fastened, and a surgeon was called. By ingeni- ously passing a leaden bullet along the line, the weight of the lead loosened the hook, and both bullet and hook Avere easily drawn up. Babbit and Battle b report an ingenious method of removing a piece of meat occluding the esophagus—the application of trypsin. Henry0 speaks of a German officer Avho accidentally swallowed a piece of beer bottle, f x \ inch, Avhich subsequently penetrated the esophagus, and in its course irritated the recur- rent laryngeal and vagi, giving rise to the most serious phlegmonous inflam- mation and distressing respiratory symptoms. A peculiar case d is that of the man Avho died after a fire at the Eddystone Lighthouse. He Avas endeavoring to extinguish the flames which Avere at a considerable distance above his head, and AA'as looking up Avith his mouth open, Avhen the lead of a melting lantern dropped down in such quantities as not only to cover his face and enter his mouth, but run over his clothes. The esophagus and tunica in the loAver part of the stomach were burned, and a great piece of lead, Aveighing over 7 J ounces, was taken from the stomach after death. Evanse relates the history of a girl of twenty-one Avho sAvallowed four arti- ficial teeth, together with their gold plate ; two years and eight days afterward she ejected them after a violent attack of retching. Gauthierf speaks of a young girl who, Avhile eating soup, swalloAved a fragment of bone. For a long time she had symptoms simulating phthisis, but fourteen years afterward the a 374, 1738, viii., 380. b 604, 1887. c 178, 1882. d 629, 1756, part ii. e 476, 1879, ii.. 75. f 663, T., xxxiv., 13. FOREIGN BODIES IN THE ESOPHAGUS. 571 bone Avas dislodged, and, although the young Avoman Avas considered in the last stages of phthisis, she completely recovered in six weeks. Gastelliera has reported the case of a young man of sixteen who sAvallowed a croAvn piece, Avhich became lodged in the middle portion of the esophagus and could not be removed. For ten months the piece of money remained in this position, during Avhich the young man Avas never without acute pain and often had con- vulsions. He vomited material, sometimes alimentary, sometimes mucus, pus, or blood, and went into the last stage of marasmus. At last, after this long-continued suffering, following a strong convulsion and syncope, the coin descended to the stomach, and the young man expectorated great quantities of pus. After thirty-five years, the coin had not been passed by the rectum. Instances of migration of foreign bodies from the esophagus are re- peatedly recorded. There is an instance5 of a needle Avhich avus swallowed and lodged in the esophagus, but tAventy-one months afterward Avas extracted by an incision at a point behind the right ear. Kerckring speaks of a girl Avho swallowed a needle which Avas ultimately extracted from the muscles of her neck. Poulet641 remarks that Vigla has collected the most interesting of these cases of migration of foreign bodies. Hevin mentions several cases of grains of Avheat abstracted from abscesses of the thoracic parietes, from thirteen to fifteen days after ingestion. Bonnet and Helmontius have reported similar facts. Volgnarius has seen a grain of Avheat make its exit from the axilla, and Polisius mentions an abscess of the back from which Avas extracted a grain of Avheat three months after ingestion. Ballyc reports a somewhat similar instance, in AA'hich, three months after ingestion, during an attack of peripneumonia, a foreign body Avas extracted from an abscess of the thorax, betAveen the 2d and 3d ribs. Ambrose d found a needle encysted in the heart of a negress. She distinctly stated that she had sAvallowed it at a time calcu- lated to have been nine years before her death. Planque speaks of a small bone perforating the esophagus and extracted through the skin. Abscess or ulceration, consequent upon periesophagitis, caused by the lodgment of foreign bodies in the esophagus, often leads to the most serious results. There is an instance662 of a soldier avIio sAvalloAved a bone Avhile eating soup, Avho died on the thirty-first day from the rupture internally of an esophageal abscess. Grelloise has reported the history of a case of a child tAventy-tAVO months old, Avho suffered for some time AA'ith impaction of a small bone in the esophagus. Less than three months afterward the patient died Avith all the symptoms of marasmus, due to difficult deglutition, and at the autopsy an abscess Avas seen in the posterior Avail of the pharynx, opposite the 3d cervical vertebra ; extensive caries AAas also noticed in the bodies of the 2d, 3d, and 4th cervical vertebrae. Guattanif mentions a curious instance in Avhich a man playing with a chestnut threw it in the air, catching it in his a 458, T. xxiii., 147. b 641, 113. c Acad, de Medecine, 1824. d 538, 1870. e 458, T. xiii., 1807. *" 641, 119. 572 SURGICAL ANOMALIES OF THE HEAD AND NECK. mouth. The chestnut became lodged in the throat and caused death on the nineteenth day. At the autopsy it Avas found that an abscess communicating Avith the trachea had been formed in the pharynx and esophagus. A peculiarly fatal accident in this connection is that in Avhich a foreign body in the esophagus ulcerates, and penetrates one of the neighboring major vessels. Collesa mentions a man of fifty-six AA'ho, Avhile eating, perceived a sensation as of a rent in the chest. The pain Avas augmented during degluti- tion, and almost immediately afterward he commenced to expectorate great quantities of blood. On the folloAving day he vomited a bone about an inch long and died on the same day. At the autopsy it avus found that there was a rent in the posterior Avail of the esophagus, about \ inch long, and a cor- responding wound of the aorta. There Avas blood in the pleura, pericardium, stomach, and intestines. There is one case in which a man of forty-seven sud- denly died, after vomiting blood, and at the autopsy it avus demonstrated that a needle had perforated the posterior wall of the esophagus and wounded the aorta.b Poulet has collected0 31 cases in which ulceration caused by foreign bodies in the esophagus has resulted in perforation of the Avails of some of the neighboring A'cssels. The order of frequence was as folioavs : aorta, 17 ; carotids, four; vena caA'a, two ; and one case each of perforation of the in- ferior thyroid artery, right coronary vein, demi-azygos v^ein, the right sub- clavicular artery (abnormal), and the esophageal artery. In three of the cases collected there Avas no autopsy and the A-esscl affected Avas not knoAvn. In a child of three years that had SAvallowed a half-penny, Atkinsd re- ports rupture of the innominate artery. No symptoms developed, but six Aveeks later, the child had an attack of ulcerative stomatitis, from Avhich it seemed to be recovering nicely, Avhen suddenly it ejected two ounces of bright red blood in clots, and became collapsed out of proportion to the loss of blood. Under treatment, it rallied someAvhat, but soon afterAvard it ejected four ounces more of blood and died in a few minutes. At the autopsy f pint of blood Avas found in the stomach, and a perforation Avas discovered on the right side of the esophagus, leading into a cavity, in Avhich a blackened half- penny Avas found. A probe passed along the aorta into the innominate pro- truded into the same cavity about the bifurcation of the vessel. Denonvilliers has described a perforation of the esophagus and aorta by a five-franc piece. A preserved preparation of this case, shoAving the coin in situ, is in the Musee Dupuytren (Fig. 203). Blaxland e relates the instance of a Avoman of forty-five avIio SAvallowed a fish bone, was seized Avith violent hematemesis, and died in eight hours. The necropsy revealed a penetration of the aorta through the thoracic portion of the esophagus. There is also in the Musee Dupuytren a preparation described by Bousquet, in which the aorta and the esophagus were perforated by a very irregular piece of bone a 313, 1855, T. xix., 25. b 476) 1877, ii., 789. c 641, 122. d 224, May 4, 1895. e 490, 1847, iv., 647. PERFORATION OF THE ESOPHAGUS. 573 (Fig. 204). Mackenzie mentions an instance of death from perforation of the aorta by a fish-bone. In some cases penetration of the esophagus allows the further penetration of some neighboring membrane or organ in the same manner as the foregoing cases. Dudleya mentions a case in which fatal hemorrhage Avas caused by penetration of the esophagus and lung by a chicken-bone. Buistb speaks of a patient avIio SAvalloAved Iavo artificial teeth. On the following day there Avas pain in the epigastrium, and by the fourth day the pain extended to the ver- tebra?, with vomiting, delirium, and death on the fifth day. At the autopsy it Avas found that a foreign body, seven cm. long had perforated the Fig. 203. —Perforation of esophagus and aorta by a Fig. 204.—Perforation of aorta by a piece of bone five-franc piece (coin in situ) (after Poulet). (after Poulet). pericardium, causing a suppurative pericarditis. Dagron242 reports a unique instance of death by purulent infection arising from perforation of the esoph- agus by a pin. The patient AA'as a man of forty-two, and, some six weeks before he presented himself for treatment, before SAvalloAving had experienced a severe pain low down in the neck. Five days before admission he had had a severe chill, folloAved by sAveating and delirium. He died of a supraclavic- ular abscess on the fifth day; a black steel pin Avas found against the esophagus and trachea. In connection with foreign bodies in the esophagus, it might be interesting a 648. 1858. b 264, 1858. 574 SURGICAL ANOMALIES OF THE HEAD AND NECK. to remark that Aslihurst a has collected 129 cases of esophagotomy for the remoA'al of foreign bodies, resulting in 95 recoveries and 34 deaths. Gau- dolpheb collected 142 cases Avith 110 recoveries. Injuries of the neck are usually inflicted Avith suicidal intent or in bat- tle. Cornelius Xepos says that Avhile fighting against the Lacedemonians, Epaminondas Avas sensible of having received a mortal wound, and appre- hending that the lance Avas stopping a AA'ound in an important vessel, remarked that he would die AA'hen it was Avithdrawn. When he Avas told that the I>u- otians had conquered, exclaiming " I die unconquered," he dreAV out the lance and perished. Petrus de Largenta speaks of a man Avith an arroAv in one of his carotids, avIio Avas but slightly affected before its extraction, but who died immediately after the removal of the arrow. Among the remarkable recov- eries from injuries of the neck is that mentioned by Boerhaave, of a young man avIio lived nine or ten days after receiving a sword-thrust through the neck between the 4th and 5th vertebrae, dividing the vertebral artery. Bene- dictus, Bonacursius, and Monroe, all mention recovery after cases of cut- throat in which the esophagus as well as the trachea was wounded, and food protruded from the external cut. Warrenc relates the history of a case in which the vertebral artery Avas Avounded by the discharge of a pistol loaded with pebbles. The hemorrhage was checked by compression and packing, and after the discharge of a pebble and a piece of bone from the wound, the man AA'as seen a month afterward in perfect health. Corson of Norristown, Pa., has reported the case of a quarryman who was stabbed in the neck with a shoemaker's knife, severing the left carotid one inch below its division. He was seen thirty minutes later in an apparently lifeless condition, but efforts at resuscitation avc re successfully made. The hemorrhage ceased spontaneously, and at the time of report, the man presented the symptoms of one who had had his carotid ligated (facial atrophy on one side, no pulse, etc.). Baron Larrey 478 mentions a case of gunshot wound in which the carotid artery was open at its dh'ision into internal and external branches, and says that the wound AAas plugged by an artilleryman until ligation, and in this primitive manner the patient was saved. Sale d reports the case of a girl of nineteen, who fell on a china bowl that she had shattered, and wounded both the right common carotid artery and internal jugular vein. There was profuse and con- tinuous hemorrhage for a time, and subsequently a false aneurysm developed, which ruptured in about three months, giving rise to enormous momentary hemorrhage ; notwithstanding the severity of the injury and the extent of the hemorrhage, complete recovery ensued.. Amose relates the instance of a woman named Mary Green who, after complete dh'ision of all the vessels of the neck, walked 23 yards and climbed over an ordinary bar-gate nearly four feet high. a 174, 385. b 497, jan. 20, 1895. c 218, 1862, lxvi., 389. d 124, 1879, 281. e 490, 1832, x., 183. WOUNDS OF THE TRACHEA AND ESOPHAGUS. 575 Cholmeley reports the instance of a Captain of the First Madras Fusil- eers, Avho Avas Avounded at Pegu by a musket-ball penetrating his neck. The common carotid Avas divided and for five minutes there was profuse hemor- rhage Avhich, hoAvever, strange to say, spontaneously ceased. The patient died in thirty-eight hours, supposedly from spinal concussion or shock.a Relative to ligature of the common carotid artery, Aslihurst mentions the fact that the artery has been ligated in 228 instances, Avith 94 recoveries. Ellisb mentions ligature of both carotids in four and a half days, as a treat- ment for a gunshot Avound, with subsequent recovery. Lewtasc reports a case of ligation of the innominate and carotid arteries for traumatic aneurysm (likely a hematoma due to a gunshot injury of the subclavian artery). The patient was in profound collapse, but steadily reacted and was discharged cured on the forty-fifth day, with no perceptible pulse at the wrist and only a feeble beat in the pulmonary artery. Garengeot, Wirth, Fine, and Evers, all mention perforating wounds of the trachea and esophagus with recoveries. Van Swieten and Hiester mention cases in AA'hich part of the trachea was carried away by a ball, with recovery. Monro, Tulpius, Bartholinus, and Par6 report severance of the trachea Avith the absence of oral breathing, in which the divided portions Avere sutured, Avith successful results. In his"Theatro Naturae " Bodinus says that William, Prince of Orange, lost the sense of taste after receiving a Avound of the larynx ; according to an old authority, a French soldier became mute after a similar accident. Davies-Colley d mentions a boy of eighteen who fell on a stick about the thickness of the index finger, transfixing his neck from right to left; he walked to a doctor's house, 250 yards aAvay, with the stick in situ. In about two weeks he was discharged completely well. During treatment he had no hemorrhage of any importance, and his voice was not affected, but for a Avhile he had slight dysphagia. Barker6 gives a full account of a barber who was admitted to a hospital two and a half hours after cutting his throat. He had a deep Avound running transversely across the neck, from one angle of the jaAV to the other, cutting open the floor of the mouth and extending from the inner border of the sterno- cleido-mastoid to the other, leaving the large vessels of the neck untouched. The razor had passed through the glosso-epiglottidean fold, a tip of the epi- glottis, and through the pharynx down to the spinal column. There Avas little hemorrhage, but the man could neither sAvalloAV nor speak. The wound AA'as sutured, tracheotomy done, and the head kept fixed on the chest by a copper splint. He Avas ingeniously fed by esophageal tubes and rectal enemata ; in three Aveeks speech and deglutition Avere restored. Shortly afterAvard the esopha- geal tube AA'as remoAfed and recovery Avas A'irtually complete. Littlef men- tions an extraordinary case of a Avoman of thirty-six Avho Avas discharged a 548, 1855, 538. b 594, 1845. c 224, 1889. d 476, 1882. e 436, May 16, 1894. f 476, 1889, ii., 91. 576 SURGICAL ANOMALIES OF THE HEAD AND NECK. from Garland's asylum, Avhere she had been an inmate for three months. This unfortunate Avoman had attempted suicide by self-decapitation from behind forward. She was found, knife in hand, Avith a huge Avound in the back of the neck and her head bobbing about in a ghastly manner. The incision had severed the skin, subcutaneous tissues and muscles, the ligaments and bone, opening the spinal canal, but not cutting the cord. The instrument used to effect this major injury Avas a blunt potato-peeling knife. Despite this terrible Avound the patient lh'ed to the sixth day. Hislopa records a case of cut-throat in a man of seA'cnty-four. He had a huge gaping Avound of the neck, extending to Avithin a half inch of the carotids on each side. The trachea Avas almost completely seA'ered, the band left Avas not more than \ inch Avide. Hislop tied four arteries, brought the ends of the trachea together Avith four strong silk sutures, and, as the operation was in the country, he washed the big cavity of the Avound out with cold spring-water. He brought the superficial surfaces together Avith ten interrupted sutures, and, notwithstanding the patient's age, the man speedily recoA'ered. This emphasizes the fact that the old theory of leaving wounds of this nature open AAas erroneous. Sollyb reports the case of a tailor of tAventy-tAvo who attempted suicide by cutting through the larynx, entirely severing the epi- glottis and three-fourths of the pharynx. No bleeding point Avas found, and recovery ensued. CoAvles c describes the case of a soldier of thirty-fiA'e who, Avhile escaping from the patrols, Avas shot by the Officer of the Day AA'ith a small bullet from a pistol. The ball entered the right shoulder, immediately over the supra- scapular notch, passed superficially upAvard and fonvard into the neck, wounding the esophagus posteriorly at a point opposite the thyroid cartilage, and lodged in the left side of the neck. The patient had little hemor- rhage, but had expectorated and sAvalloAved much blood. He had a constant desire to sAvalloAv, which continued several days. The treat- ment Avas expectant; and in less than three weeks the soldier Avas returned to duty. From the same authority there is a condensation of five reports of gunshot Avounds of the neck, from all of Avhich the patients recovered and returned to duty. Bramand describes the case of a man on Avhoni several injuries were inflicted by a drunken companion. The first Avound Avas slight; the second a deep Aesh-Avound OA'er the trapezius muscle ; the third extended from the right sterno-cleido-mastoid mkhvay upward to the middle of the jaw and doAvn to the raphe of the trachea. The external jugular, the external thyroid, and the facial arteries Avere severed. Branian did not find it necessary to ligate, but Avas able to check the hemorrhage Avith lint and persulphate of iron, in poAvder, AA'ith pressure. After fourteen hours the Avound AA'as closed ; the patient recovered, and Avas returned to duty in a short time. a 476, June 30, 1894. b 476, 1864, i., 94. c 847, 23. d 847, 90. CASES OF CUT-THROAT. 577 Thomas3 has reported the case of a man sixty-five years old who. in an attempt at suicide Avith a penknife, had made a deep wound in the left side of the neck. The sternohyoid and omohyoid muscles were divided ; the internal jugular vein Avas cut through, and its cut ends Avere collapsed and | inch apart; the common carotid artery was cut into, but not divided ; the thyroid cartilage AA'as notched, and the external and anterior jugular veins Avere severed. Clamp-forceps Avere immediately applied to the cut ves- sels and one on each side the aperture in the common carotid from Avhich a small spurt of blood, certainly not half a teaspoonful, came out. The left median basilic vein Avas exposed by an incision, and 20 ounces of Avarm saline solution were sloAvly perfused, an ordinary glass syringe with a capacity of five ounces, with an India-rubber tubing attached to a canula in the vein, being employed. After seven ounces of fluid had been injected, the man made a short, distinct inspiration ; at ten ounces a deeper one (the radial pulse could iioav be felt beating feebly); at 15 ounces the breathing became regular and deep; at 18 ounces the man opened his eyes, but did not appear to be conscious. The clamped A'essels were noAV tied AA'ith catgut and the Avound cleansed Avith phenol lotion and dressed Avith cyanid-gauze. The man AA'as surrounded by hot-Avater bottles and the foot of the bed elevated 18 inches. In the course of an hour the patient had recoA'ered sufficiently to answer in a squeaky Aoice to his name Avhen called loudly. Improvement proceeded rapidly until the twenty-second day, Avhen A'iolent hemorrhage oc- curred, preceded a feAV hours preA'iously by a small trickle, easily controlled by pressure. The wound AA'as at once opened and blood found oozing from the distal extremities of the carotid artery and jugular A'ein, Avhich Avere promptly clamped. The common carotid artery Avas not sound, so that ligatures AA'ere applied to the internal and external carotids and to the internal jugular with a small branch entering into it. The patient Avas in great collapse, but quickly rallied, only to suffer reneAved hemorrhage from the internal carotid nine days later. This Avas controlled by pressure Avith sponges, and a quart of hot water Avas injected into the rectum. From this time on the patient made a slow recovery, a small sinus in the loAver part of the neck disappearing on the removal of the catgut ligature. Adamsb describes the case of a Avoman avIio attempted suicide Avith a common table-knife, severing the thyroid, cricoid, and first three rings of the trachea, and lacerating the sternohyoid and thyroid arteries ; she finally re- covered. There is a curious case of suicidec of a Avoman who, while under the effects of opium, forced the handle of a mirror into her mouth. From all appearances, the handle had broken off near the junction and she had evidently fallen forward Avith the remaining part in her mouth, driving it forcibly against the spine, and causing the point of the handle to run dowmvard in a 224, No. 1823, p. 1420. b 476, 1850, i., 699. <■ 476, 1889, ii., 608. 37 578 SURGICAL ANOMALIES OF THE HEAD AND NECK. front of the cervical vertebrae. On postmortem examination, a sharp piece of Avood about two inches long, corresponding to the missing portion of the broken mirror handle, Avas found lying betAveen the posterior Avail of the esophagus and the spine. Ilennig* mentions a case of gunshot AA'ound ot the neck in AA'hich the musket ball was lodged in the posterior portion of the neck and Avas subsequently discharged by the anus. Injuries of the cervical vertebrae, Avhile extremely grave, and declared bv some authors to be inevitably fatal, are, hoAvever, not ahvays followed by death or permanently bad results. Banvellb mentions a man of sixty- three avIio, in a tit of despondency, threAv himself from a windoAv, having fastened a rope to his neck and to the AvindoAV-sill. He fell 11 or 12 feet, and in doing so suffered a subluxation of the 4th cervical vertebra. It sIoavIv resumed the normal position by the elasticity of the intervertebral fibroeartilage, and there Avas complete recovery in ten days. Lazzarettoc reports the history of the case of a seaman avIiosc atlas Avas dislocated by a bloAV from a falling sail-yard. The dislocation AA'as reduced and held by adhesive strips, and the man made a good recovery. Vanderpool of JJelle- A'ue Hospital, N. Y.,d describes a fracture of the odontoid process caused by a fall on the back of the head ; death, however, did not ensue until six months later. According to Ashhurst,e Philips, the elder Cline, Willard Parker, Bayard, Stephen Smith, May, and seA'eral other surgeons, have recorded com- plete recovery after fracture of the atlas and axis. The same author also adds that statistic investigation sIioavs that as large a proportion as 18 per cent, of injuries of the cervical A'crtebrae occurring in civil practice, recover. HoAvever, the chances of a fatal issue in injuries of the vertebrae vary inversely Avith the distance of the point of injury from the brain. Keen has recorded a case in Avhich a conoidal ball lodged in the body of the third cervical vertebra, from Avhich it avus extracted six Aveeks later. The paralysis, AA'hich, up to the time of extraction, had affected all four limbs, rapidly diminished. In about five Aveeks after the remoA'al of the bullet nearly the entire body of the 3d cer- vical A'ertebra, including the anterior half of the transverse process and ver- tebral foramen, Avas spontaneously discharged. Nearly eight years afterAvard Keen suav the man still living, but Avith his right shoulder and arm dimin- ished in size and partly paralyzed. Doyle f reports a case of dislocated neck Avith recovery. During a runaAvay the patient Avas throAvn from his Avagon, and avus soon after found on the road- side apparentlv dead. Physicians AA'ho Avere quickly summoned from the immediate neighborhood detected faint signs of life ; thev also found a defor- mity of the neck, AA'hich led them to suspect dislocation. An ambulance Ava< called, and Avithout any effort being made to relieA'e the deformity the man Avas placed in it and driven to his home about a mile distant. The jolting a 316, 1817. b 224. 1S82, 369. c 318, 1813, ix.. 165. d Archives of Clinical Surgery, N. Y., 1877, ii., 116. e 174, 353. f 231, Jan., 1896. INJURIES OF THE CERVICAL VERTEBRM 579 over the rough roads greatly aggravated his condition. When Dovle saAV the patient, his general appearance presented a hopeless condition, but being satisfied that a dislocation existed, Doyle immediately prepared to reduce it. Tavo men Avere told to grasp the feet and tAvo more the head, and Avere directed to make careful but strong extension. At the same time the phy- sician placed his right hand against the neck just OA'er the pomuni Adami, and his left against the occiput, and, Avhile extension AA'as being made, he flexed the head forward until the chin nearly touched the breast, after which the head avus returned to its normal position. The manipulation AA'as accompanied by a clicking sensation, caused by the replacement of the dislocated vertebra. The patient immediately shoAved signs of relief and improved rapidly. Perceptible but feeble moA'oinents Avere made by all the limbs except the right arm. The patient re- mained in a comatose condition for eight or nine days, during Avhich he had enuresis and intestinal tor- por. He suffered from seA'ere con- cussion of the brain, Avhich account- ed for his prolonged coma. De- lirium AA'as present, but he Avas carefully Avatched and not alloAved to injure himself. His recovery Avas tedious and Avas delayed by several relapses. His first com- plaint after consciousness returned (on the tenth day) AA'as of a sense of constriction about the neck, as if he AA'ere being choked. This gradually passed off, and his im- provement a vent on Avithout devel- opment of any serious symptoms. At the time of report he appeared in the best of health and Avas quite able to attend to his daily avocations. Doyle appends to his report the statement that among 394 cases embraced in Ash- hurst's statistics, in treatment of dislocations in the cervical region, the mortality has been nearly four times greater Avhen constitutional or general treatment has been relied on exclusively than Avhen attempts had been made to reduce the dislocation by extension, rotation, etc. Doyle strongly advocates attempts at reduction in such cases. Figure 205 represents a photograph of Barney Bakhvin, a sAvitchman of the Louisville and Nashville Railroad, avIio, after recovery from cervical dis- location, exhibited himself about the country, neA'er appearing Avithout his suspense >ry apparatus. Fig. 205.—B. Baldwin, " the switchman with the broken neck." 580 SURGICAL ANOMALIES OF THE HEAD AND NECK. Acheson* records a case of luxation of the cervical spine Avith recovery after the use of a jury-mast. The patient Avas a man of fifty-five, by trade a train-conductor. On July 10, 18S9, he fell backAvard in front of a train, his head striking betAveen the ties ; the brake-body caught his body, pushing it fonvard on his head, and turned him completely over. Three trucks passed over him. When dragged from beneath the train, his upper extremities Avere paralyzed. At noon the next day, nineteen hours after the accident, examination revealed bruises over the body, and he suffered intense pain at the back of the neck and base of the skull. Posteriorly, the neck presented a natural appearance ; but anteriorly, to use the author's descrip- tion, his neck resembled a combined case of mumps and goiter. The sternomastoid muscle bulged at the angle of the jaAV, and AAas flaccid, and his " Adam's apple" AAas on a leA'el with the chin. Sensation in the upper extremities AA'as partially restored, and, although numb, he uoav had poAver of moA'ement in the arms and hands, but could not rotate his neck. A diagnosis of cervical dislocation Avas made, and violent extension, AA'ith oscil- lation fonvard and backAvard, Avas practised, and the abnormal appearance sub- sided at once. No crepitus Avas noticed. On the fourth day there Avas slight hemorrhage from the mouth, Avhich Avas more seA'ere on the fifth and sixth days. The loAver jaAV had been forced past the upper, until the first molar had penetrated the tissues beneath the tongue. A plaster-of-Paris apparatus Avas applied, and in two months Avas exchanged for one of sole- leather. In rising from the recumbent position the man had to lift his head Avith his hands. Fifty days after the accident he suffered excruciating pain at the change of the Aveather, and at the approach of a storm the joints, as well as the neck, Avere iiiA'olved. It Avas believed (one hundred and seven days after the accident) that both fracture and luxation existed. His voice had become guttural, but examination of the fauces avus negative. The only evi- dence of paralysis Avas in the fingers, Avhich, AA'hen applied to anything, ex- perienced the sensation of touching gravel. The mottling of the tissues of the neck, AA'hich appeared about the fiftieth day, had entirely disappeared. According to Thorburn,b Hilton had a patient avIio lh'ed fourteen years Avith paraplegia due to fracture of the 5th, 6th, and 7th cervical vertebras. SliaAV is accredited Avith a case in Avhich the patient lived fifteen months, the fracture being aboA'e the 4th cervical vertebra. In speaking of foreign bodies in the larynx and trachea, the first to be considered Avill be liquids. There is a case on record c of an infant avIio Avas eating some coal, and being discovered by its mother Avas forced to rapidly SAvallow some Avater. In the excitement, part of the fluid SAvallowed fell into the trachea, and death rapidly ensued. It is hardly necessary to mention the instances in Avhich pus or blood from ruptured abscesses entered the trachea and caused subsequent asphyxiation. A curious instance is a 124, March, 1890. b 224, Oct. 27, 1894. <= 641, 365. FORELGN BODIES IN THE LARYNX AND TRACHEA. 581 reported by Gaujot of Val-de-Grace of a soldier who Avas Avounded in the Franco-Prussian Avar, and into Avhose Avound an injection of the tincture of iodin Avas made. The avouikI Avas of such an extent as to communicate with a bronchus, and by this means the iodin entered the respiratory tract, causing suffocation. According to Poulet, Yidal de Cassis mentions an inmate of the Charite Hospital, in Paris, Avho, full of Avine, had started to \-omit ; he per- ceived Corvisart, and kneAV he Avould be questioned, therefore he quickly closed his mouth to hide the proof's of his forbidden ingestion. The materials in his mouth Avere forced into the larynx, and he Avas immediately asphyxiated. Laennec, Merat, and many other Avriters have mentioned death caused by the entrance of vomited materials into the air-passages. Parrota has observed a child who died by the penetration of chyme into the air-passages. The bronchial mucous and underlying membrane were already in a process of digestion. Behrend, Piegu, and others cite analogous instances. The presence of a foreign body in the larynx is at all times the cause of distressing symptoms, and, sometimes, a substance of the smallest size will cause death. There is a curious accident recorded b that happened to a young man of tAventy -three, Avho Avas anesthetized in order to extract a tooth. A cork had been placed betAveen the teeth to keep the mouth open. The tooth Avas extracted but slipped from the forceps, and, together Avith the cork, fell into the pharynx. The tooth was ejected in an effort at A'omiting, but the cork entered the larynx, and, after violent struggles, asphyxiation caused death in an hour. The autopsy demonstrated the presence of the cork in the larynx. A somewhat analogous case, though not ending fatally, Avas reported by Hertzc of a Avoman of twenty-six, Avho Avas anesthetized for the extraction of the right second inferior molar. The croAvn broke off during the opera- tion, and immediately after the extraction she had a fit of coughing. About fifteen days later she experienced pain in the lungs. Her symptoms increased to the fifth Aveek, when she became so feeble as to be confined to her bed. A body seemed to be moA'ing in the trachea, synchronously Avith respiration. At the end of the fifth Aveek the missing croAvn of the tooth avus expelled after a violent fit of coughing; the symptoms immediately ameliorated, and recovery AA'as rapid thereafter. Aronsohnd speaks of a child avIio Avas playing Avith a toy Avind-instrument, and in his efforts to forcibly aspirate air through it, the child dreAV the detached reed into the respiratory passages, causing asphyxiation. At the autopsy the foreign body avus found at the superior portion of the left bronchus. There are other eases in Avhich, Avhile sucking oranges or lemons, seeds have been aspirated; and there is a case in Avhich, in a like manner, the chuv of a crab AA'as draAvn into the air-passages. There are hvo cases mentioned6 in which children playing with toy balloons, which they inflated with their breath, have, by inspiration, reversed them and a 7*9, 18S5, ii., 167. b 272, 1867. c 296, 1873. d These de Strasbourg, 1856. e 476, 1886, i., 758. 582 SURGICAL ANOMALIES OF THE HEAD AND NECK. drawn the rubber of the balloon into the opening of the glottis, causing death. Aronsohn, AA'ho has already been quoted, and AA'hose collection of instance.- of this nature is probably the most extensive, speaks of a child in the street avIio Avas eating an almond; a carriage threw the child doAvn and he sud- denly inspired the nut into the air-passages, causing immediate asphyxia. The same author also mentions a soldier Avalking in the street eating a plum, Avho, on being struck by a horse, suddenly started and SAvalloAved the seed of the fruit. After the accident he had little pain or oppression, and no cough- ing, but twelve hours afterAvard he rejected the seed in coughing. A curious accident is that in Avhich a foreign body throAvn into the air and caught in the mouth has caused immediate asphyxiation. Suetonius754 trans- mits the history of a young man, a son of the Emperor Claudius, AA'ho, in sport, threw a small pear into the air and caught it in his mouth, and, as a consequence, Avas suffocated. Guattani 563 cites a similar instance of a man avIio threAv up a chestnut, AA'hich, on being received in the mouth, lodged in the air-passages ; the man died on the nineteenth day. Brodie reported the classic obserA'ation of the celebrated engineer, Brunei, AA'ho sAvalloAved a piece of money thrown into the air and caught in his mouth. It fell into the open larynx, Avas inspired, causing asphyxiation, but was remoA'ed by inversion of the man's body. Sennert says that Pope Adrian IV. died from the entrance of a fly into his respiratory passages; and Remy and Gautier record instances of the penetration of small fish into the trachea. There are, again, instances of leeches in this location. Occasionally the impaction of artificial teeth in the neighborhood of the larynx has been unrecognized for many years. Lennox BroAvne* re- ports the history of a AA'oman AA'ho avus supposed to haA'e either laryngeal car- cinoma or phthisis, but in Avhom he found, impacted in the larynx, a plate Avith artificial teeth attached, Avhich had remained in this position tAventy-tAVo months unrecognized and unknoAvn. The patient, AA'hen questioned, remem- bered having been aAvakened in the night by a violent attack of vomiting, and finding her teeth AA'ere missing assumed they Avere throAvn aAvay Avith the ejec- tions. From that time on she had suffered pain and distress in breathing and SAvalloAving, and became the subject of progressive emaciation. After the re- moval of the impacted plate and teeth she soon regained her health. Paget'* speaks of a gentleman AA'ho for three months, unconsciously, carried at the base of the tongue and epiglottis, very closely fitted to all the surface on Avhich it rested, a full set of lost teeth and gold palate-plate. From the symptoms and history it AA'as suspected that he had SAvalloAved his set of false teeth, but, in order to prevent his Avorrving, he avus neA'er informed of this suspicion, and he neA'er once suspected the causes of his symptoms. Wrench c mentions a case illustrative of the extent to Avhich imagination a 536, I860, ii., 588. b 548, 1862, i., 59. 0 476, 1880, i., 71. FOREIGN BODIES IN THE LARYNX AND TRACHEA. 583 may produce symptoms simulating those ordinarily caused by the sAvalh)Avin» of false teeth. This man aAA'oke one morning with his nose and throat full of blood, and noticed that his false teeth, Avhich he seldom remoA'ed at night, Avere missing. He rapidly deA'cloped great pain and tumor in the larynx together Avith difficulty in deglutition and speech. After a fruitless search, Avith instrumental and laryngoseopic aid, the missing teeth Avere found—in a chest of drawers ; the symptoms immediately subsided Avhen the mental illu- sion Avas relieved. There is a curious case of a man droAvned near Portsmouth." After the recovery of his body it Avas seen that his false teeth Avere impacted at the ante- rior opening of the glottis, and it Avas presumed that the shock caused bv the plunge into the cold AA'ater had induced a violent and deep inspiration Avhich carried the teeth to the place of impaction. Perrin b reports a case of an old man of cightv-tAvo avIio lost his life from the impaction of a small piece of meat in the trachea and glottis. In the Musee Val- de-Graee is a prepared specimen of this case shoAving the foreign body in situ (Fig. 2()(>). In the same museum Perrin has also de- posited a preparation from the body of a man of sixtv-tAA'o, aa'Iio died from the entrance of a morsel of beef into the respiratory pass- ages. At the postmortem a mo- bile mass of food about the size of a hazel-nut avus found at the base of the larynx at the glossoepiglottie fossa. About the 5th ring of the trachea the caliber of this organ AA'as obstructed by a cylindric alimentary bolus about six inches long, extending almost to the bronchial diA'ision (Fig. 207). Aslihurst sIioavs a fibrinous cast, similar to that found in croup, caused by a foreign bodA' removed by "Wharton, together Avith a shaAvl-pin, from a patient at the Children's Hospital seven hours after the performance of tracheotomy. Search for the foreign body at the time of the operation AA'as prcA'ented by profuse hemorrhage. The ordinary instances of -foreign bodies in the larynx and trachea are so common that they Avill not be mentioned here. Their variety is innumerable and it is quite possible for more than tAA'o to be in the same location simul- taneously. In his treatise on this subject Gross says that he has seen two, three, and even four substances simultaneously or successively penetrate the n 476, 1*82. i., 964. b 641, 403. Fig. 206.—Foreign body in trachea and glottis. Fig. 207.—Foreign body in trachea. 584 SURGICAL ANOMALIES OF THE HEAD AND NECK. same location. Berard a presented a stick of AVood extracted from the vocal cords of a child of ten, and a Icav other similar instances are recorded. The Medical Press and Circular1* finds in an Indian contemporary some curious instances of misapplied ingenuity on the part of certain habitual crimi- nals in that country. The discovery on a prisoner of a heavy leaden bullet about | inch in diameter led to an inquiry as to the object to Avhich it Avas applied. It Avas ascertained that it served to aid in the formation of a pouch-like recess at the base of the epiglottis. The ball is allowed to slide doAvn to the desired position, and it is retained there for about half an hour at a time. This operation is repeated many times daily until a pouch the desired size results, in Avhich criminals contrive to secrete jcavcIs, money, etc., in such a Avav as to defy the most careful search, and Avithout interfering in any Avay Avith speech or respiration. UpAvard of 20 prisoners at Calcutta Avere found to be provided Avith this pouch-formation. The resources of the professional malingerer are exceedingly varied, and testify to no small amount of cunning. The taking of internal irritants is very common, but Avould-bc in-patients very frequently overshoot the mark and render recovery impossible. Castor-oil seeds, croton beans, and sundry other agents are employed Avith this object in vieAV, and the medical officers of Indian prisons have to be continually on the lookout for artificially induced diseases that baffle diagnosis and resist treat- ment. Army surgeons are not altogether unfamiliar Avith these tricks, but compared Avith the artful Hindoos the British soldier is a mere child in such matters. Excision of the larynx has found its chief indication in carcinoma, but has been employed in sarcoma, polypi, tuberculosis, enchondroma, stenosis, and necrosis. Whatever the procedure chosen for the operation, preliminary tracheotomy is a prerequisite. It should be made avcII beloAv the isthmus of the thyroid gland, and from three to fifteen days before the laryngectomy. This affords time for the lungs to become accustomed to the neAV manner of breathing, and the trachea becomes fixed to the anterior wall of the neck. PoAvers and AVhite c haA'e gathered 69 cases of either total or partial extir- pation of the larynx, to Avhich the 240 cases collected and analyzed by Eugene Kraus, in 1890, have been added. The histories of six neAV cases are given. Of the 309 operations, 101, or 32 per cent, of the patients, died Avithin the first eight Aveeks from shock, hemorrhage, pneumonia, septic infection, or ex- haustion. The cases collected by these authors sIioav a decrease in the death ratio in the total excision,—29 per cent, as against 36 per cent, in the Kraus tables. The mortality in the partial operation is increased, being 38 per cent. as opposed to 25 per cent. Cases reported as free from the disease before the lapse of three years are of little A'alue, except in that they diminish, by so much, the operath'e death-rate. Of 180 laryngectomies for carcinoma prior to January 1, 1892, 72, or 40 per cent., died as a result of the operation ; 51 of a 242, 1833, viii., 60. b 536, 18S9. ii., 189. c ,y.!8, March 23, 1895. INJURIES OF THE FACE AND JAW. 585 the remaining 108 had recurrence during the first year, and 11, or ten per cent, of the survivors, were free from relapse three or more years after opera- tion. In 77 cases of partial laryngectomy for cancer, 26, or 33 per cent., died during the first hvo months ; of the remaining 51, seven cases, or 13 per cent., are reported as free from the disease three or more years after the operation. Injuries destroying great portions of the face or jaw, but not caus- ing death, are seldom seen, except on the battle-field, and it is to military surgery that Ave must look for the most striking instances of this kind. Ribes a mentions a man of thirty-three who, in the Spanish campaign in 1811, re- ceived an injury Avhich carried aAvay the entire body of the loAver jaAA', half of each ramus, and also mangled in a great degree the neighboring soft parts. He Avas transported from the field of battle, and, despite enormous hemor- rhage and suppuration, in two months recovered. At the time of report the Avounded man presented no trace of the inferior maxillary bone, but by car- rying the finger along the side of the pharynx in the direction of the superior dental arch the coronoid apophyses could be recognized, and about six lines nearer the temporal extremity the ramus could be discovered. The tongue Avas missing for about one-third its length, and AA'as thicker than natural and retracted on the hyoid bone. The sublingual glands Avere adherent to the under part of the tongue and Avere red and over-developed. The inferior parts of the cheeks avc re cicatrized with the lateral and superior regions of the neck, and Avith the base of the tongue and the hyoid bone. The tongue Avas free under and in front of the larynx. The patient used a gilded silver plate to fix the tongue so that deglutition could be carried on. He Avas not able to articulate sounds, but made himself understood through the intervention of this plate, Avhich Avas fixed to a silver chin. The chin he used to maintain the tongue-plate, to diminish the deformity, and to retain the saliva, Avhich Avas constantly dribbling on the neck (Fig. 208). The same author quotes the instance of a man of fifty, av1io, during the siege of Alex- andria in 1801, Avas struck in the middle of his face, obliquely, by a cannon- ball, from beloAv upward and from right to left. A part of the right malar bone, the tAvo superior maxillary bones, the nasal bones, the cartilage, the vomer, the middle lamina of the ethmoid, the left maxillary bone, a portion of the left zygomatic arch, and a great portion of the inferior maxilla Avere carried away, or comminuted, and all the soft parts correspondingly lacer- ated. Several hours aftenvard this soldier Avas counted among the number of dead, but Larrey, the surgeon-in-chief of the army, with his typical vigi- lance and humanity, remarked that the patient gave signs of life, and that, despite the magnitude of his Avound, he did not despair of his recovery. Those portions in Avhich attrition Avas very great Avere removed, and the splin- ters of bone taken out, shoAving an enormous wound. Three months Avere a 302, xxix., 424. 586 SURGICAL ANOMALIES OF THE HEAD AND NICK necessary for cicatrization, but it AA'as not until the capitulation of Marabou, at Avhich place he Avas Avounded, that the patient was returned to France. At this time he presented a hideous aspect. There Avere no signs of nose, nor cartilage separating the entrance of the nostrils, and the A'ault of the nasal fossa could be easily seen. There Avas a part of the posterior region of the right superior maxilla, but the left avus entirely gone—in fact, the man pre- sented an enormous triangular opening in the center of the face, as sIioavii by the accompanying illustration (Fig. 209). The tongue and larynx were se- verely iin'olved, and the sight in the left eye Avas lost. This patient continu- ally Avore a gilded silver mask, AA'hich coA'ercd his deformity and rendered articulation a little less difficult. The saliva continually dribbled from the mouth and from the inferior internal portion of his mask, compelling him to carry some substance to receive the dribblings. Whymper" mentions an Fig. 20S.—Gunshot injury of the lower jaw. Fig. 209.— Gunshot injury of the face. analogous instance of a gunner avIio had his Avhole loAver jaAV torn aAvay by a shell, but avIio recoAered and used an ingenious contrivance in the shape of a sih'er mask for remedying the loss of the parts. Steinerb mentions a wound from a cannon-ball, AA'hich carried aAA'ay the left half of the inferior maxilla, stripping the soft parts as high as the malar, and on the left side of the neck to AA'ithin 1-J- inches of the clavicle, laying bare the transverse-processes of the 2d and 3d A'crtebrae, and exposing the external carotid and most of its branches. It sometimes happens that a foreign body, such as the breech of a gun, may be imbedded for some time in the face, Avith subsequent safe remoA'al. Keithc mentions an instance of the successful removal of the breech of a foAvling-piecc from the face, at the root of the nose, after a lodgment of four months; and Fraserd cites an analogous instance in AA'hich the breech a 490, 1833. b526, 1849. c 54s, igns, 416. d21s. 1863. 170. A CURIOUS ACCIDENT. 587 Avas imbedded in the bones of the face for eight years. Smith a records an instance in Avhich a broken piece of tobacco-pipe penetrated the cheek, re- mained there for seven months, but avus successfully extracted. Before leaving accidents to the head and neck, a most curious case, cited lw ()'Xeill,b Avill be briefly revieAved. A boy of twelve avus entrusted to carry a neAV iron pot to the destination of its purchaser. Probably to facilitate transportation, the bov removed his hat and placed the pot obliquely on the back part of his head, but a sudden movement caused it to slip fonvard and doAviiAvard over the head. UnaA'ailing efforts Avere made at the time and after he reached home, to remove the pot from his head, but in A'ain, and he continued all the night greatly prostrated by fright, hunger, and thirst, together Avith the efforts at removal. The next morning he AA'as taken to a neighbor- ing blacksmith, AA'ho, by greasing one of his fingers, managed to insinuate it betAveen the head and pot. Placing the other side of the pot against an anvil, he struck over the location of his finger a quick, heavy tap AA'ith a hammer, and the pot fell to pieces. The little patient Avas much exhausted by all his treatment and Avant of sleep, and, in fact, could hardly have endured his situa- tion much longer. a 476, 1S64, i., 490. b 476, 1889, i., 156. CHAPTER XI. SURGICAL ANOMALIES OF THE EXTREMITIES. Reunion of Digits.—An interesting phenomenon noticed in relation to severed digits is their Avonderful capacity for reunion. Restitution of a severed part, particularly if one of considerable function, naturally excited the interest of the older Avriters. Lochera has cited an instance of avulsion of the finger Avith restitution of the avulsed portion; and Brulet,b Van Esh, Farmer,:!:i* Ponteau, Rcgnault, and Rosenberg cite instances of reunion of a digit after amputation or scA'crancc. Eve's " Remarkable Cases in Surgery" contains many instances of reunion of both fingers and thumbs, and in more recent years several other similar cases haA'e been reported.0 At the Emergency Hospital in Washington, D. C, there Avas a boy brought in Avho had completely severed one of his digits by a sharp bread-cutter. The amputated finger Avas av rapped up in a piece of brown paper, and, being apparently healthy and the AA'ound absolutely clean, it avus fixed in the normal position on the stump, and covered by a bichlorid dressing. In a short time complete; function Avas restored. In this instance no joint Avas involved, the amputation being in the middle of the 2d phalanx. Staton d has described a case in Avhich the hand Avas severed from the arm by an accidental blow from an axe. The wound extended from the styloid process directly across to the trapezium, dividing all the muscles and blood-vessels, cutting through bones. A small portion of the skin beloAv the articulation, Avith the ulna, remained intact. After an unavoidable delay of an hour, Staton proceeded to replace the hand with silver sutures, adhesive plaster, and splints. On the third day pulsation avus plainly felt in the hand, and on the fourteenth day the sutures were removed. After some time the patient Avas able to extend the fingers of the wounded member, and finally to grasp Avith all her Avonted strength. The reproduction or accidental production of nails after the original part has been torn aAvay by A'iolenee or destroyed by disease, is quite inter- esting. Sometimes Avhen the Avhole last phalanx has been removed, the nail regroAvs at the tip of the remaining stump. Tulpius842 seems to have met Avith this remarkable condition. Marechal de Rougeres,e Voigtel, and Ormanceyf have related instances of similar groAvths on the 2d phalanx a 456, ii., 405. b 297, No. 223. c 313, Aug., 1865 ; 224, Jan., 1862. d 604, 1880. e 462, T. xxvii., 177. f 461, March, 1809. 588 AVULSION OF THE DIGITS. 589 after the loss of the 1st. For several months a woman had suffered from an ulcer of the middle finger of the right hand, in consequence of a whitloAv ; there Avas loss of the 3d phalanx, and the Avhole of the articular surface and part of the compact bony structure of the 2d. On examining the sore, Ormancey saAV a bony sequestrum Avhich appeared to keep it open. He extracted this, and, until cicatrization Avas complete, he dressed the stump Avith saturnine cerate. Some months afterward Ormancey saAV with astonishment that the nail had been reproduced; instead of folloAving the ordinary direc- tion, hoAvever, it lay directly over the face of the stump, groAving from the back toAvard the palmar aspect of the stump digit, as if to cover and protect the stump. Blandin has observed a case of the same descriptions A third occurred at the Hopital de la Charite, in a Avoman, who, in consequence of a AvhitloAV, had lost the Avhole of the 3d phalanx of one of the forefingers. The soft and fleshy cushion AA'hich here coA'ered the 2d phalanx Avas termin- ated by a small, blackish nail, like a grain of spur rye. It is probable that in these cases the soft parts of the 3d phalanx, and especially the ungual matrix, had not been Avholly destroyed. In his lectures Chevalier speaks of analogous cases. In some instances avulsion of a finger is effected in a peculiar manner. In 1886 Anehe reported to his confreres in Bordeaux a rare accident of this nature that occurred to a carpenter. The man's finger aahs caught betAveen a rope and the block of a pulley. By a sudden and violent move- ment on his part he disengaged the hand but left the 3d finger attached to the pulley. At first examination the AA'ound looked like that of an ordinary amputation by the usual oval incision ; from the center of the AA'ound the proximal fragment of the 1st phalanx projected. Polaillonb has collected 42 similar instances, in none of Avhich, hoAA'ever, Avas the sev- erance complete. It occasionally happens that in avulsion of the finger an entire tendon is stripped up and torn off Avith the detached member. Yogelc describes an instance of this nature, in Avhich the long flexor of the thumb Avas torn off with that digit. In the Surgical Museum at Edinburgh there is preseiwed a thumb and part of the flexor longus pollicis attached, Avhich were avulsed simultane- ously. Nunnely d has seen the little finger together Avith the tendon and body of the longer flexor muscle avulsed by machinery. Stonee details the description of the case of a boy named Lowry, avIiosc left thumb Avas caught between rapidly twisting strands of a rope, and the last phalanx, the neigh- boring soft parts, and also the entire tendon of the flexor longus pollicis Avere instantly torn aAvay. There AAas included even the tendinous portion of that small slip of muscle taking its origin from the anterior aspect of the head and upper portion of the ulna, and Avhich is so delicate and insignificant as to a " Anatomie Topographique," p. 558, Paris. b Quoted 476, 1886, ii., 641. c Med.-Chir. Beobachtungen, 353. <* 779, 1859. e 124, 1854. 590 SURGICAL ANOMALIES OF THE EXTREMITIES. be generally overlooked by anatomists. There Avas great pain along the course of the tract of abstraction of the tendon. Pinkertona describes a carter of thirty-one Avho Avas bitten on the thumb by a donkey. The man pulled violently in one direction, and the donkev, Avho had seized the thumb firmly AA'ith his teeth, pulled forcibly in the other direction until the tissues gave way and the man ran off, leaving his thumb in the donkey's mouth. The animal at once dropped the thumb, and it was picked up by a companion Avho accompanied the man to the hospital. On examination the detached portion Avas found to include the terminal phalanx of the thumb, together with the tendon of the flexor longus pollicis measuring ten inches, about half of which length had a fringe of muscular tissue hanging from the free borders, indicating the extent and the penniforni arrangement of the fibers attached to it. Meyer b cites a case in Avhich the index finger avus torn off and the flexor muscle tAvisted from its origin. The authors know of an unreported case in Avhich a man running in the street touched his hand to a hitching block he Avas passing ; a ring on one of his fingers caught in the hook of the block, and tore off the finger Avith the attached tendon and muscle. There is a similar instance of a Scotch gentleman Avho slipped, and, to prevent falling, he put out his hand to catch the railing. A ring on one of his fingers became entangled in the railing and the force of the fall tore off the soft parts of the finger together Avith the ring. The older Avriters mentioned as a curious fact that avulsion of the arm, unaccompanied by hemorrhage, had been noticed. Belchier,629 Carmichael, '-M and doughc report instances of this nature, and, in the latter case, the progress of healing Avas unaccompanied by any uncomfortable symptoms. In the last century Hunczoysky observed complete avulsion of the arm by a cannon-ball, Avithout the slightest hemorrhage. The Ephemerides contains an account of the avulsion of the hand Avithout any bleeding, and Woolcombd has observed a huge AA'ound of the arm from Avhich hemorrhage Avas similarly absent. Later obsen'ations have shoAvn that in this accident absence of hem- orrhage is the rule and not the exception. The Avound is generally lacerated and contused and the mouths of the vessels do not gape, but are tAvisted and crushed. The skin usually separates at the highest point and the muscles protrude, appearing to be tightly embraced and almost strangulated by the skin, and also by the tendons, \ressels, and nerves Avhich, crushed and tAvisted Avith the fragments of bone, form a conical stump. Cheselden reports the history of a case, Avhich has since become classic, that he observed in St. Thomas' Hospital in London, in 1837. A miller had carelessly throAvn a slip- knot of rope about his Avrist, Avhich became caught in a revolving cog, draAV- ing him from the ground and violently throwing his body against a beam. The force exerted by the cog drawing on the rope AA'as sufficient to avulse his Avhole arm and shoulder-blade. There Avas comparatively little hemorrhage a 381, 1887, 43. b 701, 1879. c 564, iii. d 629, lx. AVULSION OF THE ARM. 591 and the man Avas insensible to pain; being so dazed and surprised he really Avas unconscious of the nature of his injury until he suav his arm in the Avheel. According to Billroth the avulsion of an arm is usually folloAved by fatal shock. Fischer, however, relates the case of a lion-tamer Avhose Avhole left arm Avas torn from the shoulder by a lion ; the loss of blood being very slight and the patient so little affected by shock that he AA'as able to Avalk to the hospital. Musseya describes a boy of sixteen who had his left arm and shoulder- blade completely torn from his body by machinery. The patient became so involved in the bands that his body Avas securely fastened to a drum, while his legs hung dangling. In this position he made about 15 revolutions around the drum before the motion of the machinery could be effectually stopped by cutting off the AA'ater to the great Avheel. When he Avas disentan- gled from the bands and taken doAvn from the drum a huge Avound was seen at the shoulder, but there AA'as not more than a pint of blood lost. The collar- bone projected from the Avound about half an inch, and hanging from the Avound Avere two large nerves (probably the median and ulnar) more than 20 inches long. He Avas able to stand on his feet and actually Avalked a feAV steps ; as his frock Avas opened, his arm, with a clot of blood, dropped to the floor. This boy made an excellent recovery. The space betAveen the plastered ceil- ing and the drum in Avhich the revolutions of the body had taken place Avas scarcely 7} inches Avide. Horsbeck's case Avas of a negro of thirty-five Avho, while pounding resin on a 12-inch leather band, had his hand caught betAveen the Avheel and band. His hand, forearm, arm, etc., Avere rapidly dniAvn in, and he Avas carried around until his shoulder came to a large beam, Avhere the body Avas stopped by resistance against the beam, fell to the floor, and the arm and scapula Avere completely avulsed and carried on beyond the beam. In this case, also, the man experienced little pain, and there Avas comparatively little hemorrhage. Maclcanb reports the history of an accident to a man of tAventy-threc Avho had both arms caught betAveen a belt and the shaft AA'hile Avorking in a Avoolen factory, and Avhile the machinery Avas in full operation. He Avas carried around the shaft AA'ith great A'elocitv until his arms avc re torn off at a point about four inches beloAv the shoulder-joint on each side. The patient landed on his feet, the blood spurting from each brachial artery in a large stream. His felloAV-Avorkmen, Avithout delay, Avound a piece of rope around each bleeding member, and the man recoA'ered after primary amputa- tion of each stump. Will0 gives an excellent instance of aA'ulsion of the right arm and scapula in a girl of eighteen, who Avas caught in flax-spinning ma- chinery. The axillary artery AAas seen lying in the Avound, pulsating feebly, but had been efficiently closed by the torsion of the machinery. The girl re- covered. Additional eases of avulsion of .the upper extremity are reported by il 124, 1837, xxi., 385. b ,;;>;_>, issO. c ±>a, 1884. i., 1135. 592 SURGICAL ANOMALIES OF THE EXTREMITIES. Aubinais,8 Bleynie,b Charles,0 Oeorge,'1 James,e Jones/ Marcano,* Bcl- chier,575 BraitliAvaite,h and Hendry.' Avulsion of the Lower Extremity.—The symptoms following avulsion of the upper extremity are seen as Avell in similar accidents to the log and thigh, although the latter are possibly the more fatal. Horlbeekj quotes Benomont's description of a small boy avIio had his leg torn off at the knee by a carriage in motion; the child experienced no pain, and Avas more concerned about the punishment he expected to receive at home for disobedi- ence than about the loss of his leg. Carter k speaks of a boy of tAvelve Avho incautiously put the great toe of his left foot against a pinion Avheel of a mill in motion. The toe avus fastened and drawn into the mill, the leg fol- loAving almost to the thigh. The Avhole left leg and thigh, together Avith the left side of the scrotum, Avere torn off; the boy died as a result of his injuries. Aslihurst reported to the Pathological Society of Philadelphia the case of a child of nine avIio had its right leg caught in the spokes of a carriage Avheel. The child was picked up unconscious, with its thigh entirely severed, and the bone broken off about the middle third ; about three inches higher the muscles were torn from the sheaths and appeared as if cut Avith a knife. The great sciatic nerve avus found hanging 15 inches from the stump, having gh'en Avay from its division in the popliteal space. The child died in tweh'e hours. One of the most interesting features of the case AA'as the rapid cooling of the body after the accident and prolongation of the coolness Avith slight variations until death ensued. Aslihurst remarks that Avhile the cutaneous surface of the stump avus acutely sensitive to the touch, there Avas no manifestation of pain evinced upon handling the exposed nerve. With reference to injuries to the sciatic nerve, Kiister1 mentions the case of a strong man of thirty, avIio in Avalking slipped and fell on his back. Immediately after rising to his feet he felt seAere pain in the right leg and numbness in the foot. He avus unable to stand, and AA'as carried to his house, Avhere Kiister found him suffering great pain. The diagnosis had been fracture of the neck of the femur, but as there was no crepitation and passive movements caused but little pain, Kiister suspected rupture of the sciatic nerve. The subsequent history of the case confirmed this diagnosis. The patient Avas confined to bed six Aveeks, and it Avas five months afterAvard before he Avas able to go about, and then only Avith a crutch and a stick. Parkm mentions an instance of rupture of the sciatic nerA'e caused by a patient giving a violent lurch during an operation at the hip-joint. The instances occasionally observed of recovery of an injured leg after a Soc. Acad. Loire inf., 1862. b 673, 1867-8, i., 11. c 476, 1-72. i., 216. d 315, 1879, xxxix., 69. e 180, 186S, xiii., 117. f 224, 1870, i., 545. g242, 1875, 228. b 490, 1832. i 299, 1875. J 264, 1859, 433. *528, 1792, ii., 17. 1 199, March 26, 18s;;. m 450, 1884, 323. RUPTURE OF THE QUADRICEPS TENDON. 593 extensive severance and loss of substance are most marvelous. Mortona mentions a boy of sixteen, Avho Avas struck by one of the blades of a reaping machine, and had his left leg cut through about 11 inches above the ankle- joint. The foot Avas hanging by the portion of skin corresponding to the posterior quarter of the circumference of the leg, together Avith the posterior tibial vessels and nerves. These Avere the only structures escaping division, although the ankle-joint itself Avas intact. There Avas comparatively little hemorrhage and no shock ; a ligature avus applied to the A'essels, the edges of the Avound were drawn together by Avire sutures, and the cut surfaces of the tibia were placed in as good apposition as possible, although the loAver frag- ment projected slightly in front of the upper. The Avound avus dressed and healing progressed favorably ; in three months the Avound had filled up to such an extent that the man was alloAved to go on crutches. The patient Avas discharged in five months, able to Avalk very well, but OAving to the loss of the function of the extensor tendons the toes dragged. Washington'' reports in full the case of a boy of eleven, Avho, in handing a foAvling piece across a ditch, Avas accidentally shot. The contents of the gun were discharged through the leg above the ankle, carrying away five-sixths of the structure—at the time of the explosion the muzzle of the gun was only tAvo feet away from his leg. The portions removed Avere more than one inch of the tibia and fibula (irregular fractures of the ends above and beloAv), a cor- responding portion of the posterior tibial muscle, and the long flexors of the great and small toes, as Avell as the tissue interposed betAveen them and the Achilles tendon. The anterior tibial artery avus fortunately uninjured. The remaining portions consisted of a strip of skin Iavo inches in breadth in front of the Avound, the muscles which it covered back of the Avound, the Achilles tendon, and another piece of skin, barely enough to cover the tendon. The Avound Avas treated by a bran-dressing, and the limb Avas saved AA'ith a shorten- ing of but 1| inches. There are several anomalous injuries Avhich deserve mention. Markoe c observed a patient of seventy-tAvo, Avho ruptured both the quadriceps tendons of each patella by slipping on a piece of ice, one tendon first giA'ing Avay, and folloAved almost immediately by the other. There Avas the usual depres- sion immediately above the upper margin of the patella, and the other dis- tinctive signs of the accident. In three months both tendons had united to such an extent that the patient Avas able to Avalk sIoavIv. Gibneyd records a case in AA'hich the issue Avas not so successful, his patient being a man avIio, in a fall ten years prcA'iously, had ruptured the right quadriceps tendon, and four years later had suffered the same accident on the opposite side. As a result of his injuries, at the time (ribney saw him, he had completely lost all poAver of extending the knee-joint. Partridge6 mentions an instance, in a a 476, 1873. b 124, 1877, i., 332. c 597, 1884. d 597, Dec. 29, 1884. e 54s. 1868, i., 175. 38 594 SURGICAL ANOMALIES OF THE EXTREMITIES. strong and healthy man, of rupture of the tendon of the left triceps cubiti caused by a fall on the pavement. There are numerous eases in which the tendo Achillis has recoA'ered after rupture,—in fact, it is unhesitatingly severed Avhen necessity demands it, sufficient union ah\'ays being anticipated. None of these cases of rupture of the tendon are unique, parallel instance- ex- isting in medical literature in abundance. Marshalla had under his observation a case in Avhich the femoral artery Avas. ruptured by a cart-Avheel passing over the thigh, and death ensued although there Avere scarcely any external signs of contusion and positively no fracture. BoerhaaA'c cites a curious instance in Avhich a surgeon attempted to stop hemorrhage from a Avounded radial artery by the application of a caus- tic, but the material applied made such inroads as to destroy the median artery and thus brought about a fatal hemorrhage. Spontaneous fractures are occasionally seen, but generally in advanced age, although muscular action may be the cause. There are several cases on record in Avhich the muscular exertion in throAving a stone or ball, or in vio- lently kicking the leg, has fractured one or both of the bones of an extremity. In old persons intracapsular fracture may be caused by such a trivial thing as turning in bed, and even a sudden tAvist of the ankle has been sufficient to produce this injury. In a boy of thirteen Storrsb has reported fracture of the femur Avithin the acetabulum. In addition to the causes enumerated, inflam- mation of osseous tissue, or osteoid carcinoma, has been found at the seat of a spontaneous fracture. One of the most interesting subjects in the history of surgery is the gradual evolution of the rational treatment of dislocations. Possibly no por- tion of the whole science Avas so backAvard as this. Thirty-five centuries ago Darius, son of Hydaspis, suffered a simple luxation of the foot; it Avas not diagnosed in this land of Apis and of the deified discoverer of medicine. Among the Avise men of Egypt, then in her acme of civilization, there Avas not one to reduce the simple luxation Avhich any student of the present day Avould easily diagnose and successfully treat. Throughout the dark ages and doAvn to the present century, the hideous and unnecessary apparatus employed, each decade bringing forth neAV types, is abundantly pictured in the older books on surgery ; in some almost recent Avorks there are pictures of Avindlasses and of individuals making superhuman efforts to pull the luxated member back—all of Avhich Avere given to the student as advisable means of treatment. Relative to anomalous dislocations the field is too large to be discussed here, but there are tAvo recent ones worthy of mention. Bradley c relates an instance of death folloAving a subluxation of the right humerus backAvard on the scapula. It could not be reduced because the tendon of the biceps lay betAveen the head of the humerus and a piece of the bone Avhich Avas chipped off. a 224, 1870, ii., 116. b 656, 1843. c 224, ls77, i., 544. C ONGENITA L DISL 0 CA TIONS. 595 Baxter-Tyriea reports a dislocation of the shoulder-joint, of unusual origin, in a man AA'ho Avas riding a horse that ran aAvay up a steep hill. After going a feAV hundred yards the animal abated its speed, Avhen the rider raised his hand to strike. Catching sight of the whip, the horse sprang fonvard, while the man felt an acute pain and a sense of something haA'ing given Avav at his shoulder. He did not fall off, but rode a little further and AA'as helped to dismount. On examination a subcoracoid dislocation of the head of the humerus Avas found. The explanation is that as the Aveight of the Avhip AA'as inconsiderable (four ounces) the inertia of the arm converted it into a leATer of the first order. Instead of fulfilling its normal function of preA'enting dis- placement, the coraco-acro- mial arch acted as a fulcrum. The limb from the fingers to that point acted as the " long arm," and the head and part of the neck of the humerus served as the " short arm." The inertia of the arm, left behind as it Avere, supplied the poAver, Avhile the ruptured capsular ligament and displacement of the head of the bone Avould represent the Avork done. Congenital Disloca- tions.—The extent and ac- curacy of the knoAvledge pos- sessed by Hippocrates on the subject of congenital disloca- tions have excited the admir- ation of modern Avriters, and until a comparath'ely recent time examples of certain of the luxations described by him had not been recorded. With regard, for instance, to congenital dislocations at the shoulder- joint, little or nothing avus known save Avhat Avas contained in the Avritings of Hippocrates, till K. M. Smith and Guerin discussed the lesion in their works. Among congenital dislocations, those of the hips are most common—in fact, 90 per cent, of all. They are sometimes not recognizable until after the lapse of months and sometimes for years, but their causes—faulty develop- ments of the joint, paralysis, etc.—are supposed to have existed at birth. One or both joints may be involved, and according to the amount of involvement the gait is peculiar. As to the reduction of such a dislocation, the most that a 476, No. 3767, 1165. Fig. 210.—Case of congenital luxation of the femora (Hirst). 596 SURGICAL ANOMALIES OF THE EXTREMITIES. can be done is to diminish the deformity and functional disability by traction and palliative measures Avith apparatus. The normal structure of the joint does not exist, and therefore the dislocation admits of no reduction. Congenital dislocations of the shoulder are also seen, oAving to faulty development of the glenoid fossa ; and at the knee, the leg generally being in extreme hyperexten- sion, the foot sometimes resting on the abdomen. Congenital luxation of the femora, when it appears in adult Avomen (Fig. 210) is a prominent factor in dystocia. There is a dislocation found at birth, or occurring shortly after, due to dropsy of the joint in utero ; and another form due to succeeding paralysis of groups of muscles about the joint. The interesting instances of major amputations are so numerous and so Avell knoAvn as to need no comment here. Amputation of the hip with re- covery is fast becoming an ordinary operation ; at Westminster Hospital in London, there is preserved the right humerus and scapula, presenting an enor- mous bulk, which was removed by amputation at the shoulder-joint, for a large lymphosarcoma groAving just above the claA'icle. The patient Avas a man of twenty-two, and made a good recovery. Another similar preparation is to be seen in London at St. Bartholomew's Hospital. Simultaneous, synchronous, or consecutive amputations of all the limbs have been repeatedly performed. Champenois'1 reports the case of a Sumatra boy of seven, Avho Avas injured to such an extent by an explosion as to necessitate the amputation of all his extremities, and, despite his tender age and the extent of his injuries, the boy completely recovered. Jack- son, quoted by Ashhurst,b had a patient from whom he simultaneously ampu- tated all four limbs for frost-bite. Midlerc reports a case of amputation of all four limbs for frost-bite, with recovery. The patient, aged twenty-six, while traveling to his home in Northern Minnesota, Avas overtaken by a severe snow storm, Avhich con- tinued for three days; on December 13th he was obliged to leave the stage in a snoAv-drift on the prairie, about 110 miles distant from his destination. He wandered over the prairie that day and night, and the following four days, through the storm, freezing his limbs, nose, ears, and cheeks, taking no food or Avater until, on December 16th, he was found in a dying condi- tion by Indian scouts, and taken to a station-house on the road. He did not reach the hospital at Fort Kidgely until the night of December 24th—eleven days after his first exposure. He was almost completely exhausted, and, after thaAving the ice from his clothes, stockings, and boots,—Avhich had not been removed since December 13th,—it Avas found that both hands and forearms Avere completely mortified up to the middle third, and both feet and legs as far as the upper third ; both knees over and around the patellae, and the alse and tip of the nose all presented a dark bluish appearance and fairly circumscribed SAvelling. No evacuation of the boAvels had taken place for over tAvo Aveeks, a 662, 1869, 507. b i74) 107. c 847, 216. MULTIPLE AMPUTATIONS. 597 and as the patient suffered from singultus and constant pain over the epigastric region, a light cathartic Avas given, Avhich, in tAventy-four hours, gave relief. The four frozen limbs were enveloped in a solution of zinc chlorid. The frozen ears and cheeks healed in due time, and the gangrenous parts of the nose separated and soon healed, Avith the loss of the tip and parts of the alee, leaving the septum somewhat exposed. On January 10th the lines of demar- cation Avere distinct and deep on all four limbs, though the patient, seconded by his Avife, at first obstinately opposed operative interference ; on January 13th, after a little hesitancy, the man consented to an amputation of the arms. This was successfully carried out on both forearms, at the middle third, the patient losing hardly any blood and complaining of little pain. The great relief afforded by this operation so changed his aA'ersion to being operated upon that on the next day he begged to have both legs amputated in the same manner, Avhich Avas done, three days afterward, Avith the same favorable result. After some minor complications the patient left for his home, perfectly recov- ered, June 9, 1866. Begg of Dundeea successfully performed quadruple amputation on a Avoman, the victim of idiopathic gangrene. With artificial limbs she Avas able to earn a livelihood by selling fancy articles which she made herself. Phis woman died in 1885, and the four limbs, mounted on a lay figure, were placed in the Royal College of Surgeons, in London. Wallace, of Pock Rapids, IoAva, has successfully removed both forearms, one leg, and half of the remaining foot, for frost-bite. Allen b describes the case of a boy of eight who Avas run OA'er by a locomotive, crushing his right leg, left foot, and left forearm to such an extent as to necessitate primary triple amputation at the left elboAV, left foot, and right leg, the boy recovering. Ashhurst remarks that Luckie, Alexander, Koehler, Lowman, and Armstrong have successfully removed both legs and one arm simultaneously for frost-bite, all the patients making excellent recoveries in spite of their mutilations ; he adds that he himself has successfully resorted to synchronous amputation of the right hip- joint and left leg for a railroad injury occurring in a lad of fifteen, and has tAvice synchronously amputated three limbs from the same patient, one case recovering. Wharton c reports a case of triple major amputation on a negro of tAventy- one, AA'ho Avas run over by a train (Fig. 211). His right leg Avas crushed at the knee, and the left leg crushed and torn off in the middle third; the right forearm and hand Avere crushed. In order to avoid chill and exposure, he AAas operated on in his old clothes, and Avhile one limb Avas being amputated the other AA'as being prepared. The most injured member Avas removed first. IveeoA'ery Avas uninterrupted. There are tAvo cases of spontaneous amputation Avorthy of record. Boerhaavc mentions a peasant near Leyden, AA'hose axillary artery Avas divided a 224, 1HS6, i., 81. b 476, 1889, i., 730. c 533, March 31, 1894. 598 SURGICAL ANOMALIES OF THE EXTREMITIES. Avith a knife, causing great effusion of blood, and the patient fainted. The mouth of the vessel was retracted -•> Fig. 211.—Synchronous triple amputation (AA'harton). far as to render ligature impossible, and the poor man Avas abandoned to Avhat Avas considered an inevitable fate by his unenlightened attendants. Expecting to die every moment, he continued seAeral days in a languid state, but the hemorrhage ceased spontaneously, and the arm decayed, shrunk, and dried into a mummified stump, Avhich he carried about for quite a Avhile. hooker a speaks of a fracture of the forearm, near the loAver part of the middle third, in a patient aged fourteen. Incipient gangrene beloAv the seat of fracture, Avith associate inflammation, devel- oped ; but on account of the increas- ing gangrene it Avas determined to amputate. On the fifth day the line of demarcation extended to the spine of the scapula, laying bare the bone and expos- ing the acromion process and im'olving the pec- toral muscles. It Avas again decided to let Nature continue her Avork. The bones exfoliated, the spine and the acromial end of the scapula came away, and a good stump Avas formed. Figure 212 represents the patient at the age of tAventy-eight. By ingenious mechanical contrivances persons avIio have lost an extremity are enabled to per- form the ordinary functions of the missing mem- ber Avith but slight deterioration. Artificial arms, hands, and legs have been developed to such a degree of perfection that the modern mechanisms of this nature are very unlike the cumbersome and intricate contrivances formerly used. Le Progres Medical b contains an interesting account of a curious contest held betAveen dis- membered athletes at Nogcnt-Sur-Marne, a small toAvn in the Department of the Seine, in France. Responding t< > a general a 133, 1879, xx., 210. b Quoted* 476, 1895, ii., 220. Fig. 212.—Spontaneous amputation at the shoulder (Rooker). DISMEMBERED ATHLETES. 599 invitation, no less than seven individuals avIio had lost either leg or thigh, com- peted in running races for prizes. The enterprising- cripples AA'ere divided into tAvo classes : the cuismrd*, or those who had lost a thigh, and jambards, or those avIio had lost a leg ; and, contrary to Avhat might have been expected, the grand champion came from the former class. The distance in each race was 200 meters. M. Roullin, Avhose thigh, in consequence of an accident, Avas amputated in 1887, succeeded in traversing the course in the remarkable time of thirty seconds (about 219 yards); whereas M. Florrant, the speediest jambard, required thirty-six seconds to run the same distance; and Avas, moreover, defeated by two other cuissards besides the champion. The junior race Avas Avon in thirty-five seconds, and this curious day's sport Avas ended by a course de consolation, Avhich Avas carried off in thirty-three seconds by M. Mausire, but Avhether he AA'as a cuissard or a jambard Avas not stated. On seA'eral occasions in England, cricket matches haA'e been organized betAA'een armless and legless men. In Charles Dickens' paper, "All the Year Round," October 5, 1861, there is a reference to a cricket match betAA'een a one-armed elcA'en and a one-legged eleA'en. There is a recent report from De Kalb, Illinois, of a boy of thirteen avIio had lost both legs and one arm, but avIio AA'as neA'ortheless enabled to ride a bicycle specially constructed for him by a neighboring manufacturer. With one hand he guided the handle bar, and bars of steel attached to his stumps serA'ed as legs. He experienced no trouble in balancing the wheel; it is said that he has learned to dismount, and soon expects to be able to mount alone ; although riding only three Aveeks, he has been able to traverse one-half a mile in two minutes and ten seconds. While the foregoing instance is an exception, it is not extraordinary in the present day to see persons Avith artificial limbs riding bicycles, and e\'en in Philadelphia, May 30, 1896, there Avas a special bicycle race for one- legged contestants. The instances of interesting cases of foreign bodies in the extremities are not numerous. In some cases the foreign body is tolerated many years in this location. There are to-day many veterans AA'ho have bullets in their extremities. Girdwooda speaks of the removal of a foreign body after tAventy-five vears' presence in the forearm. Pike b mentions a man in India, avIio, at the age of tAventy-tAA'O, after killing a Avounded hare in the usual manner by striking it on the back of the neck Avith the side of the hand, noticed a slight cut on the hand AA'hich soon healed but left a lump under the skin. It gave him no trouble until tAvo months before the time of report, when he asked to have the lump removed, thinking it Avas a stone. It Avas cut down upon and removed, and proved to be the spinous process of the vertebra of a hare. The bone Avas living and healthy and had formed a sort of arthrodial joint on the base of the phalanx of the little finger and had remained in this position for nearly tAventy-two years. a 251, 1866. b 224, 1889, ii., 1331. 600 SURGICAL ANOMALIES OF THE EXTREMITIES Whitea has described a case in AA'hich a nail broken off* in the foot, separated into 26 splinters, Avhich, after intense suffering, Avere successfully removed. There avus a case recently reported of a man admitted to the Bcllevue Hospital, Ncav York, avIiosc arm Avas supposed to have been frac- tured by an explosion, but instead of Avhich II feet of lead wire were found in it by the surgeons. The man Avas a machinist in the employ of the hast River Lead Co., and had charge of a machine Avhich converted molten lead into Avire. This machine consists of a steel box into Avhich the lead is forced, being pressed through an aperture | inch in diameter by hydraulic pressure of 600 tons. Reaching the air, the lead becomes hard and is Avound on a large Avheel in the form of Avire. Just before the accident this small aperture had become clogged, and the patient seized the projecting Avire in his hand, intending to free the action of the machine, as he had previously done on many occasions, bv a sharp, strong pull ; but in so doing an explosion occurred, and be AA-as hurled to the floor unconscious. While on the Avay to the hospital in the ambulance, he became conscious and complained of but little pain except soreness of the left arm about the elboAv. The SAvelling, AA'hich had developed very rapidly, made it impossible for the surgeons to make an examination, but on the folloAving day, Avhen the inflammation had subsided sufficiently, a diagnosis of fracture of the bones of the arm AA'as made. There Avas no ex- ternal injury of the skin of any magnitude', and the surgeons decided to cut doAvn on the trifling contusion, and remove what appeared to be a fragment of bone, lodged slightly above the Avrist. An anesthetic Avas administered, and an incision made, but to the amazement of the operators, instead of bone, a piece of Avire one inch in length and | inch in diameter Avas remoA'ed. On further exploration piece after piece of the wire Avas taken out until finally the total length thus removed aggregated 11 feet, the longest piece measuring tAvo feet and the shortest \ inch. The wire was found imbedded under the mus- cles of the arm, and some of it had become Avcdgcd betAveen the bones of the forearm. Probably the most remarkable feature of this curious accident Avas the fact that there Avas no fracture or injury to the bone, and it was thought possible that the function of the arm Avould be but little impaired. Touseyb reports a case of foreign body in the axilla that Avas taken for a necrotic fragment of the clavicle. The patient Avas a boy of sixteen, who climbed up a lamp-post to get a light for his bicycle lamp ; his feet slipped off the ornamental ledge Avhich passed horizontally around the post about four feet from the ground, and he fell. In the fall a lead pencil in his Avaistcoat pocket caught on the ledge and Avas drh'en into the axilla, breaking off out of sight. This Avas supposed to be a piece of the chiA'icle, and was only discovered to be a pencil Avhen it Avas removed six Aveeks after. There are seAeral diseases of the bone having direct bearing on the anomalies of the extremities Avhich should have mention here. Osteomalacia a 647, 1860. b 597, Jan. 12, 1895. RA CHITIS. 601 is a disease of the bones in adult life, occurring most frequently in puerperal women, but also seen in women not in the puerperal state, and in men. It is characterized by a progressive softening of the bone-substance, from a gradual absorption of the lime-salts, and gives rise to considerable deformity, and occa- sionally to spontaneous fracture. Rachitis or rickets is not a disease of adult life, but of infancy and child- hood, and never occurs after the age of puberty. It seldom begins before six months or after three years. There are several theories as to its causation, one being that it is due to an ab- normal development of acids. There is little doubt that defecth'e nutrition and bad hygienic surroundings are prominent factors in its pro- duction. The principal pathologic change is seen in the epiphyseal lines of long bones and Fig. 213.—Appearance during life of the highest grade of rachitis: pseudoosteonialacia (Pippingskjold). Fig. 214. —Extreme deformity of skele- ton due to rickets, showing enlargement of the ends of the bones (Sp. 1545, Warren Museum). beneath the periosteum. Figure 21o sIioavs the appearance during life of a patient Avith the highest grade of rachitis, and it can be easily understood Avhat a barrier to natural child-birth it would produce. In rachitis epiphyseal sAvellings are seen at the Avrists and ankle-joints, and in superior cases at the ends of the phalanges of the fingers and toes. When the shaft of a long bone is affected, not only deformity, but even fracture may occur. lTnder these circumstances the humerus and femur appear to be the bones 602 SURGICAL ANOMALIES OF THE EXTREMITIES. most likely to break ; there is an associate deformity of the head, knoAvn as '•' eraniotabes," together with pigeon-breast and A'arious spinal curvature. The accompanying illustration (Fig. 214) is from a dniAving of a skeleton in the Warren Museum in Boston. The subject Avas an Indian, twenty-one years of age, one of the Six Nations. His mode of locomotion Avas by a large wooden boAvl, in Avhich he sat and moved forward by advancing first one side of the boAvl and then the other, by means of his hands. The nodules or " adventitious joints" Avere the result of imperfect ossification, or, in other Avords, of motion before ossification Avas completed. Fig. 215.—Two adult cases of achondroplasia (Thomson). Analogous to rachitis is achondroplasia, or the so-called fetal rickets—a disease in AA'hich deformity results from an arrest, absence, or perversion of the normal process of enchondral ossification. It is decidedly an intrauterine affec- tion, and the great majority of fetuses die in utero. Thomson a reports three living cases of achondroplasia. The first Avas a child fh'e months of age, of pale complexion, bright and intelligent, its head measuring 2'A inches in length. There Avas a narrow thorax shoAving the distinct beads of rickets ; the upper and loAver limbs Avere A'ery short, but improA'ed under antirachitic a 318, June, 1893. DEFORMED JOINTS. 603 treatment. The child died of pneumonia. The other hvo cases (Fig. 215) Avere in adults, one thirty-nine and the other thirty-six. The men Avere the same height, 49 inches, and resembled each other in all particulars. Thev both enjoyed good health, and, though someAvhat dwarfed, were of consider- able intelligence. Neither had married. Both the upper and loAver limbs shoAved exaggerations of the normal curves ; the hands and feet Avere broad and short; the gait of both of these little men Avas Avaddling, the trunk sAvaving Avhen they attempted to make any rapid progress. Osteitis deformans is a hyperplasia of bone described by Paget in 1856. Paget's patient Avas a gentleman of forty-six avIio had always enjoyed good health ; Avithout assignable cause he began to be subject to aching pains in the thighs and legs. The bones of the left leg began to increase in size, and a year or tAvo later the left femur also enlarged considerably. During a period of tAventy years these changes were folloAved by a growth of other 1 tones. The spine became firm and rigid, the head increased 5^ inches in circumference. The bones of the face were not affected. When standing, the patient had a peculiar boAved condition of the legs, AA'ith marked flexure at the knees. He finally died of osteosarcoma, originating in the left radius. Paget collected eight cases, five of Avhom died of malignant disease. The postmortem of Paget's case showed extreme thickening in the bones affected, the femur and cranium particularly shoAving osteosclerosis. Several cases have been recorded in this country ; according to Warren, Thieberge analyzed 4;> eases ; 21 Avere men, 22 Avomen ; the disease appeared usually after forty. Acromegaly is distinguished from osteitis deformans in that it is limited to hypertrophy of the hands, feet, and face, and it usually begins earlier. In gigantism the so-called "giant growth of bones" is often congenital in character, and is unaccompanied by inflammatory symptoms. The deformities of the articulations may be congenital but in most cases are acquired. When these are of extreme degree, locomotion is effected in most curious Avays. Ankylosis at unnatural angles and even complete reversion of the joints has been noticed. Par6 gives a case of reA'ersion, and of crooked hands and feet; and BarloAva speaks of a child of two and three- quarter years Avith kyphosis, but mobility of the lumbar region, AA'hich Avalked on its elboAvs and knees. The pathology of this deformity is obscure, but there might have been malposition in utero. Wilson presented a similar ease before the Clinical Society of London, in 18S8. The "Camel-boy," exhibited some years ago throughout the United States, had reA'ersion of the joints, Avhich resembled those of quadrupeds. He Avalked on all fours, the mode of progression resembling that of a camel. Figure 216 represents Orloff, " the transparent man," an exhibitionist, sIioav- ing curious deformity of the long bones and atrophy of the extremities. He derived his name from the remarkable transparency of his deformed members a 476, 1890, ii. 604 SURGICAL ANOMALIES OF THE EXTREMITIES. to electric light, due to porosity of the bones and deficiency of the overlying tissues. Figure 217, taken from Hutchinson's " Archives of Surgery," a represents an extreme case of deformity of the knee- joints in a boy of seven, the result of severe osteoarthritis. The knees and elboAvs Avere completely ankvlosed. Fig. 216.—Extreme deformity of the bones and joint* Fig. 217.—Deformed knee-joints from severe osteoarthritis (Hutchinson). Infantile spinal paralysis is often the cause of distressing deformities, forbidding locomotion in the ordinary manner. In a paper on the surgical ___________________________________ and mechanical treatment tof such deformities Wil- "v. lardb mentions a boy of \ * ^^^ fourteen, the victim of in- fantile paralysis, AA'ho at the age of eleven had never Avalked, but dragged his legs along (Fig. 218). 11 is legs Avere greatly tAvisted, and there Avas flexion at right angles at the hips and knees. There Avas equinoA'arus in the left foot and equinoA'algus in the right. By an operation of ubcutaneons section at the hips, knees, and feet, Avith application of plaster- a Vol. v., 82. b 124, May, 1891. Fig. 218.—Distortion of the joints from infantile spinal paralysis (Willard). ANOMALOUS GROWTH OF LONG RONES. 605 of-Paris and extension, this hopeless cripple Avalked Avith crutches in tAvo months, and Avith an apparatus consisting of elastic straps over the quadriceps femoris, peroneals, and Aveakened muscles, the valgus-foot being supported beneath the sole. In six months he Avas walking long distances ; in one year he moved speedily on crutches. Willard also mentions another case of a girl of eleven Avho Avas totally unable to support the body in the erect position, but could move on all fours, as shoAvn in figure 219. There was equino- varus in the right foot and valgus in the left. The left hip avus greatly distorted, not only in the direction of flexion, but there Avas also tAvisting of the femoral neck, simulating dislocation. This patient Avas also operated on in the same manner as the preceding one. Fig. 219.—Mode of locomotion in a case of deformity from infantile spinal paralysis (Willard). Relative to anomalous increase or hypertrophy of the bones of the extremities, Fischer sIioavs that an increase in the length of bone may fol- Ioav slight injuries. He mentions a boy of tAvelve, who Avas run over by a Avagon and suffered a contusion of the bones of the right leg. In the course of a year this leg became 4-J- cm. longer than the other, and the bones Avere also much thicker than in the other. Fischer also reports seA'eral cases of abnormal groAvth of bone folloAving necrosis. A case of shortening 3-f cm., after a fracture, avus reduced to one cm. by compensatory groAvth. Elonga- tion of the bone is also mentioned as the result of the inflammation of the joint. Warren also quotes Taylor's case of a lady avIio fell, injuring, but not fracturing, the thigh. Gradual enlargement, Avith an outAvard curving of the bone, afterAvard took place. CHAPTEPv XII. SURGICAL ANOMALIES OF THE THORAX AM) ABDOMEN. Injuries of the lung or bronchus are ahvays serious, but contrary to the general idea, recovery after extensive wound of the lung is quite a common occurrence. Kven the older Avriters report many instances of remarkable re- coveries from lung-injuries, despite the primitive and dirty methods of treat- ment. A revieAV of the literature previous to this century sIioavs the names of A mens, Brunner, Collomb, Fabricius Hildanus, Yogel, Rhodius, Petit, Guerin, Koler, Peters, Flebbe, and Stalpart,750 as authorities for instances of this nature. h\ one of the journals108 there is a description of a man Avho was Avounded by a broad-sAvord thrust in the mediastinum. After death it Avas found that none of the viscera avc re Avounded, and death Avas attributed to the fact that the in-rush of air counterbalancing the pressure within the lungs left them to their oavii contractile force, Avith resultant collapse, obstruc- tion to the circulation, and death. It is said that Vesalius demonstrated this condition on the thorax of a pig. Gooclr''82 gives an instance of a boy of thirteen Avho fell from the top of a barn upon the sharp proAv of a plough, inflicting an oblique Avound from the axilla to beloAv the sternum, slightly above the insertion of the diaphragm. Several ribs Avere severed, and the left thoracic cavity Avas Avholly exposed to vieAV, showing the lungs, diaphragm, and pericardium all in motion. The lungs soon became gangrenous, and in this horrible state the patient lived tAvelve days. One of the curious facts noticed by the ancient Avriters Avas the amelioration of the symptoms caused by thoracic Avounds after hemorrhage from other locations ; and naturally, in the treatment of such injuries, this circumstance Avas used in advocacy of depletion. Monro speaks of a gentle- man AA'ho AA'as Avounded in a duel, and Avho had all the symptoms of hemo- thorax ; his condition Avas immediately relieved bv the eA'acuation of a con- siderable quantity of bloody matter Avith the urine. SAvammerdam records a similar case, and Fabricius ab Aquapendente noticed a case in which the opening in the thorax showed immediate signs of improvement after the patient voided large quantities of bloodv urine. Glandorp also calIn- attention to the foregoing facts. Xicolaus Xovocomensis narrates the details of the case of one of his friends, suffering from a penetrating Avound of the 606 LOSS OF LUNG-TISSUE. 607 thorax, avIio Avas relieved and ultimately cured by a bloody evacuation Avith the stool. There is an extraordinary recovery reported a in a boy of fifteen avIio, by falling into the machinery of an elevator, Avas severely injured about the chest. There Avere six extensh'e lacerations, five through the skin about six inches long, and one through the chest about eight inches long. The .'Id, 4th, oth, and 6th ribs Avere fractured and torn apart, and about an inch of the substance of the 4th rib avus lost. SoA'eral jagged fragments were removed ; a portion of the pleura, tAvo by four inches, had been torn aAvay, exposing the pericardium and the left lung, and shoAving the former to have been penetrated and the latter torn. The lung collapsed completely, and for three or four months no air seemed to enter it, but respiration gradually returned. The lacerated integument could only be closed approximately by sutures. It is worthy of remark that, although extremely pale, the patient complained of but little pain, and exhibited only slight symptoms of shock. The pleural cavity subsequently filled AA'ith a dirty serum, but eA'en this did not interfere with the healing of the Avound and the restoration of the lung ; the patient recovered Avithout lateral curA'ature. Bartholf reports a case of rapid recovery after perforating Avound of the lung. The pistol-ball entered the back 1J inches to the right of the spinous process of the 6th dorsal vertebra, and passed upAvard and very slightly in- Avard toAvard the median line. Its track could be folloAved only 14; inches. Emphysema appeared fifteen minutes after the reception of the Avound, and soon became pronounced throughout the front and side of the neck, a little over the edge of the loAver jaAV, and on the chest tAvo inches beloAv the sternum and one inch beloAv the chwiole. In four hours respiration became very fre- quent, short, and gasping, the thoracic Avails and the abdomen scarcely mov- ing. The man continued to improA'e rapidly, the emphysema disappeared on the seventh day, and eighteen days after the reception of the avouikI he Avas discharged. There AA'as slight hemorrhage from the Avound at the time, but the clot dried and closed the AA'ound, and remained there until it Avas removed on the morning of his discharge, leaving a small, dry, Avhite cicatrix. Loss of Lung-tissue.—The old Amsterdam authority, Tulpius,842 has recorded a ease in Avhich a piece of lung of about three fingers' breadth pro- truded through a large Avound of the lung under the left nipple. This Avound received no medical attention for forty-eight hours, AA'hen the protruding por- tion of lung avus thought to be dead, and Avas ligated and cut off; it Aveighed about three ounces. In about hvo Aveeks the Avound healed Avith the lung adherent to it and this condition Avas found six years later at the necropsy of this individual. Tulpius quoted Cclsus and Hippocrates as authorities for the surgical treatment of this ease. In 1787 Bell gave an account of a case in Avhich a large portion of the lung protruded and was strangulated by the a Annual of the Universal Medical Sciences, 1892. 608 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. edges of the thoracic Avound, yet the patient made a good recovery. Fabri- cius Hildanus334 and Ruysch699 record instances of recovery in Avhich large pieces of lung ha\'e been cut off; and it is said that Avith General Wolfe at Quebec there Avas another officer avIio Avas shot through the thorax and who recoA'ered after the remoA'al of a portion of the lung. In a letter to one of his medical friends Roscius says that he succeeded in cutting off part of a pro- truding, livid, and gangrenous lung, after a penetrating Avound of the chest, Avith a successful result. Halea reports a case of a penetrating stab-Avound in Avhich a piece of lung Avas removed from a man of tAventy-five. Taitb claims that surgical treatment, as exemplified by Biondi's experi- ment in remoA'ing portions of lung from animals, such as dogs, sheep, cats, etc., is not practical ; he adds that his deductions are misleading, as the opera- tion avus done on healthy tissue and in deep and narroAV-chested animals. Excision of diseased portions of the lung has been practised by Kron- lein (three cases), Ruggi of Bologna (tAvo cases), Block, Milton, Weinleeh- ner ; one of Kronlein's patients recovered and Milton's survived four months, but the others promptly succumbed after the operation. Tuffierc is quoted as showing a patient, aged twenty-nine, upon Avhom, for beginning tubercu- losis, he had performed pneumonectomy four years before. At the operation he had removed the diseased area at the apex of the right lung, together Avith sound tissue for tAvo cm. in eA'ery direction. Tuffier stated that the result of his operation had been perfectly successful and the patient had shoAvn no sus- picious symptoms since. Rupture of the Lung Without Fracture.—It is quite possible for the lung to be ruptured by external violence Avithout fracture of the ribs ; there are several such eases on record. The mechanism of this rare and fatal form of injury has been very aptly described by Gosseiin as due to a sudden pres- sure exerted on the thoracic wall at the moment of full inspiration, there being a spasm of the glottis or obstruction of the larynx, in consequence of Avhich the lung bursts. An extravasation of air occurs, resulting in the deA'elopment of emphysema, pneumothorax, etc. Subsequently pleurisy, pneumonia, or even pus in the pleural ca\'ity often result. Hemoptysis is a possible, but not a marked symptom. The mechanism is identical AA'ith that of the bursting of an inflated paper bag Avhen struck by the hand. Other observers discard this theory of M. Gosseiin and claim that the rup- ture is due to direct pressure, as in the cases in Avhich the heart is ruptured Avithout fracture of the ribs. The theory of Gosseiin Avould not explain these cardiac ruptures from external violence on the thoracic Avails, and, therefore, Avas rejected by some. Pare, Morgagni, Portal, HeAvson Smith, Dupuytren, Laennec, and others mention this injury. Gosseiin reports two cases ter- minating in recovery. Aslihurst reports having seen three cases, all of Avhich terminated fatally before the fifth day ; he has collected the histories of 39 a 526, 1851. b 224, 1884, i., 1178. c 533, Nov. 23, 1^*5. RUPTURE OF THE LUNG WITHOUT FRACTURE. 609 cases, of which 12 recovered. Otis has collected reports of 25 cases of this form of injury from military practice exclusively. These were generally caused by a bloAV on the chest, by a piece of shell, or other like missile. Among the 25 cases there were 11 recoveries. As Ashhurst very justly remarks, this injury appears more fatal in civil than in military life. I'yle a reports a case successfully treated, as folloAvs :— " LeAvis W., ten years old, white, born in Maryland, and living now in the District of Columbia, was brought in by the Emergency Hospital ambu- lance, on the afternoon of November 10th, with a history of having been run over by a hose-cart of the District Fire Department. The boy AA'as in a state of extreme shock, having a Aveak, almost imperceptible pulse ; his respirations Avere shallow and rapid, and his temperature subnormal. There Avere no signs of external injury about his thoracic cavity and no fracture of the ribs could be detected, although carefully searched for ; there Avas marked emphy- sema ; the neck and side of the face were enormously SAVollen with the extra- vasatcd air ; the tissues of the left arm Avere greatly infiltrated Avith air, Avhich enabled us to elicit the familiar crepitus of such infiltration Avhen an attempt at the determination of the radial pulse was made. Consciousness Avas never lost. There Avere several injuries to the face and scalp; and there Avas hem- orrhage from the nose and mouth, Avliich Avas attributed to the fact that the patient had fallen on his face, striking both nose and lip. This was confirmed subsequently by the absence of any evidences of hemoptysis during the Avhole period of convalescence. The saliva was not even blood-streaked ; therefore, it can be said with verity that there Avas no hemoptysis. Shortly after admission the patient reacted to the stimulating treatment, his pulse became stronger, and all evidences of threatened collapse disappeared. He rested Avell the first night and complained of no pain, then or subsequently. The improvement AA'as continuous. The temperature remained normal until the evening of the fifth day, AA'hen it rose to 102.2°, and again, on the evening of the sixth, to 102.3°. This rise AA'as apparently Avithout significance as the patient at no time seemed disturbed by it. On the eighth day the tempera- ture again reached the normal and has since remained there. The boy is apparently well now, suffers no inconvenience, and has left the hospital, safe from danger and apparently free from any pulmonary embarrassment. He uses Avell-developed diaphragmatic breathing Avhich is fully sufficient." Pollockb reports the case of a boy of seven, Avhose lung Avas ruptured by a four-wheeled cab Avhich ran over him. He Avas discharged avcII in thirty- tAvo days. Bouilly c speaks of recovery in a boy of seventeen, after a rupture of the lung Avithout fracture. There are several other interesting cases of recovery on record. There are instances of spontaneous rupture of the lung, from severe cough. Hicks d speaks of a child of ten months suffering Avith a severe cough a 533, Feb. 24, 1894. b 700,1877-8, 246. c 368, Oct. 15, 1881. <* 490, April 22,1837,119. 39 610 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. resembling pertussis, avIiosc lung ruptured about two Aveeks after the begin- ning of the cough, causing death on the second day. Ferrari" relates a curious case of rupture of the lung from deep inspiration. Complete penetration or transfixion of the thoracic cavity is not necessarily fatal, and some marvelous instances of recovery after injuries of this nature, are recorded. Eveb remarks that General Shields Avas shot through the body by a discharge of a cannon at Cerro Gordo, and Avas given up as certain to die. The General himself thought it Avas grape-shot that traversed his chest. He showed no signs of hemoptysis, and although in great pain, Avas able to give commands after reception of the Avound. In this case, the ball had evidently entered Avithin the right nipple, had passed betAveen the lungs, through the mediastinum, emerging slightly to the right of the spine. Guthrie chas mentioned a parallel instance of a ball travers- ing the thoracic cavity, the patient completely recovering after treatment. Girard, AVeeds, Meacham, Bacon, Fryer and othersd report cases of perfo- rating gunshot Avounds of the chest Avith recovery. ScavcII e describes a case of transfixion of the chest in a youth of eighteen. After moAving and Avhile carrying his scythe home, the patient accidentally fell on the blade ; the point passed under the right axilla, between the 3d and 4th right ribs, horizontally through the chest, and came out through correspond- ing ribs of the opposite side, making a small opening. He fell to the ground and lay still until his brother came to his assistance ; the latter with great forethought and caution carefully calculated the curvature of the scythe blade, and thus regulating his direction of tension, successfully withdreAV the instru- ment. There Avas but little hemoptysis and the patient soon recovered. Cheliusf records an instance of penetration of the chest by a carriage shaft, Avith subsequent recovery. Hoyland s mentions a man of tAventy-five Avho AA'as discharging bar-iron from the hold of a ship ; in a stooping position, pre- paratory to hoisting a bundle on deck, he Avas struck by one of the bars AA'hich pinned him to the floor of the hold, penetrating the thorax, and going into the Avood of the flooring to the extent of three inches, requiring the com- bined efforts of three men to extract it. The bar had entered posteriorly betAveen the 9th and 10th ribs of the left side, and had traversed the thorax in an upward and outward direction, coming out anteriorly betAveen the 5th and 6th ribs, about an inch beloAv and slightly external to the nipple. There AA'as little constitutional disturbance, and the man AA'as soon discharged cured. BroAvn h records a case of impalement in a boy of fourteen. While running to a fire, he struck the point of the shaft of a carriage, Avhich passed through his left chest, beloAv the nipple. There was, strangely, no hemorrhage, and no symptoms of so seA'ere an injury ; the boy recovered. There is deposited in the Museum of the Royal College of Surgeons in a 659, 1855. b 744, 1848. 0 476, 1853. d 847, 27 et seq. « 124, 1849. f 265, i. 8 491, 1863, ii., 241. b Trans. Med. Soc. Pa., 1877, pt. 2, 730. MAJOR THORACIC WOUNDS. 611 London, a mast-pivot, 15 inches in length and weighing between seven and eight pounds, Avhich had passed obliquely through the body of a sailor. The specimen is accompanied by a colored picture of the sufferer himself in two positions. The name of the sailor was Taylor, and the accident occurred aboard a brig lying in the London docks. One of Taylor's mates was guid- ing the pivot of the try-sail into the main boom, Avhen a tackle gave way. The pivot instantly left the man's hand, shot through the air point doAvnward, striking Taylor above the heart, passing out lower down posteriorly, and then imbedded itself in the deck. The unfortunate subject was carried at once to the London Hospital, and notwithstanding his transfixion by so formidable an instrument, in five months Taylor had recovered sufficiently to walk, and ultimately returned to his duties as a seaman. In the same museum, near to this spike, is the portion of a shaft of the carriage which passed through the body of a gentleman who happened to be standing near the vehicle when the horse plunged violently forward, Avith the result that the off shaft penetrated his body under the left arm, and came out from under the right arm, pinning the unfortunate man to the stable door. Immediately after the accident the patient walked upstairs and got in bed ; his recovery progressed uninterruptedly, and his Avounds Avere practically healed at the end of nine Aveeks ; he is reported to have lived eleven years after this terrible accident. In the Indian Medical Gazette a there is an account of a private of thirty- five, who Avas thrown forward and off his horse while endeavoring to mount. He fell on a lance which penetrated his chest and came out through the scapula. The horse ran for about 100 yards, the man hanging on and trying to stop him. After the extraction of the lance the patient recovered. Long- more b gives an instance of complete transfixion by a lance of the right side of the chest and lung, the patient recovering. Ruddock0 mentions cases of penetrating Avounds of both lungs with recovery. There is a most remarkable instance of recovery after major thoracic wounds recorded by BrokaAV.d In a brawl, a shipping clerk receh'ed a thoracic Avound extending from the 3d rib to Avithin an inch of the navel, 13J inches long, completely severing all the muscular and cartilaginous structures, including the cartilages of the ribs from the 4th to the 9th, and Avounding the pleura and lung. In addition there Avas an abdominal wound 6 J inches long, extending from the naA'el to about two inches above Poupart's ligament, causing almost complete intestinal evisceration. The lung was partially collapsed. The cartilages Avere ligated with heavy silk, and the hemorrhage checked by ligature and by packing gauze in the inter- chondral spaces. The patient speedily recovered, and Avas discharged in a little over a month, the only disastrous result of his extraordinary injuries being a small A-entral hernia. a 435, 1873, 44. b 476, 1871, i., 78. c 656, 1842. d 702, Dec, 1890. 612 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. In wounds of the diaphragm, particularly those from stabs and gun- shot injuries, death is generally due to accompanying lesions rather than to injury of the muscle itself. The older Avriters, particularly Glandorp,:!8° Hollerius, and Alexander Benedictus, made a favorable diagnosis of wounds made in the fleshy portions of the diaphragm, but despaired of those in the tendinous portions. Bertrand, Fabricius Hildanus,334 la Motte, Ravaton, Valentini,794 and Glandorp, record instances of recovery from Avounds of the diaphragm. There are some peculiar causes of diaphragmatic injuries on record, laughter, prolonged vomiting, excessive eating, etc., being mentioned. On the other hand, in his " Essay on Laughter (du Ris)," Joubert quotes a case in Avhich involuntary laughter was caused by a Avound of the diaphragm ; the laughter mentioned in this instance AA'as probably caused by convulsive move- ments of the diaphragm, due to some unknoAvn irritation of the phrenic nerve. Bremuse a gives an account of a man avIio literally split his diaphragm in two by the ingestion of four plates of potato soup, numerous cups of tea and milk, followed by a large dose of sodium bicarbonate to aid digestion. After this meal his stomach sAvelled to an enormous extent and tore the dia- phragm on the right side, causing immediate death. The diaphragm may be ruptured by external violence (a fall on the chest or abdomen), or by violent squeezing (railroad accidents, etc.), or according to Ashhurst, by spasmodic contraction of the part itself. If the injury is unaccompanied by lesion of the abdominal or thoracic A'iscera, the prognosis is not so unfavorable as might be supposed. Unless the laceration is ex- tremely small, protrusion of the stomach or some other viscera into the tho- racic cavity will almost invariably result, constituting the condition known as internal or diaphragmatic hernia. Par6618 relates the case of a Captain who Avas shot through the fleshy portion of the diaphragm, and though the wound was apparently healed, the patient complained of a colicky pain. Eight months afterAvard the patient died in a violent paroxysm of this pain. At the postmortem by Guillemeau, a man of great eminence and a pupil of Pare, a part of the colon AAas found in the thorax, having passed through a Avound in the diaphragm. Gooch382 saAV a similar case, but no history of the injury could be obtained. Bauschb mentions a case in Avhich the omentum, stomach, and pancreas were found in the thoracic cavity, having protruded through an extensive opening in the diaphragm. Muys, Bonnet, Blancard, Schenck, Sennert, Fantoni, and Godefroy record instances in AA'hich, after rupture of the diaphragm, the viscera have been found in the thorax; there- are many modern cases on record. Internal hernia through the diaphragm is mentioned by Cooper, Bowles, Fothergill, Monro, Ballonius, Derrecagiax, and Schmidt. Sir Astley Cooper c mentioned a case of hernia ventriculi from external violence, wherein the diaphragm was lacerated without any fracture a 807, 1878. b Leipzig, 1665. c 550, vi., 374. PERITONITIS IN THE THORACIC CAVITY. 613 of the ribs. The man Avas aged tAventy-seven, and being an outside pas- senger on a coach (and also intoxicated), when it broke doAvn he was pro- jected some distance, striking the ground with considerable force. He died on the next day, and the diagnosis Avas verified at the necropsy, the opening in the diaphragm causing stricture of the bowel. Postempskia successfully treated a wound of the diaphragm complicated with a Avound of the omentum, Avhich protruded between the external opening betAveen the 10th and 11th ribs; he enlarged the wound, forced the ribs apart, ligated and cut off part of the omentum, returned its stump to the abdo- men, and finally closed both the Avound in the diaphragm and the external Avound Avith sutures. Quoted by Ashhurst, Hunter recorded a case of gun- shot Avound, in AA'hich, after penetrating the stomach, bowels, and diaphragm, the ball lodged in the thoracic cavity, causing no difficulty in breathing until shortly before death, and even then the dyspnea was mechanical—from gase- ous distention of the intestines. Peritonitis in the thoracic cavity is a curious condition which may be brought about by a penetrating wound of the diaphragm. In 1872 Sargent communicated to the Boston Society for Medical Improvement an account of a postmortem examination of a woman of thirty-seA'en, in Avhom he had ob- served major injuries tAventy years before. At that time, while sliding doAvn some hay from a loft, she Avas impaled on the handle of a pitchfork Avhich entered the vagina, penetrated 22 inches, and was arrested by an upper left rib, Avhich it fractured ; further penetration Avas possibly prevented by the woman's feet striking the floor. Happily there was no injury to the bladder, uterus, or intestines. The principal symptoms Avere hemorrhage from the vagina and intense pain near the fractured rib, followed by emphysema. The pitchfork-handle avus AvithdraAvn, and was afterAA'ard placed in the museum of the Society, the abrupt bloody stain, 22 inches from the rounded end, being plainly shown. During tAventy years the Avoman could never lie on her right side or on her back, and for half of this time she spent most of the night in the sitting position. Her last illness attracted little attention because her life had been one of suffering. After death it Avas found that the cavity in the left side; of the chest Avas entirely filled AA'ith abdominal viscera. The open- ing in the diaphragm Avas four inches in diameter, and through it had passed the stomach, transverse colon, a feAV inches of the descending colon, and a considerable portion of the small intestines. The heart Avas crowded to the right of the sternum and Avas perfectly healthy, as was also the right lung. The left lung avus compressed to the size of a hand. There were marked signs of peritonitis, and in the absence of sufficient other symptoms, it could be said that this woman had died of peritonitis in the left thoracic cavity. Extended tolerance of foreign bodies loose in the thoracic cavity has been noticed. Tulpius842 mentions a person who had a sponge shut up a 174, 398. 614 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. in his thoracic cavity for six Aveeks ; it Avas then voided by the mouth, and the man recoA'ered. Fabricius Hildanus334 relates a similar instance in which a sponge-tent Avas expelled by coughing. Arnota reports a case in Avhich a piece of iron Avas found in a cyst in the thorax, Avhere it had re- mained for fourteen years. Leachb gives a case in Avhich a bullet aahs im- pacted in the chest for forty-tAvo years. Snyder' speaks of a fragment of knife-blade which Avas lodged in the chest tAvelve years and finally coughed up- Foreign Bodies in the Bronchi.—Walnut kernels, coins, seeds, beans, corks, and even sponges have been removed from the bronchi. In the pres- ence of Sir Morrell Mackenzie, Johnston of Baltimore removed a toy loco- motive from the subglottic cavity by tracheotomy and thyreotomy. The child had gone to sleep Avith the toy in his mouth and had subsequently swallowed it.d Eldredgee presented a hopeless consumptive, Avho as a child of five had SAvalloAved an umbrella ferrule AA'hile Avhistling through it, and avIio expelled it in a fit of coughing twenty-three years after. Eve of Nashvillef mentions a boy avIio placed a fourpenny nail in a spool to make a Avhistle, and, by a A'iolent inspiration, drew the nail deep into the left bronchus. It Avas removed by tracheotomy. Listen removed a large piece of bone from the right bronchus of a woman, and Houston tells of a case in Avhich a molar tooth Avas lodged in a bronchus causing death on the eleventh day. Warren mentions spontaneous expulsion of a horse-shoe nail from the bronchus of a boy of tAvo and one-half years. From Dublin, in 1844, Houston reports the case of a girl of sixteen who inhaled the Avooden peg of a small fiddle and in a fit of coughing three months afterAvard expelled it from the lungs. In 1849 Solly communicated the case of a man Avho in- haled a pebble placed on his tongue to relieve thirst. On removal this pebble Aveighed 144 grains. Watson of Murfreesboro removed a portion of an umbrella rib from a trachea, but as he failed to locate or remove the ferrule, the case terminated fatally. Brighamg mentions a child of five Avho Avas seized Avith a fit of coughing while she had a small brass nail in her mouth ; pulmonary phthisis ensued, and in one year she died. At the post- mortem examination the nail Avas found near the bifurcation of the right bronchus, and, although colored black, Avas not corroded. Marcaccih reported an observation of the removal of a bean from the bronchus of a child of three and a half years. The child swalloAved the bean -Avhile playing, immediately cried, and became hoarse. No one having noticed the accident, a diagnosis of croup was made and four leeches Avere applied to the neck. The dyspnea augmented during the night, and there a 550, 1827, xiii., 281. b ]75} 1857. c 267, 1870, xi., 401. d Archives of Clinical Surgery, N. Y., 1876, i., 211, et seq. e Rhode Island Med. Soc., Providence, 1860, i., 82. f 579, 1853, v., 129. g 124, 1836, 46. b 720,1876, clxx., p. 271. FOREIGN BODIES IN THE BRONCHI 615 was a Avhistling sound with each respiratory movement. On the next day the medical attendants suggested the possibility of a foreign body in the larynx. Tracheotomy Avas performed but the dyspnea continued, showing that the foreign body Avas lodged below the incision. The blood of one of the cut vessels entered the trachea and caused an extra paroxysm of dvspnea, but the clots of blood Avere removed by curved forceps. Marcacci fils prac- tised suction, and placed the child on its head, but in vain. A feather Avas then introduced in the Avound Avith the hope that it Avould clean the trachea and provoke respiration ; Avhen the feather was AvithdraAvn the bean folloAved. The child Avas much asphyxiated, hoAvever, and five or six minutes elapsed before the first deep inspiration. The Avound Avas closed, the child recovered its voice, and Avas Avell four days afterward. Annandale suav a little patient avIio had SAvalloAved a bead of glass, Avhich had lodged in the bronchus. He introduced the handle of a scalpel into the trachea, producing sufficient irri- tation to provoke a brusque expiration, and at the second attempt the foreign body Avas expelled. Hulke a records the case of a Avoman, the victim of a peculiar accident happening during the performance of tracheotomy, for an affection of the larynx. The internal canule of the tracheotomy-tube fell into the right bronchus, but Avas removed by an ingenious instrument extem- poraneously devised from silver Avire. A feAV years ago in this country there Avas much public excitement and neAvspaper discussion over the daily reports which came from the bedside of a gentleman who had SAvalloAved a cork, and Avhich had become lodged in a bronchus. Tracheotomy Avas performed and a special corkscrcAV devised to extract it, but unfortunately the patient died of sIoav asphyxiation and exhaustion. Herrickb mentions the case of a boy of fourteen months Avho SAvalloAved a shawl-pin two inches long, Avhich re- mained in the lungs four years, during Avhich time there AAas a constant dry and spasmodic cough, and corresponding depression and emaciation. When it Avas ultimately coughed up it appeared in one large piece and several smaller ones, and Avas so corroded as to be very brittle. After dislodgment of the pin there Avas subsidence of the cough and rapid recoA'ery. Lapeyrec mentions an elderly gentleman Avho received a sudden slap on the back Avhile smoking a cigarette, causing him to start and take a very deep inspiration. The cigarette was drawn into the right bronchus, Avhere it remained for tAvo months Avithout causing symptoms or revealing its presence. It then set up a circumscribed pneumonia and cardiac dropsy Avhich continued tAvo months longer, at AA'hich time, during a violent fit of coughing, the cigar- ette AAas expelled enveloped in a waxy, mucus-like matter. Louis relates the ease of a man avIio carried a louis-d'or in his lung for six and a half years. There is a case on record d of a man who received a gunshot Avound, the ball entering behind the left claA'icle and passing doAviiAvard and across to the right claA'icle. Sometime afterward this patient expectorated two pieces of a 476, 1876. b 218, 1871. c 476, 1890, 628. <* 133, 1873, 146. 616 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. bone and a piece of gum blanket in AA'hich he Avas enveloped at the time of the injury. Carpenter a describes a case of fatal pleuritis, apparently due to the presence of four artificial teeth Avhich had been sAvallowed thirteen years before. Cardiac Injuries.—For ages it has been the common opinion relative to injuries of the heart that they are necessarily fatal and that, as a rule, death immediately folioavs their reception. Notwithstanding this current belief a careful examination of the literature of medicine presents an astounding num- ber of cases in Avhich the heart has been positively wounded, and the patients haA'e lived days, months, and eA'en recovered ; postmortem examination, by revealing the presence of cicatrices in the heart, confirming the original diag- nosis. This question is one of great interest as, in recent years, there has been constant agitation of the possibility of surgical procedures in cardiac as well as cerebral injuries. Del Vecchio b has reported a series of experiments on dogs Avith the conclusion that in case of wounds in human beings suture of the heart is a possible operation. In this connection he proposes the fol- io Aving operative procedure : Tavo longitudinal incisions to be made from the loAver border of the 3d rib to the upper border of the 7th rib, one run- ning along the inner margin of the sternum, the other about ten mm. inside the nipple-line. These incisions are joined by a horizontal cut made in the fourth intercostal space. The 4th, 5th, and 6th ribs and cartilages arc divided and the outer cutaneous flaps turned up; pushing aside the pleura with the finger, expose the pericardium and incise it longitudinally; suture the heart-wound by interrupted sutures. Del Vecchio adds that Fischer has collected records of 376 cases of wounds of the heart with a mortality two to three minutes after the injury of 20 per cent. Death may occur from a fc\v seconds to nine months after the accident. Keen and Da Costac quote Del Vecchio, and, in comment on his observations, remark that death in cases of Avound of the heart is due to pressure of effused blood in the pericardial sac, and, because this pressure is itself a check to further hemorrhage, there seems, as far as hemorrhage is concerned, to be rather a question whether operative interference may not be itself more harmful than beneficial. It might be added that the shock to the cardiac action might be sufficient to check it, and at present Ave Avould have no sure means of starting pulsation if once stopped. In heart-injuries, paracentesis, followed, if necessary, by incision of the peri- cardium, is advised by some surgeons. Realizing the fatality of injuries of the heart, in consequence of which al- most any chance by operation should be quickly seized by surgeons rather than trust the lives of patients to the infinitesimal chance of recovery, it Avould seem that the profession should carefully consider and discuss the feasi- bility of any procedure in this direction, no matter how hypothetic. Halld states that his experience in the study of cardiac Avounds, chiefly a 392, 1842. b 684, April 4, 189."). c 843, 337. d 533, Nov. 2, 1895. SURVIVAL AFTER CARDIAC INJURIES. 617 on game-animals, Avould lead him to the conclusion that transA'erse wounds of the loAver portions of the heart, giving rise to punctures rather than extensive lacerations, do not commonly cause cessation of life for a time varying from some considerable fraction of a minute to many minutes or even hours, and especially if the puncture be valvular in character, so as to prevent the loss of much blood. HoAvever, if the wound im'olve the base of the organ, Avith extensive laceration of the surrounding parts, death is practically instantane- ous. It would seem that injury to the muscular walls of the heart is much less efficient in the production of immediate death than destruction of the cardiac nervous mechanism, serious irritation of the latter producing almost instantaneous death from shock. In addition, Hall cites several of the instances on which he based his conclusions. He mentions tAvo wild geese which flew respectively 4; and f of a mile after having been shot through the heart, each with a pellet of BB shot, the base in each instance being unin- jured ; in several instances antelope and deer ran several rods after being shot Avith a rifle ball in a similar manner ; on the other hand, death was prac- tically instantaneous in several of these animals in which the base of the heart was extensively lacerated. Again, death may result instantaneously from Avounds of the precordial region, or according to Erichscn, if held directly over the heart, from the discharge of a pistol containing poAvder alone, a result occasionally seen after a blow on the precordial region. It is Avell, hoAvever, to state that in times of excitement, one may receive an injury which will shortly prove fatal, and yet not be aAvare of the fact for some time, perhaps even for seA'eral minutes. It would appear that the nervous system is so highly tuned at such times, that it does not respond to reflex irritations as readily as in the absence of excitement. Instances of Survival after Cardiac Injuries.—We briefly cite the principal interesting instances of cardiac injuries in Avhich death has been delayed for some time, or from Avhich the patient ultimately recovered. Par6618 relates the case of a soldier Avho received a bloAV from a halberd, penetrating the left ventricle, and Avho Avalked to the surgeon's tent to have his Avound dressed and then to his own tent 250 yards aAA'ay. Diemerbroeck a mentions tAvo instances of long survival after cardiac injuries, in one of Avhich the patient ran 60 paces after receiving the wound, had complete composure of mind, and survived nine days. There is an instanceb in Avhich a man ran 400 paces after penetration of the left ventricle, and lived for five hours. Morand57r> gives an instance of survival for five davs after Avound of the right ventricle. Saucerotte0 speaks of survival for three days after injury to the heart. Babingtond speaks of a case of heart-injury, caused by transfixion by a bayonet, in which the patient survived nine hours. Other older cases are as a 303, L. ii., cap. vi., 266 and 381. b 470, T. xxxv. c Melanges de Chirurgie, etc. d Medical Records, etc., 1798, No. 4. 618 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. folloAvs : l'Ecluse,a seA'en days ; the Ephemerides, four and six days ; Col de Vilars, tAvelve days; Marcucci,b eighteen days; Bartholinus/ five davs; Durande,d five days ; Boyer, five days ; Capelle,e tAventy-six hours ; Fahncr, eleven days; Marigues/ thirteen days; Morgagni, eight days; la Motte, « tAvelve hours ; Rhodius,h Riedlin,1 tAvo days ; Saviard,713 eleven days ; Sen- nert, J three days ; Triller,k fourteen days ; and Tulpius,1 tAvo and fifteen days ; and Zittman,"1 eight days. The Due de Berri, heir to the French throne, who Avas assassinated in 1826, lived several hours AA'ith one of his ventricles opened. His surgeon, Dupuytren, aa as reprimanded for keeping the Avound open a\ ith a probe intro- duced every tAvo hours, but this procedure has its advocates at the present day. Kandalln mentions a gunshot wound of the right A'entricle AA'hich did not cause death until the sixty-seventh day. Grant ° describes a Avound in Avhich a ball from a revolver entered a little to the right of the sternum, between the carti- lages of the 5th and 6th ribs, and then entered the right ventricle about an inch from the apex. It emerged from the loAver part, passed through the diaphragm, the cardiac end of the stomach, and lodged in the left kidney. The patient remained in a state of collapse fifteen hours after being shot, and with little or no nourishment lived twenty-six days. At the postmortem ex- amination the Avounds in the organs were found to be healed, but the cicatrices were quite eA'ident. BoAvling p gives a case of gunshot Avound of the shoulder in which death resulted eleA'en weeks after, the bullet being found in the left ventricle of the heart. Thompson q has reported a bayonet Avound of the heart, after the reception of Avhich the patient lived four days. The bayonet entered the ventricle about 1J inches from the left apex, traversing the left Avail obliquely, and making exit close to the septum ventriculorum. Rob- erts r mentions a man Avho ran 60 yards and lived one hour after being shot through both lungs and the right auricle. Currans mentions the case of a soldier who, in 1809, Avas Avounded by a bullet Avhich entered his body to the left of the sternum, between the 2d and 3d ribs. He Avas insensible a half hour, and was carried aboard a fighting ship croAvded AA'ith sailors. There AA'as little hemorrhage from his Avound, and he survh'ed fourteen days. At the postmortem examination some interesting facts Avere revealed. It Avas found that the right ventricle was transversely opened for about an inch, the ball haA'ing penetrated its anterior surface, near the origin of the pulmonary artery (Fig. 220). The ball Avas found loose in the pericardium, where it had fallen during the necropsy. There Avas a circular lacerated opening in the tricuspid vah'e, and the ball must have been in the right auricle during the a 418, 1744. b Orteschi Giornale di Medicina, Venet, 1763. c 190, cent, i., hist. 77. d Hufeland, N. Annalen. i., p. 301. e Journal de Sante, T. i. f 462, T. xlviii, 243. g Chirnrgie, obs. 228. b 680, cent, ii., obs. 39. i 683, 1700, 985. j Opera chirurg., L. v., P. iv., c. 3. k Diss. Viteb., 1775. 1 842, L. ii., c. is. m 835, cent, iii., cas. 50. n 124, 1829. o 124, July, 1857. P 476, 1852, ii., 491. q 548, 1863, ii., 487. * 681, 1871, xii., 607. s 476, 1887, i., 673. SURVIVAL AFTER CARDIAC INJURIES. 619 fourteen days in which the man lived. Vite a mentions an example of remark- able tenacity of life after reception of a cardiac Avound, the subject living four days after a knife-Avound penetrating the chest into the pericardial sac and pass- ing through the left A'entricle of the heart into the opposite Avail. Boone b speaks of a gunshot Avound in which death Avas postponed until the thirteenth da a-. Bullock c mentions a case of gunshot Avound in Avhich the ball Avas found lodged in the cavity of the ventricle four days and eighteen hours after inflic- tion of the wound. Carnochan d describes a penetrating Avound of the heart in a subject in Avhom life had been protracted eleven days. After death the bullet Avas found buried and encysted in the heart. Holly e reports a case of pistol-shot Avound through the right ventricle, septum, and aorta, Avith the ball in the left A'entricle. There Avas apparent recovery in fourteen days and sudden death on the fifty-fifth day. Hamiltonf gives an instance of a shoemaker sixty-three years old avIio, Avhile carrying a bundle, fell Avith rupture of the heart and lived several minutes. On postmortem ex- amination an opening in the heart was found large enough to admit a bloAv- pipe. Noble g speaks of duration of life for fh'e and a half days after rup- ture of the heart; and there are in- stances on record in Avhich life has been prolonged for thirteen hoursh and for fifty-three hours * after a simi- lar injury. GlazebrookJ reports the case of a colored man of thirty, of pOAVerftll physique,Avho AA'as admitted Fig. 220.-AVound of the heart; survival, fourteen days to the Freedmen's Hospital, Wash- (Cl,rran)- ington, D. C, at 12.30 a. m., on February 5, 1895. Upon examination by the surgeons, an incised Avound Avas discovered one inch above the left nipple, 3^ inches to the left of the median line, the incision being 2 J inches in length and its direction parallel Avith the 3d rib. The man's general condition Avas fairly good, and the Avound Avas examined. It AA'as impossible to trace its depth further than the 3d rib, although probing avus resorted to; it Avas therefore considered a simple Avound, and dressed accordingly. TAvelve hours later symptoms of internal hemorrhage were noticed, and at 8 a. m., February 6th, the man died after surviving his injury thirty-tAVO hours. A necropsy Avas held three hours after death, and an oblique incision f inch in a 681, 1S76. t b 124, 1879, 589. o 712, 1858, i., 295. d 128, 1855. e 538, 1878. * * 476, 1860. 8 476, 1889, i., 774. •'221, 1SS1, ii., 1051. i 224, 1889, ii., 204. J ')33, lxvi., 508. 620 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. length AA-as found through the cartilage-end of the 3d rib. A -imilar Avound Avas next found in the pericardium, and upon examining the heart there was seen a clean, incised wound ^ inch in length, directly into the right ventricle, the endocardial Avound being £ inch long. Both the pericardium and left pleura Avere distended Avith fresh blood and large clots. Church a reports a case of gunshot wound of the heart in a man of sixty-seven Avho survived three hours. The Avound had been made by a pistol bullet (32 caliber), was situated 1£ inches below the mammary line, and slightly to the left of the center of the sternum ; through it considerable blood had escaped. The postmortem examination shoAved that the ball had pierced the sternum just above the xiphoid cartilage, and had entered the pericardium to the right and at the kmer part. The sac Avas filled Avith blood, both fresh and clotted. There was a ragged Avound in the anterior Avail J inch in diameter. The Avound of exit Avas f inch in diameter. After traAersing the heart the ball had penetrated the diaphragm, Avounded the omentum in several places, and become lodged under the skin posteriorly betAA'een the 9th and 10th ribs. Church adds that the " Index Catalogue of the Surgeon-General's Library " at Washington contains 22 cases of direct injury to the heart, all of Avhich lived longer than his case : 17 lived OA'er three days ; eight lh'ed o\rer ten days ; tAvo lived over tAventy-five days ; one died on the fifty-fifth day, and there Avere three Avell-authenticated recoveries. Purple b tabulates a list of 42 cases of heart-injury which survived from thirty minutes to seventy days. Fourteen instances of gunshot Avounds of the heart haA'e been collected from U. S. Army reports,0 in all of AA'hich death folloAved A'ery promptly, ex- cept in one instance in Avhich the patient survived fifty hours. In another case the patient lived tAventy-six hours after reception of the injury, the coni- cal pistol-ball passing through the anterior margin of the right lobe of the lung into the pericardium, through the right auricle, and again entered the right pleural cavity, passing through the posterior margin of the loAver lobe of the right lung; at the autopsy it Avas found in the right pleural cavity. The left lung and cavity Avere perfectly normal. The right lung Avas engorged and someAvhat compressed by the blood in the pleural cavity. The pericar- dium Avas much distended and contained from six to eight ounces of partially coagulated blood. There was a fibrinous clot in the left ventricle. Nonfatal Cardiac Injuries.—Wounds of the heart are not necessarily fatal. Of 401 cases of cardiac injury collected by Fischerd there AA'ere as many as 50 recoveries, the diagnosis being confirmed in 33 instances by an autopsy in Avhich there were found distinct signs of the cardiac injury. By a peculiar arrangement of the fibers of the heart, a Avound transverse to one layer of fibers is in the direction of another layer, and to a certain extent, therefore, valvular in function; it is probably from this fact that punctured wounds of the heart are often attended AA'ith little or no bleeding. a 533, Oct. 27, 1894. b 597, xiv#> 411-434. c 847, 33. 107, i., 22. c 306, ii., c. xii., 222. d 458, T. xxv. and xxvi. e 548, 1878, i., 676. *" 312, 1864, li., 407. 8 476, 1859, ii., 337. •» 318, lxvi., 384. i Quart. Jour. Calcutta Med. and Phys. Soc, 1837, i., 291. J 312, liv., 478. k538, xxix.,93. 1 "Maladiesdes Voies Urinaires." m 526,1853. n 476, 1849, ii., 41. 638 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. a fork Avhich Avas passed from the anus tAventy months after it Avas sAvalhnved. Wilson a mentions an instance of gastrotomy Avhich Avas performed for the extraction of a fork SAvalloAved sixteen years before. There is an interesting case b in Avhich, in a delirium of typhoid fever, a girl of tAventy-tAvo SAvalloAved tAvo iron forks, Avhich Avere subsequently expelled through an abdominal abscess. A French Avoman of thirty-five,c Avith suicidal intent, SAvalloAved a four-pronged fork, which Avas removed four years afterAA'ard from the thigh. For tAvo years she had suffered intense pain in both thighs. In the Royal College of Surgeons in London there is a steel button-hook 31 inches in length Avhich Avas accidentally swalloAved, and Avas passed three Aveeks later by the anus, without having given rise to any symptom.619 Among the insane a favorite trait seems to be sAAalloAving nails. In the Philosophical Transactions d is an account of the contents of the stomach of an idiot Avho died at thirty-three. In this organ Avere found nine cart-Avheel nails, six screAvs, tAvo pairs of compasses, a key, an iron pin, a ring, a brass pommel Aveighing nine ounces, and many other articles. The celebrated Dr. Lcttsom, in 1802, spoke of an idiot avIio SAvallowed four pounds of old nails and a pair of compasses. A lunatic in England (> SAvallowed ten ounces of screAvs and bits of crockery, all of Avhich Avere passed by the anus. Board- man f gh-es an account of a child affected AA'ith hernia who sAA'alloAved a nail 2i inches long. In a few days the nail Avas felt in the hernia, but in due time it Avas passed by the rectum. BloAver g reports an account of a nail passing safely through the alimentary canal of a baby. Armstrong11 mentions an insane hair-dresser of tAventy-three, in avIiosc stomach after death were found 30 or more Spoon handles, 30 nails, and other minor articles. Closmadenc 363 reported a remarkable case which Avas extensively quoted.1 The patient Avas an hysteric young girl, an inmate of a com'ent, to Avhom he AAas called to relieve a supposed fit of epilepsy. He found her half-asphyxiated, and believed that she had SAA'alloAved a foreign body. He was told that under the influence of exaggerated religious scruples this girl inflicted penance upon herself by SAvalloAving earth and holy medals. At the first dose of the emetic, the patient made a strong effort to A'omit, Avhereupon a cross seven cm. long appeared betAveen her teeth. This was taken out of her mouth, and Avith it an enormous rosary 220 cm. long, and having seven medals attached to it. Hunt-' recites a case occurring in a pointer dog, Avhich SAvalloAved its collar and Chain, only imperfectly masticating the col- lar. The chain and collar Avere immediately missed and search made for them. For several days the dog Avas ill and refused food. Finally the gamekeeper saAV the end of the chain hanging from the dog's anus, and tak- ing hold of it, he drew out a yard of chain Avith links one inch long, Avith a a 476, 1887, i., 1109. t> Neue Jahrbiicher der deutschen Medizin und Chirurgie, 1823. c 593, 1853. d 629, 1700-20, v. e 476) i866? ^ 619. f 230, 1867. g 224, 1870. ^476, 1852. i 548, 1859, ii., 273. J 476, 1872, ii., 837. FOREIGN BODIES IN THE ALIMENTARY CANAL. 639 cross bar at the end tAvo inches in length; the dog soon recoA'ered. The collar was never found, and had apparently been digested or previously passed. Fear of. robbery has often led to the SAvalloAving of money or jewelry. Araillant, the celebrated doctor and antiquarian, after a captivity of four months in Algiers, Avas pursued by Tunis pirates, and swallowed 15 medals of gold ; shortly after arriving at Lyons he passed them all at stool. Fournier and Dureta published the history of a galley slave at Brest in whose stomach were found 52 pieces of money, their combined weight being one pound, lOf; ounces. On receiving a sentence of three years' imprison- ment, an Englishman,b to prevent them being taken from him, swallowed seven half-croAvns. He suffered no bad effects, and the coins not appearing the affair was forgotten. AVhile at stool some twenty months afterward, having taken a purgative for intense abdominal pain, the seven coins fell clattering into the chamber. Hevin mentions the case of a man who, on be- ing captured by Barbary pirates, swallowed all the money he had on his per- son. It is said that a certain Italian swallowed 100 louis d'ors at a time. It occasionally happens that false teeth are accidentally swallowed, and even passed through the intestinal tract. Easton c mentions a young man who accidentally swallowed some artificial teeth the previous night, and, to further their passage through the bowel, he took a dose of castor oil. AA'hen seen he was suffering with pain in the stomach, and was advised to eat much heavy food and avoid aperients. The folloAving day after several free move- ments he felt a sharp pain in the lower part of his back. A large enema Avas given and the teeth and plate came away. The teeth were cleansed and put back in his mouth, and the patient walked out. Nine years later the same accident again happened to the man but in spite of treatment nothing was seen of the teeth for a month afterward, when a body appeared in the rec- tum Avhich proved to be a gold plate with the teeth in it. In The Lancet of December 10, 1881, there is an account of a vulcanite tooth-plate AA'hich Avas SAvallowed and passed forty-two hours later. Billroth'1 mentions an instance of gastrotomy for the removal of swallowed artificial teeth, Avith recovery; and another case in which a successful esophagotomy was per- formed. Gardinere mentions a Avoman of thirty-three Avho SAvallowed tAvo false teeth Avhile supping soup. A sharp angle of the broken plate had caught in a fold of the cardiac end of the stomach and had caused violent hematemesis. Death occurred seventeen hours after the first urgent symptoms. In the Museum of the Royal College of Surgeons in London there is an intestinal concretion weighing 470 grains, Avhich Avas passed by a Avoman of seventy avIio had suffered from constipation for many years. Sixteen years a 462, T. xiii. t> 490, May 20, 1837. c 476, 1882, i., 381. d 476, 1885, i., 591. e 253, March, 1881. 640 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. before the concretion Avas passed she Avas knoAvn to have SAvallowed a tooth. At one side of the concretion a piece had been broken off exposing an incisor tooth Avhich represented the nucleus of the formation. Manasse 199 recently re- ported the case of a man of forty-four Avhose stomach contained a stone Aveighing 75 grams. He Avas a joiner and, it Avas supposed, habitually drank some alcoholic solution of shellac used in his trade. Quite likely the shellac had been precipitated in the stomach and gave rise to the calculus. Berwick a mentions a child of eight months who Avas playing Avith a de- tached organ-handle, and put it in its mouth. Seeing this the mother attempted to secure the handle, but it Avas pushed into the esophagus. A physician Avas called, but nothing Avas done, and the patient seemed to suffer little inconvenience. Three days later the handle aahs expelled from the anus. Teakleb reports the successful passage through the alimentary canal of the handle of a music-box. Hashimoto, Surgeon-General of the Imperial Japanese Army, tells of a Avoman of forty-nine Avho Avas in the habit of in- ducing vomiting by irritating her fauces and pharynx AA'ith a Japanese tooth- brush—a Avooden instrument six or seven inches long with bristles at one end. In May, 1872, she accidentally SAvalloAved this brush. Many minor symptoms developed, and in eleven months there appeared in the epigastric region a fluctuating swelling, AA'hich finally burst, and from it extended the end of the brush. After A'ainly attempting to extract the brush the attend- ing physician contented himself AA'ith cutting off the projecting portion. The opening subsequently healed ; and not until thirteen years later did the pain and swelling return. On admission to the hospital in October, 1888, iavo fistulous openings Avere seen in the epigastric region, and the foreign body was located by probing. Finally, on November 19, 1888, the patient was anes- thetized, one of the openings enlarged, and the brush extracted. Fh'e weeks later the openings had all healed and the patient Avas restored to health. Garciac reports an interesting instance of foreign body in a man between forty-five and fifty. This man was afflicted Avith a syphilitic affection of the mouth, and he constructed a swab ten inches long with which to cleanse his fauces. AVhile making the application alone one day, a spasmodic movement caused him to relinquish his grasp on the handle, and the SAvab disappeared. He Avas almost suffocated, and a physician was summoned; but before his arrival the swab had descended into the esophagus. Tavo Aveeks later, gastro- peritoneal symptoms presented, and as the stick Avas located, gastrotomy Avas proposed ; the patient, hoAvever, Avould not consent to an operation. On the twenty-sixth day an abscess formed on the left side beloAv the nipple, and from it was discharged a large quantity of pus and blood. Four days after this, believing himself to be better, the man began to redress the Avound, and from it he saAV the end of a stick protruding. A physician Avas called, and by traction the stick was Avithdrawn from between the 3d and 4th ribs; a 224, 1890, i., 1367. b 510, 1884. c 610, June, 1854. FOREIGN BODIES IN THE INTESTINES. 641 forty-nine days after the accident the Avound had healed completely. Two years afterward the patient had an attack of cholera, but in the fifteen subse- quent years he lived an active life of labor. Occasionally an enormous mass of hair has been removed from the stom- ach. A girl of tAventya with a large abdominal swelling was admitted to a hospital. Her illness began five years previously, with frequent attacks of vomiting, and on three occasions it was noticed that she became quite bald. Abdominal section was performed, the stomach opened, and from it was removed a mass of hair Avhich weighed five pounds and three ounces. A good recovery ensued. In the Museum of St. George's Hospital, London,619 are masses of hair and string taken from the stomach and duodenum of a girl of ten. It is said that from the age of three the patient had been in the habit of eating these articles. There is a record in the last century of a boy of sixteen who ate all the hair he could find ; after death his stomach and intestines were almost com- pletely lined Avith hairy masses. In the Journal of the American Medical Association, March 1, 1896, there is a report of a case of hair-swallowing. Foreign Bodies in the Intestines.—AVhiteb relates the history of a case in Avhich a silver spoon was swallowed and successfully excised from the intestinal canal. Houston0 mentions a maniac who swalloAved a rusty iron spoon 11 inches long. Fatal peritonitis ensued and the spoon was found impacted in the last acute turn of the duodenum. In 1895, in London,619 there Avas exhibited a specimen, including the end of the ileum with the adja- cent end of the colon, showing a dessertspoon Avhich was impacted in the latter. The spoon Avas seven inches long, and its bowl measured \\ inches across. There was much ulceration of the mucous membrane. This spoon had been swallowed by a lunatic of twenty-two, who had made two previous ineffect- ual attempts at suicide. Mason d describes the case of a man of sixty-five who, after death by strangulated hernia, was opened, and two inches from the ileocecal valve was found an earthen egg-cup which he had swallowed. Mason also relates the instance of a man who swallowed metal balls 2\ inches in diameter; and the case of a Frenchman who, to prevent the enemy from finding them, SAvalloAved a box containing despatches from Napoleon. He was kept prisoner until the despatches were passed from his boAvels. Denby e discovered a large egg-cup in the ileum of a man. Fillionf mentions an in- stance of recovery folloAving the perforation of the jejunum by a piece of horn which had been SAvalloAved. Madden s tells of a person, dying of intestinal obstruction, in whose intestines were found several ounces of crude mercury and a plum-stone. The mercury had evidently been taken for purgative effect. Rodenbaugh h mentions a most interesting case of beans sprouting Avhile in the bowel. Harrisoni relates a curious case in which the swallowed a 476, 1895, i., 1581. d 476, 1870, i., 701. g 629, 1732. 41 b 541, 1807, iv., 367. e 476, 1834. h 613, 1876. c 311, 1830, v., 319. f 462, T. lxiii., 538. i 476, 1883, i., 863. 642 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. loAver epiphysis of the femur of a rabbit made its Avay from the boAvel to the bladder, and Avas discharged thence by the urethra. In cases of appendicitis foreign bodies have been found lodged in or about the vermiform appendix so often that it is quite a common lay idea that appendicitis is invariably the result of the lodgment of some foreign body accidentally SAvalloAved. In recent years the literature of this subject proves that a great variety of foreign bodies may be present. A feAV of the interesting cases Avill be cited in the folloAving lines :— In the Ngav England Medical Journal, 1843, is an account of a vermiform appendix which Avas taken from the body of a man of eighty-eight avIio had died of pneumothorax. During life there Avere no symptoms of disease of the appendix, and after death no adhesions Avere found, but this organ Avas remarkably long, and in it AA'ere found 122 robin-shot. The old gentleman had been excessively fond of birds all his life, and Avas accustomed to bolt the meat of small birds Avithout properly cheAving it;. to this fact Avas attri- buted the presence of these shot in the appendix. A someAvhat similar case a Avas that of a man avIio died in the Hotel-Dieu in 1833. The ileum of this man contained 92 shot and 120 plum stones. Bucklerb reports a case of appendicitis in a child of tAvelve, in Avhich a common-sized bird-shot Avas found in the appendix. Packard0 presented a case of appendicitis in Avhich two pieces of rusty and crooked Avire, one 2| and the other 1-| inches long, Avere found in the omentum, having escaped from the appendix. IIoAved describes a case in AA'hich a double oat, AA'ith a hard enA'elope, Avas found in the vermiform appendix of a boy of four years and one month of age. Pres- cotte reports a case of what he calls fatal colic from the lodgment of a chocolate-nut in the appendix ; and Noyesf relates an instance of death in a man of thirty-one attributed to the presence of a raisin-seed in the A'ermiform appendix. Needles, pins, peanuts, fruit-stones, peas, grape-seeds, and many similar objects have been found in both normal and suppurath'e A'ermiform appendices. Intestinal Injuries.—The degree of injury that the intestinal tract may sustain, and after recoA'ery perform its functions as usual, is most extraordinary ; and even Avhen the injury is of such an extent as to be mortal, the persistence of life is remarkable. It is a Avell known fact that in bull-fights, after mor- tal injuries of the abdomen and boAvels, horses are seen to struggle on almost until the sport is finished. Fontaine g reports a case of a AVelsh quarryman avIio AAas run over by a heavy four-horse A'ehicle. The stump of a glass bot- tle Avas crushed into the intestinal cavity, and the bowels protruded and Avere bruised by the Avheels of the Avagon. The grit Avas so firmly ground into the boAvel that it Avas impossible to remove it; yet the man made a complete re- ft 368, 1834. b 810, 1856, vii., 266. c "Proceedings Patholog. Soc. of Phila.," 1858, i., 170. <* oiq, I860, lxiii., 231. e 589, 1815, iv., 221. f 299, 1875, x., 30. S 681, 1875, xix., 109. SLOUGHING OF THE INTESTINES. 643 covery. Nicolls a has the case of a man of sixty-nine, a workhouse maniac, who on August 20th attempted suicide by running a red-hot poker into his abdo- men. His Avound was dressed and he was recovering, but on September 11th he tore the cast off his abdomen, and pulled out of the wound the omentum and 32 inches of colon, which he tore off and threAv between his pallet and the wall. Strange to say he did not die until eight days after this horrible injury. Tardieu b relates the case of a chemist Avho removed a large part of the mesentery Avith a knife, and yet recovered. Delmas of Montpellier reports the history of a Avagoner with complete rupture of the intestines and rupture of the diaphragm, and who yet finished his journey, not dying until eighteen hours after. Successful Intestinal Resection.—In 1755 Nedham c of Norfolk re- ported the case of a boy of thirteen who Avas run over and eviscerated. It was found necessary to remove 57 inches of the protruding bowel, but the boy made a subsequent recovery. Ivoebererlcd of Strasburg performed an operation on a woman of twenty-two for the relief of intestinal obstruction. On account of numerous strictures it Avas found necessary to remove over tAvo yards of the small intestine ; the patient recovered without pain or trouble of any kind. In his dissertation on " Ruptures " Arnaud remarks that he cut away more than seven feet of gangrenous bowel, his patient surviving. Beehc6 reports recovery after the removal of 48 inches of intestine. The case Avas one of strangulation of an umbilical hernia. Sloughing of the Intestine Following Intussusception.—Lobstoin488 mentions a peasant woman of about thirty avIio avus suddenly seized with an attack of intussusception of the boAvel, and Avas apparently in a mori- bund condition when she had a copious stool, in Avhich she evacuated three feet of boAvel Avith the mesentery attached. The Avoman recovered, but died five months later from a second attack of intussusception, the ileum rupturing and peritonitis ensuing. There is a record in this countryf of a Avoman of forty-five avIio discharged 44 inches of intestine, and who survived for forty- two days. The autopsy showed the sigmoid flexure gone, and from the caput ceci to the termination the colon only measured 14 inches. Vater^ gives a history of a penetrating abdominal wound in Avhich a portion of the colon hung from the wound during fourteen years, forming an artificial anus. Among others mentioning considerable sloughing of intestine folloAving intussusception, and usually with complete subsequent recovery, are Bare, h 13 inches of the ileum; Blackton,1 nine inches; BoAver,J 14 inches; Daw- son,k 29 inches; Sheldon,1 4| feet; Stanley,111 three feet; Tremaine,n 17 inches ; and Grossoli,0 40 cm. a 312, 1854, xxxii., 214. b Hi, xxxix.,157. c 629, 1755, xlix., part i., 238 <* 545, 1881. e Trans. Amer. Inst. Homeop., 1870, Chicago, 871. f 124, 1846. 8 629, 1719-33. b 124, 1863. i 548, 1853. j 149, 1803. k 817, 1840. 1 546, 1850. m 426, 1826. n 252, 1879. o 746, 1875. 644 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. Rupture of the Intestines.—It is quite possible for the intestine to be ruptured by external violence, and cases of rupture of all parts of the bowel have been recorded. Titorier a gives the history of a case in Avhich the colon AAas completely separated from the rectum by external violence. Hinder b re- ports the rupture of the duodenum by a violent kick. LYcles,0 Ely/1 and Pollock e also mention cases of rupture of the duodenum. Zimmerman/ At- Avell,8 and Allan h report cases of rupture of the colon. Operations upon the gastrointestinal tract have been so improved in the modern era of antisepsis that at the present day they arc quite common. There are so many successful cases on record that the Avhole subject deserves mention here. Gastrostomy is an operation for establishing a fistulous opening in the stomach through the anterior Avail. Many operations have been devised, but the results of this maneuver in malignant disease have not thus far been very satisfactory. It is quite possible that, being an operation of a serious nature, it is never performed early enough, the patient being fatally Aveak- ened by inanition. Gross and Zesas1 have collected, respectively, 207 and 162 cases Avith surprisingly different rates of mortality : that of Gross being only 29.47 per cent, Avhile that of Zesas Avas for cicatricial stenoses 60 per cent., and for malignant cases 84 per cent. It is possible that in Zesas's statistics the subjects Avere so far advanced that death Avould have resulted in a short time Avithout operation. Gastrotomy Ave have already spoken of. Pyloroplasty is an operation devised by Heineke and Mikulicz, and is designed to remove the mechanic obstruction in cicatricial stenoses of the pylorus, at the same time creating a new pylorus. Gastroenterostomy and pylorectomy are operations devised for the re- lief of malignant disease of the pylorus, the diseased portions being removed and the parts resected. Gastrectomy or extirpation of the stomach is considered by most sur- geons entirely unjustifiable, as there is seldom hope of cure or prospect of amelioration. La Tribune Medicale for January 16, 1895,j gives an abstract of Langenbuch's contribution upon total extirpation of the stomach. Three patients were treated, of whom tAvo died. In the first case, on opening the abdominal cavity the stomach Avas found very much contracted, present- ing extensive carcinomatous infiltration on its posterior surface. After divi- sion of the epiploon section Avas made at the pylorus and at the cardiac ex- tremities ; the portions removed represented seven-eighths of the stomach. The pylorus Avas stitched to the remains of the cardiac orifice, making a cavity about the size of a hen's egg. In this case a cure Avas accomplished in three Aveeks. The second case Avas that of a man in Avhom almost the entire stomach a 463, xi. b 435, 1866. f 827, 1840, 603. b476, 1878, ii., 332. o 548, 1863. d218. 1859. e 700, 1877. g Indiana Jour, of Med., Indianapolis, 1875. 1 845, 705. J 843, 246. FOREIGN BODIES IN THE RECTUM. 645 was removed, and the pyloric and cardiac ends were stitched together in the wound of the parietes. The third case Avas that of a man of sixty-two Avith carcinoma of the pylorus. After pylorectomy, the line of suture avus con- fined Avith iodoform-gauze packing. Unfortunately the patient suffered with bronchitis, and coughing caused the sutures to give way; the patient died of inanition on the twenty-third day. Enterostomy, or the formation of a fecal fistula above the ileocecal valve, was performed for the first time by Nelaton in 1840, but the mortality since 1840 has been so great that in most cases it is deemed inadmissible. Colostomy, an operation designed to make a fistulous opening in any por- tion of the rectum, was first practised by Littre. In early times the mor- tality of inguinal colostomy Avas about five per cent., but has been gradually reduced until Konig reports 20 cases AA'ith only one death from peritonitis, and ('ripps 26 cases with only one death.a This will always retain its place in operative surgery as a palliative and life-saving operation for carcinoma- tous stenosis of the loAver part of the colon, and in cases of carcinoma of the rectum in Avhich operation is not feasible. Intestinal anastomosis, Avhereby tAvo portions of a severed or resected boAvel can be intimately joined, excluding from fecal circulation the portion of boAvel Avhich has become obstructed, avus originally suggested by Maison- neuve, and aa;is studied experimentally by von Hacken. Billroth resorted to it, and Senn modified it by substituting decalcified bone-plates for sutures. b Since that time, Abbe, Matas, Davis, BrokaAV, Robinson, Stamm, Baracz, and Dawburn, have modified the material of the plates used, substituting cat- gut rings, untanned leather, cartilage, raAV turnips, potatoes, etc. Recently, Murphy of Chicago has invented a button, Avhich has been extensh'ely used all over the world, in place of sutures and rings, as a means of anastomosis. Hardly any subject has had more discussion in recent literature than the merits of this ingenious contrivance. Foreign Bodies in the Rectum.—Probably the most celebrated case of foreign body introduced into the rectum is the classic one mentioned by Hevin.c Some students introduced the frozen tail of a pig in the anus of a French prostitute. The bristles Avere cut short, and having prepared the passage AA'ith oil, they introduced the tail Avith great force into the rectum, alloAving a portion to protrude. Great pain and A'iolent symptoms folloAved ; there Avas distressing A'omiting, obstinate constipation, and fever. Despite the efforts to Avithdnvw the tail, the arrangement of the bristles AA'hich alloAA'ed entrance, prevented removal. On the sixth day, in great agony, the Avoman applied to Marchettis, avIio ingeniously adopted the simple procedure of tak- ing a long holloAV reed, and preparing one of its extremities so that it could be introduced into the rectum, he Avas enabled to pass the reed entirely around the tail and to AvithdraAV both. Relief Avas prompt, and the removal of the a 845, 715. b 845, 720. c Quoted 641, 353. 646 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. foreign body Avas folloAved by the issue of stercoraceous matter which had accumulated the six days it had remained in situ. Tuffet302is quoted as mentioning a farmer of forty-six aaIio, in masturba- tion, introduced a barley-head into his urethra. It Avas found necessary to cut the foreign body out of the side of the glans. A year later he put in his anus a cylindric snuff-box of large size, and this had to be removed by surgical methods. Finally, a drinking goblet was used, but this resulted in death, after much suffering and lay treatment. In his memoirs of the old Academy of Surgery in Paris, Morand speaks of a monk Avho, to cure a violent colic, introduced into his fundament a bottle of t'eaii de (a reine de Hongrie, Avith a small opening in its mouth, by Avhich the contents, drop by drop, could enter the intestine. He found he could not remove the bottle, and A'iolent inflammation ensued. It Avas at last necessary to secure a boy with a small hand to extract the bottle. There is a record of a case a in AA'hich a tin cup or tumbler avus pushed up the rectum and then passed into the colon Avhere it caused gangrene and death. It Avas found to measure 3?, by ;>r by two inches. There is a French ease b in Avhich a preserve-pot three inches in diameter Avas introduced into the rectum, and had to be broken and extracted piece by piece. Cloquetc had a patient avIio put into his rectum a beer glass and a pre- serving pot. Montanari removed from the rectum of a man a mortar pestle 30 cm. long, and Poulet641 mentions a pederast Avho accidentally killed himself by introducing a similar instrument, 55 cm. long, Avhich per- forated his intestine. Studsgaard mentions that in the pathologic collection at Copenhagen there is a long, smooth stone, 17 cm. long, weighing 900 gm., Avhich a peasant had introduced into his rectum to relieve prolapsus. The stone1 Avas extracted in 1756 by a surgeon named Frantz Dyhr. Jeffreys'1 speaks of a person avIio, to stop diarrhea, introduced into his rectum a piece of AA'ood measuring seven inches. There is a remarkable case recorded e of a stick in the anus of a man of sixty, the superior extremity in the right hypochondrium, the inferior in the concavity of the sacrum. The stick measured 32 cm. in length ; the man recoA'ered. It is impossible to comprehend this extent of straightening of the intestine Avithout great twisting of the mesocolon. Tompsettf mentions that he Avas called to see a workman of sixty-five, suffering from extreme rectal hemorrhage. He found the man very feeble, Avithout pulse, pale, and livid. By digital examination he found a hard body in the rectum, which he AA'as sure Avas not feces. This body he removed AA'ith a polyp-forceps, and found it to be a'cylindric candle-box, Avhich measured six inches in circum- ference, 24; in length, and If in diameter. The remoA'al Avas folloAved by a veritable flood of fecal material, and the man recovered. Laneg reports a 218. 1855. b 297, T. iii., 177. c 446, 1844. d 476, 1*6*. e 365, 1868. * 476, 1869, i., 448. g 224, May 9, 1874. FOREIGN BODIES IN THE RECTUM. 647 perforation of the rectum by the introduction of two large pieces of soap; there Avas coincident strangulated hernia. Hunter a mentions a native Indian, a resident of Coorla, Avho had intro- duced a bullock's horn high up into his abdomen, which neither he nor his friends could extract. He Avas chloroformed and placed in the lithotomy position, his buttocks brought to the edge of the bed, and after dilatation of the sphincter, by traction Avith the fingers and tooth-forceps, the horn Avas ex- tracted. It measured* 11 inches long. The young imbecile had picked it up on the road, Avhere it had been rendered extremely rough by exposure, and this caused the difficulty in extraction. In Nelson's Northern Lancet, 1852,582 there is the record of a case of a man at stool, who slipped on a coav's horn, Avhich entered the rectum and lodged beyond the sphincter. It avus only remoA'ed Avith great difficulty. A convict at Brestb put up his rectum a box of tools. Symptoms of vomiting, meteorism, etc., began, and became more A'iolent until the seventh day, Avhen he died. After death, there Avas found in the transverse colon, a cylindric or conic box, made of sheet iron, covered AA'ith skin to protect the rectum and, doubtless, to aid expulsion. It AAas six inches long and five inches broad and Aveighed 22 ounces. It contained a piece of gun- barrel four inches long, a mother-sere av steel, a screAV-driver, a suav of steel for cutting Avood four inches long, another saAV for cutting metal, a boring syringe, a prismatic file, a half-franc piece and four one-franc pieces tied to- gether Avith thread, a piece of thread, and a piece of talloAV, the latter presum- ably for greasing the instruments. On investigation it avus found that these conic cases Avere of common use, and Avere ahvavs thrust up the rectum base first. In excitement this prisoner had pushed the conic end up first, thus rendering expulsion almost impossible. Oglec gives an interesting case of foreign body in the rectum of a boy of seventeen. The boy Avas supposed to be suffering with an abdominal tumor about the size of a pigeon's egg under the right cartilages ; it had been noticed four months before. On ad- mission to the hospital the lad Avas suffering Avith pain and jaundice; sixteen days later he passed a stick ten inches long, Avhich he reluctantly confessed that he had introduced into the anus. During all his treatment he Avas con- scious of the nature of his trouble, but he suffered rather than confess. Studsgaard d mentions a man of thirtyTfive avIio, for the purpose of stopping diarrhea, introduced into his rectum a preserve-bottle nearly seven inches long Avith the open end uppermost. The next morning he had violent pain in the abdomen, and the bottle could be felt through the abdominal Avail. It Avas necessary to perform abdominal section through the linea alba, divide the sigmoid flexure, and thus remove the bottle. The intestine Avas sutured and the patient recovered. The bottle measured 17 cm. long, five cm. in diameter at its loAver end, and three cm. at its upper end. « 777, I860. »' 51S, 1861, ii., 564. c 548, 1863, ii., 599. d 425, 1878. 648 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. Briggsa reports a case in which a wine glass Avas introduced into the rectum, and although removed twenty-four hours afterAvard, death ensued. Hoekenhullb extracted 402 stones from the rectum of a boy of seven. Lan- dererc speaks of a curious case in Avhich the absorptive poAver of the rectum was utilized in the murder of a boy of fifteen. In order to come into the possession of a large inheritance the murderess poisoned the boy by introduc- ing the ends of some phosphorous matches into his rectum, causing death that night; there was intense inflammation of the rectum. The Avoman Avas speedily apprehended, and committed suicide Avhen her crime Avas knoAvn. Complete transfixion of the abdomen does not ahvays have a fatal issue. In fact, Iavo older Avriters, AViseinann and Muys, testify that it is quite possible for a person to be transfixed Avithout having any portion of the intestines or viscera wounded. In some nations in olden times, the extremest degree of punishment avus transfixion by a stake. In his voyages and travels,d in describing the death of the King of Demaa at the hands of his page, Mendez Pinto says that instead of being reserved for torture, as Avere his successors Ravaillac, and Gerard, the slayer of William the Silent, the assassin Avas impaled alive Avith a long stake Avhich Avas thrust in at his funda- ment and came out at the nape of his neck. There is a record e of a man of twenty-five, a soldier in the Chinese Avar of 1860, avIio, in falling from his horse, avus accidentally transfixed by a bayonet. The steel entered his back two inches to the left of the last dorsal A'ertebra, and reappeared two inches to the left and beloAv the umbilicus; as there Avas no symptom of visceral wound there Avere apparently no injuries except perforation of the parietes and the peritoneum. The man recoA'ered promptly. Rossf reports a case of transfixion in a young male aborigine, a native of Ncav South Wales, who had received a spear-Avound in the epigastrium dur- ing a quarrel; extraction Avas impossible because of the sharp-pointed barbs ; the spear Avas, therefore, saAved off, and Avas remoA'ed posteriorly by means of a small incision. The edges of the AA'ound Avere cleansed, stitched, and a compress and bandage applied. During the night the patient escaped and joined his comrades in the camp, and on the second day Avas suffering with radiating pains and distention. The folloAving day it Avas found that the stitches and plaster had been remoA'ed, and the anterior Avound Avas gaping and contained an ichorous discharge. The patient Avas bathing the wound AA'ith a decoction of the leaves of the red-gum tree. NotAvithstanding that the spear measured seA'en inches, and the interference of treatment, the ab- dominal AA'ound closed on the sixth day, and recovery Avas uninterrupted. Gilkrist s mentions an instance in Avhich a ramrod AA'as fired into a soldier's abdomen, its extremity lodging in the spinal column, Avithout causing the slightest evidence of Avounds of the intestines or viscera. A minute postmor- a 579, 1880. b 176, 1886-87, iii., 547. c 156 ; and quoted 224. 1882, i., 498. d London, 1663, 264. e 548, March 30, 1861. f 476, 1891. K 476, 1832, ii., 147. TRANSFIXION OF THE ABDOMEN. 649 tern examination Avas held some time afterward, the soldier having died bv droAvning, but the results were absolutely negative as regards any injury done by the passage of the ramrod. Humphreys11 says that a boy of eleven, Avhile "playing soldier" with an- other boy, accidentally fell on a rick-stake. The stake Avas slightly curved at its upper part, being 43 inches long and three inches in circumference, and sharp-pointed at its extremity. As much as 17| inches entered the body of the lad. The stake entered just in front of the right spermatic cord, passed beneath Poupart's ligament into the cavity of the abdomen, traversed the whole cavity across to the left side ; it then entered the thorax by perforating the diaphragm, displaced the heart by pushing it to the right of the ster- num, and pierced the left lung. It then passed anteriorly under the muscles and integument in the axillary space, along the upper third of the humerus, which avus extended beyond the head, the external skin not being ruptured. The stick remained in situ for four hours before attempts at ex- traction were made. On account of the displacement of the heart it Avas de- cided not to give chloroform. The boy AA'as held doAvn by four men, and Humphreys and his assistant made all the traction in their power. After removal not more than a teaspoonful of blood followed. The heart still remained displaced, and a lump of intestine about the size of an orange pro- truded from the Avound and was replaced. The boy made a sIoav and uninter- rupted recovery, and in six weeks was able to sit up. The testicle sloughed, but five months later, when the boy avus examined, he was free from pain and able to walk. There Avas a slight enlargement of the abdomen and a cica- trix of the Avound in the right groin. The right testicle Avas absent, and the apex of the heart was displaced about an inch. Woodbury b reports the case of a girl of fourteen, avIio fell seA'en or eight feet directly upon an erect stake in a cart; the tuberosity was first struck, and then the stake passed into the anus, up the rectum for tAvo inches, thence through the rectal wall, and through the body in an obliquely upAvard direc- tion. Striking the ribs near the left nipple it fractured three, and made its exit. The stake Avas three inches in circumference, and 27 inches of its length passed into the body, six or seven inches emerging from the chest. This girl recovered so rapidly that she Avas able to attend school six Aveeks afterAvard. In a case reported by Bailey0 a middle-aged Avoman, while slid- ing down a hay-stack, struck directly upon a pitchfork handle which entered the vagina ; the Avhole Aveight of the Avoman AAas successfully maintained by the cellular tissue of the uterovaginal culdesac. Minotd speaks of the passage of one prong of a pitchfork through the body of a man of twenty-one, from the perineum to the umbilicus ; the man recovered. Hamilton e reports a case of laceration of the perineum AA'ith penetration a .-)4S, 1871, ii., 392. b579? 1*74, xiv., 151. c Ibid <*21S, 1861, 80. e Trans. Belmont M. Soc, Bridgeport, Ohio, 1849-50, 55. 650 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. of the pelvic cavity to the depth of ten inches by a stick | inch thick. ProAVse a mentions the history of a case of impalement in a man of thirtA-four, Avho, coming doAvn a hay-stack, alighted on the handle of a pitchlbrk which struck him in the middle of the scrotum, and passed up between the skin and fascia to the 10th rib. Recovery was prompt. There are several cases on record in which extensive Avounds of the ab- dominal parietes AA'ith protrusion and injury to the intestine have not been folloAved by death. Injuries to the intestines themselves have already been spoken of, but there are several cases of evisceration Avorthy of record. Doughty b says that at midnight on June 7, 1868, he Avas called to see a man Avho had been stabbed in a street altercation Avith a negro. AVhen lirst seen in the street, the patient Avas lying on his back with his abdomen ex- posed, from Avhich protruded an enormous mass of intestines, which avc re covered Avith sand and grit ; the small intestine (ileum) was incised at one point and scratched at another by the passing knife. The incision, about an inch in length, Avas closed AA'ith a single stitch of silk thread, and after thor- ough cleansing the Avhole mass Avas returned to the abdominal cavity. In this hernial protrusion Avere recognized four or five feet of the ileum, the cecum Avith its appendix, part of the ascending colon AA'ith corresponding por- tions of the mesentery; the distribution of the superior mesentery, made more apparent by its living pulsation, Avas more beautifully displayed in its succession of arches than in any dissection that Doughty had ever Avitnessed. NotAvithstanding the extent of his injuries the patient recovered, and at last reports Avas doing finely. Barnes c reports the history of a negro of tAventy-five who was admitted to the Freedmen's Hospital, Ncav Orleans, May 15, 1867, suffering from an incised Avound of the abdomen, from AA'hich protruded eight inches of colon, all of the stomach, and nearly the Avhole of the small intestines. About 2| feet of the small intestine, having a Avhitish color, appeared to be filled Avith food and had much of the characteristic feeling of a sausage. The rest of the small intestine had a dark-brown color, and the stomach and colon, distended Avith gas, Avere leaden-colored. The viscera had been exposed to the atmosphere for over an hour. Having nothing but cold Mississippi Avater to Avash them Avith, Barnes preferred returning the intestines Avithout any attempt at re- moving blood and dirt further than wiping with a cambric handkerchief and the stripping they Avould naturally be subjected to in being returned through the opening. In ten minutes they Avere returned ; they were carefully ex- amined inch by inch for any wound, but none Avas found. Three silver sutures Avere passed through the skin, and a firm compress applied. The patient Avent to sleep shortly after his wound was dressed, and never had a single subsequent bad symptom ; he Avas discharged on May 24th, the wound being entirely healed, Avith the exception of a cartilage of a rib which had not reunited. a 224, 1884, ii., 20. b 847, 93. c 847, 95. GUNSHOT WOUNDS OF THE ABDOMEN. 651 Rogersa mentions the case of a carpenter of thirty-six avIio Avas struck by a missile throAvn by a circular saAv, making a Avound tAvo inches above the umbilicus and to the left. Through the opening a mass of intestines and a portion of the liver, attached by a pedicle, protruded. A portion of the liver Avas detached, and the liver, as Avell as the intestines, were replaced, and the man recovered. Baillie,b Bhadoory,0 Barker, Edmundson,d Johnson,e and others, record instances of abdominal Avounds accompanied by extensive protrusion of the intestines, and recovery. Shahf mentions an abdominal wound Avith protru- sion of three feet of small intestine. By treatment with ice, phenol, and opium, recovery Avas effected without peritonitis. A mong nonfatal perforating gunshot wounds of the abdomen, Lo- ring g reports the case of a private in the First Artillery Avho recoA'ered after a double gunshot perforation of the abdomen. One of the balls entered 5 J- inches to the left of the umbilicus, and two inches above the crest of the ilium, making its exit tAvo inches above the crest of the ilium, on a line with and tAvo inches from the 4th lumbar vertebra. The other ball entered four inches beloAv and to the rear of the left nipple, making its exit four inches directly below the point of entrance. In their passages these balls did not wound any of the viscera, and with the exception of traumatic fever there was no disturbance of the health of the patient. Schellh records the case of a soldier Avho Avas Avounded July 3, 1867, by a conoid ball from a Rem- ington revolver of the Army pattern. The ball entered on the left side of the abdomen, its loAver edge grazing the center of Poupart's ligament, and passing backAvard, inAvard, and slightly upward, emerged one inch to the left of the spinous process of the sacrum. On July 6th all the symptoms of peritonitis made their appearance. On July 11th there AAas free dis- charge of fecal matter from both anterior and posterior wounds. This discharge continued for three days and then ceased. By August 12th both wounds were entirely healed. Mineer1 reports a case of a Avound from a revolver-ball entering the abdomen, passing through the colon, and extracted just above the right ilium. Under simple treatment the patient recovered and AA'as returned to duty about ten Aveeks afterAvard. There are a number of cases on record in Avhich a bullet entering the abdominal cavity is subsequently voided either by the bladder or by the bowel. DueachetJ mentions Iavo cases at the GeorgetoAvn Seminary Hospital during the late Avar in AA'hich Alinie balls entering the abdominal Avail Avere voided by the anus in a much battered condition. Bartlettk reports the case of a young man AA'ho aajis accidentally shot in the abdomen Avith a Colt's re- volver. Immediately after the accident he complained of constant and press- a 269, 187."), 884. b 435, 1866, i., 9. c 435, 1872. vii., 135. d.312, xxxvi., 209. e 536, 1867, iii., 225. f 435, ix., 297. g S47, 55. b847, is. i Ibid. J 130, 1863, vii., 134. * 331, 1856. 652 SURGICAL ANOMALIES OF THORAX AND ABDOMEN ing desire to void his urine. While urinating on the evening of the third day, the ball escaped from the urethra and fell Avith a click into the chamber. After the discharge of the ball the intolerable symptoms impro\red, and in two or three Aveeks there Avas complete recovery. Hoag mentions a man avIio was Avounded by a round musket-ball Aveighing 400 grains. It had evidently passed through the lung and diaphragm and entered the alimentary canal; it AAas voided by the rectum five days after the injury. Lenox a mentions the fact of a bullet entering the abdominal wall and subsequently being passed from the rectum. Day and Judkins report similar cases. Rundle b speaks of the lodgment of a bullet, and its escape, after a period of seven and one-half years, into the alimentary canal, causing internal strangulation and death. Wounds of the liver often end A'ery happily, and there are many cases on record in AA'hich such injuries have been folioAved by recovery, even Avhen associated Avith considerable loss of liver-substance. In the older records, Glandorp380 and Scultetus mention cures after large Avounds of the liver. Fabricius Hildanus reports a case that ended happily, in Avhich a piece of liver Avas found in the Avound, haA'ing been separated by a sAVord-thrust. There is a remarkable example0 of recovery after multiple A'isceral wounds, self-in- flicted by a lunatic. This man had 18 wounds, 14 having penetrated the abdomen, the liver, colon, and the jejunum being injured ; by frequent bleed- ing, strict regimen, dressing, etc., he recovered his health and senses, but relapsing a year and a half later, he again attempted suicide, Avhich gave the opportunity for a postmortem to learn the extent of the original injuries. Plater,635 Schenck, Cabrolius,245 the Ephemerides, and Nollesond mention recovery after Avounds of the liver. Salmuth706 and the Ephemerides report questionable instances in Avhich portions of the lh'er Avere ejected in violent A'omiting. Macphersone describes a Avound of the liver occurring in a Hindoo of sixty avIio had been struck by a spear. A portion of the liver AA'as protruding, and a piece Aveighing 1\ ounces Avas removed, complete re- coA'ery folloAving. Postempskif mentions a case of suture of the liver after a stab-Avound. Six sutures of chromicized cat-gut Avere carefully tightened and fastened with a single loop. The patient left his bed on the sixth day and completely recov- ered. Garni* reports a case of harpoon-wound of the liver. AVhile in a dory spearing fish in the Rio Nuevo, after a sudden lurch of the boat, a young man of twenty-eight fell on the sharp point of a harpoon, which penetrated his abdomen. About one inch of the harpoon Avas seen protruding from be- Ioav the tip of the ensiform cartilage ; the harpoon Avas seven inches long. It Avas found that the instrument had penetrated the right lobe of the liver; on passing the hand backAvard along the inferior surface of the liver, the point a 250, 1872-73, 112. b 54* 1H66, i., 306. c Mem. de l'Acad. Rov. des Sciences. 1705. d 462, T. xxii., 258. e 661, 1846. f 684, June 9, 1888. g 476. 1894, i., 1371. WOUNDS OF THE LIVER. 653 could be felt projecting through its posterior border. On account of two sharp barbs on the spear-point, it Avas necessary to push the harpoon further in to disengage the barbs, after AA'hich it Avas easily remoA'ed. Recovery fol- loAved, and the patient Avas discharged in twenty-one days. Romme a discusses the subject of punctured wounds of the liver, as a spe- cial text using the case of the late President Carnot. He says that in 543 cases of traumatism of the liver collected by Elder, 65 Avere caused by cutting or sharp-pointed instruments. Of this group, 23 recovered and 42 died. The chief causes of death were hemorrhage and peritonitis. The principal symptoms of Avounds of the liver, such as traumatic shock, col- lapse, local and radiating pains, nausea, vomiting, and respiratory disturb- ances avc re all present in the case of President Carnot. From an experi- ence gained in the case of the President, Romme strongly recommends exploratory celiotomy in all penetrating Avounds of the liver. Zeidlerb re- ports three cases of Avound of the liver in which recoA'ery ensued. The hemorrhage in one ease Avas arrested by the tampon, and in the other by the Pacquelin cautery. McMillan0 describes a man of tAventy av!io Avas kicked by a horse over the liver and rupturing that organ. A large quantity of offensh'e fluid avus dnuvn off from the liver, and the man recovered. Frazerd reports a ease of rupture of lh'er and kidney in a boy of thirteen avJio Avas squeezed betAA'een the tire and driving chain of a mill, but who recovered despite his serious symptoms. Allene mentions recovery after an extensive incised Avound of the abdomen, liver, and lung. Massief cites an instance of gunshot Avound of the right hypochondrium, Avith penetration and protrusion of the liver. The patient, a boy of seA'en, recovered after excision of a small part of the protruding liver. LaAvson Tail has incised the liver to the extent of three inches, evacuated two gallons of hydatids, and obtained successful recovery in ten Aveeks. There are several cases of Avound of the liver folloAved by recovery re- ported by surgeons of the United States Army.g AVhitehead mentions a man of tAvcnty-tAvo avIio on June 3, 1867, Avas shot in the liver by a slug from a pistol. At the time of the injury he bled freely from the Avound of entrance, continuing to lose blood and bile until daylight the next morning, when the hemorrhage ceased, but the Aoav of bile kept on. By June 10th there Avas considerable improvement, but the AA'ound discharged blood-clots, bile, and serum. When the patient left the hospital on July 15th the wound Avas healthy, discharging less than \\ ounces during the tAventy-four hours, of a mixture of free bile, and bile mixed AA'ith thick material. AVhen last heard from—Julv 27, 1867—the patient was improving finely in flesh and strength. MeKee mentions a commissary-sergeant stationed at Santa Fe, a La Tribune Medicule, July 5, 1894. b 300, Sept. 13, 1894. c 476, 1860, ii., 431. d 536, 1878, 200. e 591, 1855. * 593, ix., 146. e 847, 49. 654 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. NeAV Mexico, avIio recoA'ered after a gunshot Avound of the liver. Hassig re- ports the case of a private of twenty-six Avho Avas Avounded in a i'rav near Paducah, Kentucky, by a conoid ball, Avhich passed through the liA'er. The ball Avas cut out the same day. The patient recovered and AA'as returned to duty in May, 1868. Patzki mentioned a private in the Sixth Cavalry, aged tAventy-five, Avho recoA'ered from a gunshot Avound of the abdomen, penetrat- ing the right lobe of the liA'er and the gall-bladder. Resection of the Liver.—It is remarkable to Avhat extent portions of the liver may be resected by the knife, cautery, or ligature, and the patient recoA'er. Langenbuch records a case in Avhich he successfully re- moved the greater portion of the left lobe of a Avoman of thirty. The lobe had been extensively de- formed by tight lacing, and caused serious inconvenience. There Avas considerable hemorrhage, but the A'cssels Avere secured, and the Avoman made a good recovery.845 McAVhinnic, in The Lancet, re- cords a case of dislodgment of an enlarged liver from tight lacing. Terrilon a mentions an instance in which a portion of the liA'er Avas removed by ligature after celi- otomy. The ligature was removed in seven days, and the sphacelated portion of the liver came off with it. A cicatrix Avas completed at the end of six Aveeks, and the patient, a woman of fifty-three, made an excellent recovery. Bastianelli b discusses those cases in Avhich portions of the liver, having been constricted from the general body of the organ and remaining attached by a pedicle, give rise to movable tumors of the abdomen. He records such a case in a Avoman of thirty-seven Avho had five children. A piece of liver weighing 500 grams Avas removed, and with it the gall-bladder, and the patient made an uninterrupted recovery. Tricomi reports a case in which it was found necessary to remove the left lobe of the liver. An attempt had been made to remove a liver-tumor the size of a fist by constricting the base Avith an elastic ligature. This attempt was a failure, and cure was also un- a Quoted 536, 1890, ii., 263. b 843, 236. Fig. 222.—Floating liver (Keen and AVhite). OPERATIONS ON THE GALL-BLADDER. 655 successfully attempted by Avire ligature and the thermocautery. The groAvth Avas cut aAA'ay, bleeding Avas arrested by the thermocautery and by iron-solu- tion, the Avound entirely healed, and the patient recovered. Valerian von Meister has proved that the liver has marvelous poAvers of regeneration, and that in rabbits, cats, and dogs, eA'en three-fourths of the organ may be repro- duced in from forty-five to sixty-five days. This regeneration is brought about chiefly by hypertrophy of the lobules.3 Floating liver is a rare malady in Avhich the liver forms an abdominal prominence that may be moved about, and AA'hich changes its situation as the patient shifts the attitude. The condition usually arises from a lax abdominal Avail folloAving repeated pregnancies. The accompanying illustration (Fig. 222) exhibits a typical case verified by postmortem examination.845 Hypertrophy of the Liver.—The average Aveight of the normal liver is from 50 to 55 ounces, but as noted by PoAvell,''42 it may become so hyper- trophic as to Aveigh as much as 40 pounds. Bonet describes a liver weighing 18 pounds ; and in his " Medical and Surgical Observations," Gooch speaks of a liver Aveighing 28 pounds. Vieussens, the celebrated anatomist,b reports an instance in Avhich the liver Aveighed 20 pounds, and in his "Aphorisms," Vctter cites a similar instance. In 1811 Kraus of Germany describes a liver Aveighing 25 pounds; modern instances of enlarged liver are too numerous to be quoted here. Rupture of the gall-bladder, although generally folloAved by death, is not ahvays fatal. In such cases bile is usually found in the abdominal cavity. Fergus c mentions a case in Avhich, after this accident, the patient Avas considered coiwalescent and AA'as Avalking about, Avhen, on the seventh day, peritonitis suddenly developed and proved fatal in tAvo days. Several cases of this accident have been reported as treated successfully by incision and drainage (Lane) or by inspiration (Bell). In these cases large quantities of bile escaped into the abdominal cavity. Peritonitis does not necessarily follow."45 Cholecystotomy for the relief of the distention of the gall- bladder from obstruction of the common or cystic duct and for the removal of gall-stones AA'as first performed in 1867 by Bobbs of Indianapolis, but it is to Marion Sims, in 1878, that perfection of the operation is due. It has been gradually improved and developed, until to-day it is a most suc- cessful operation. Tait reports 54 cases with 52 perfect recoveries. Cho- lyecystectomy, or excision of the gall-bladder, was first practised in 1880 by Langenbucli of Berlin, and is used in cases in which gall-stones are repeatedly forming. Ashhurst's statistics show only four deaths in 28 cases. At St. BartholomeAv's Hospital, in London, is a preserved specimen of a gall-bladder Avhich had formed the contents of a hernial sac, and Avhich, near the fundus, shows a constriction caused by the femoral ring. It Avas a 843, 237. b "Traite des Mai. Internes," T. ii. c 174, 400. 656 SURGICAL ANOMALIES OF THORAX AND ABDOMEN taken from a Avoman of forty-five AA'ho Avas admitted into the hospital Avith a strangulated femoral hernia. The sac Avas opened and its contents avc re re- turned. The Avoman died in a few days from peritonitis. The gall-bladder Avas found close to the femoral ring, and shoAved a marked constriction. The liver AAas misshapen from tight lacing, elongated and dniAvn dowmvard toAvard the ring. There Avas no evidence that any portion of intestine or other structure besides the gall-bladder had passed through the ring.'119 The fatality of rupture of the spleen is quite high. Out of 8;>) eases of injury to this organ collected by Elder, and quoted by MaoCormae, only 11 recovered; but the mortality is less in punctured or incised wounds of this organ, the same authorities mentioning 29 recoveries out of 35 cases. In his "Surgery" Gooeh says that at the battle of Dettingen one of Sir Robert Rich's Dragoons avus left all night on the field, weltering in his blood, his spleen hanging out of his body in a gangrenous state. The next morn- ing he Avas carried to the surgeons avIio ligated the large vessels, and extir- pated the spleen ; the man recovered and AA'as soon able to do duty. In the Philosophical Transactions a there is a report of a man avIio Avas Avounded in the spleen by a large hunting-knife. Fergusson found the spleen hanging from the \vound and ligated it. It separated in ten days and the patient recovered. Williams b reports a stab-wound of the spleen in a negro of tAventy-one. The spleen protruded, and the protruding part aahs ligated by a silver Avire, one-half of the organ sloughing off; the patient recovered. Sir Astley Cooper mentions a curious case, in which, after vomiting, during Avhich the spleen avus torn from its attachments, this organ produced a SAvelling in the groin Avhich avus supposed to be a hernia. The A'omiting continued, and at the end of a Aveek the Avoman died ; it Avas then found that the spleen had been turned half round on its axis, and detached from the diaphragm ; it had become enlarged ; the tAvist interrupted the return of the blood. Por- tal0 speaks of a rupture of the spleen simply from engorgement. There AA'as no history of a fall, contusion, or other injury. Tait d describes a ease of rupture of the spleen in a Avoman who, in attempting to avoid her hus- band's kick, fell on the edge of the table. There Avere no signs of external violence, but she died the third day afterAvard. The abdomen Avas found full of blood, and the spleen and peritoneal covering was ruptured for three inches. Splenectomy, excision of the spleen, has been performed a number of times, Avith varying results, but is more successful Avhen performed for injury than Avhen for disease. Ashhurstm has tabulated a total of 109 operations, 27 having been for traumatic causes, and all but five having terminated suc- cessfully ; of 82 operations for disease, only 32 recovered. Yulpius has col- lected 117 cases of splenectomy, Avith a death-rate of 50 per cent. If, Iioav- a 629, 1738. b 230, xii., 86. c 39, T. v., 345. d 605, 1844, L, 104. RUPTURE OF THE THORACIC DUCT. 657 ever, from these cases we deduct those suffering with leukocythemia and lardaceous spleen, in Avhich the operation should not be performed, the mor- tality in the remaining 85 cases is reduced to 33 per cent. Terrier speaks of splenectomy for torsion or twisting of the pedicle, and such is mentioned by Sir Astley Cooper, Avho has found records of only four such cases. Conk- lina reports a successful case of splenectomy for malarial spleen, and in re- vieAving the subject he says that the records of the past decade in operations for simple hypertrophy, including malaria, shoAv 20 recoveries and eight deaths. He also adds that extirpation in cases of floating or displaced spleen Avas attended with brilliant results. Zuccarellib is accredited Avith reporting tAvo cases of splenectomy for malarial spleen, both of AA'hich recovered early. He gives a table of splenectomies performed in Italy, in Avhich there were nine cases of movable spleen, with two deaths ; eight cases of simple hyper- trophy, with three deaths; 12 cases of malarial spleen, with three deaths; four cases of leukemia and pseudoleukemia, with two deaths. In his experi- ments on rabbits it was proved by Tizzoni, and in his experiments on dogs, by Crede, that an individual could live without a spleen; but these observa- tions were only confirmatory of what had long been knoAvn, for, in 1867, Pean successfully removed a spleen from a woman of twenty. Tricomic reports eight cases in Avhich he had extirpated the spleen for various morbid conditions, with a fortunate issue in all but one. In one case he ligated the splenic artery. In The Lancetd there is an account of three recent excisions of the spleen for injury at St. Thomas Hospital in London, and it is added that they are among the first of this kind in Great Britain. Abnormalities of Size of the Spleen.—The spleen may be extremely small. Storcke mentions a spleen that barely weighed an ounce; Schenck ( speaks of one in the last century that weighed as much as 20 pounds. Frank351 describes a spleen that Aveighed 16 pounds; there is another record of one Aveighing 15 pounds/ Elliot8 mentions a spleen AA'eighing 11 pounds ; Burrowsh one, 11 pounds; Blasius, four pounds; Osiander, nine pounds; Blanchard,213 3\ pounds ; Richardson,1 3\ pounds; and Hare,J 93 ounces. The thoracic duct, although so much protected by its anatomical posi- tion, under exceptional circumstances has been ruptured or wounded. Kirchnerk has collected 17 cases of this nature, Iavo of which were due to contusions of the chest, one each to a puncture, a cut, and a shot-wound, and three to erosion from suppuration. In the remaining cases the account fails to assign a definite cause. Chylothorax, or chylous ascites, is generally a re- sult of this injury. Krabbel mentions a patient AA'ho was run OA'er by an empty coal car, and avIio died on the fifth day from suffocation due to an effu- sion into the right pleural caA'ity. On postmortem examination it Avas found a 538, July 28, 1894. b 843, 252. <= Ibid. d Quoted Amer. Med. Review, Dec, 1895. »■■ 752, i., 114. t 282, 1732, 260. g 524, vii., 46. b 528, vii. i 548, 1852, ii., 399. j 548, 1861, i., 289. k 845, 454. 42 658 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. that the effusion was chyle, the thoracic duct being torn just opposite the 9th dorsal vertebra, Avhich had been transversely fractured. In one of Kin-li- ner's cases a girl of nine had been A'iolently pushed against a Avindow-sill striking the front of her chest in front of the 3d rib. She suffered from pleural effusion, which, on aspiration, proved to be chyle. She ultimately recovered her health. In 1891 Eyer reported a case of rupture of the thora- cic duct, causing death on the thirty-eighth day. The young man had been caught between a railroad car and an engine, and no bones Avere broken. Manleya reports a case of rupture of the thoracic duct in a man of thirty-fh'e, Avho was struck by the pole of a brcAvcry wagon ; he Avas knocked doAvn on his back, the Avheel passing squarely over his abdomen. There AA'as subsequent bulging Ioav doAvn in the right iliac fossa, caused by the pres- ence of a fluid, AA'hich chemic and microscopic examination proyed was chyle. From five to eight ounces a day of this fluid Avere discharged, until the tenth day, when the bulging Avas opened and drained. On the fifteenth day the Avound Avas healed and the man left the hospital quite restored to health. Keen has reported four instances of accidental injury to the thoracic duct, near its termination at the base of the left side of the neck ; the Avounding was in the course of removals for deep-seated growths in this region. Three of the cases recovered, having sustained no detriment from the injury to the thoracic duct. One died ; but the fatal influence was not specially connected AA'ith the wound of the duct. Possibly the boldest operation in the history of surgery is that for ligation of the abdominal aorta for inguinal aneurysm. It Avas first practised by Sir Astley Cooper in 1817, and has since been performed several times with a uniformly fatal result, although Monteiro's patient sur- A'ived until the tenth day, and there is a record in Avhich ligature of the abdominal aorta did not cause death until the eleventh day.b Loreta of Bologna is accredited Avith operating on December 18, 1885, for the relief of a sailor Avho Avas suffering from an abdominal aneurysm caused by a bloAV. An incision Avas made from the ensiform cartilage to the umbilicus, the aneurysm exposed, and its cavity filled up with tAvo meters of silver-plated Avire. Twenty days after no evidence of pulsation remained in the sac, and three months later the sailor Avas Avell and able to resume his duties. Ligation of the common iliac artery, which, in a case of gunshot injury, was first practised by Gibson of Philadelphia in 1812, is, happily, not ahvays fatal. Of 82 cases collected by Ashhurst, 23 terminated suc- cessfully. Foreign bodies loose in the abdominal cavity are sometimes voided at stool, or may suppurate externally. Fabricius Hildanus334 gives us a history of a person Avounded with a sword-thrust into the abdomen, the point break- a 533, lxv.,1894, 491. b 810, 1853. FRACTURE OF THE LOWER SPINE. 659 ing off. The SAvord remained one year in the belly and Avas voided at stool. Erichsen a mentions an instance in which a cedar lead-pencil staved for eight months in the abdominal cavity. Desgranges b gives a case of a fish-spine in the abdominal cavity, and ten years afterward it ulcerated through an ab- scess in the abdominal Avail. Keetleyc speaks of a man Avho Avas shot when a boy; at the time of the accident the boy had a small spelling-book in his pocket. It Avas not until adult life that from an abscess of the groin Avas expelled Avhat remained of the spelling-book that had been driven into the abdomen during boyhood. Kyled speaks of the removal of a corn- straAv 33 inches in length by an incision ten inches long, at a point about equidistant from the umbilicus to the anterior spinous process of the right ilium. There are several instances on record of tolerance of foreign bodies in the skin and muscles of the back for an extended period. Gaye speaks of a curious case in AA'hich the point of a sheath-knife remained in the back of an individual for nine years. Bush reported to Sir Astley Cooperf the history of a man avIio, as he supposed, received a Avound in the back by can- ister shot Avhile serving on a Tartar privateer in 1779. There was no ship- surgeon on board, and in about a month the wound healed Avithout surgical assistance. The man suffered little incoiiA'enience and performed his duties as a seaman, and Avas impressed into the Royal Navy. In August, 1810, he complained of pain in the lumbar region. He avus submitted to an examina- tion, and a cicatrix of this region Avas noticed, and an extraneous body about \ inch under the integument Avas felt. An incision was made down it, and a rusty blade of a seaman's clasp-knife extracted from near the 3d lumbar vertebra. The man had carried this knife for thirty years. The Avound healed in a feAV days and there Avas no more inconvenience. Fracture of the lower part of the spine is not ahvays fatal, and not- withstanding the lay-idea that a broken back means certain death, patients with Avell-authenticated cases of vertebral fracture have recovered. War- ren6 records the case of a Avoman of sixty Avho, while carrying a clothes- basket, made a misstep and fell 14 feet, the basket of wet clothes striking the right shoulder, chest, and neck. There avus fracture of the 4th dorsal ver- tebra at the transverse processes. By seizing the spinous process it could be bent backward and forward, Avith the peculiar crepitus of fractured bone. The clavicle was fractured tAvo inches from the acromial end, and the sternal end AA-as driven high up into the muscles of the neck. The arm and hand were paralyzed, and the AA'oman suffered great dyspnea. There Avas at first a grave emphysematous condition due to the laceration of several broken ribs. There Avas also suffusion and ecchymosis about the neck and shoulder. Although complicated Avith tertiary syphilis, the Avoman made a fair recovery, a 550, 1855, 15. b 463, iii., 343. c 536, 1884, ii., 419. d Western Laucet, Cincinnati, 1848. e 218, 1850. t 550, 1817. g 520, 1882. 660 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. and eight Aveeks later she Avalked into a doctor's office. Many similar and equally Avonderful injuries to the spine are on record. The results sometimes folloAving the operation of laminectomy for fracture of the A-ertebrae are often marvelous. One of the most successful on record is that reported by Dundore.a The patient Avas a single man who lived in Mahanoy, Pa., and Avas admitted to the State Hospital for Injured Persons, Ashland, Pa., June 17, 1889, suffering from a partial dislocation of the 9th dorsal vertebra. The report is as folloAvs :—" He had been a laborer in the mines, and Avhile Avorking Avas injured March 18, 1889, by a fall of top rock, and from this date to that of his admission had been under the care of a local physician Avithout any sign of improvement. At the time of his admission he Aveighed but 98 pounds, his weight previous to the injury being 145. He exhibited entire loss of motion in the lower extremities, with the exception of very slight movement in the toes of the left foot; sensation Avas almost nil up to the hips, above Avhich it Avas normal; he had complete retention of urine, Avith a severe cystitis. His tongue Avas heavily coated, the boAvels constipated, and there was marked anorexia, Avith considerable anemia. His temperature A'aried from 99° to 100° in the morning, and from 101° to 103° in the evening. The time which had elapsed since the accident precluded any attempt at reduction, and his anemic condition Avould not Avarrant a more radical method. " He Avas put on light, nourishing diet, iron and strychnin Avere given internally, and electricity Avas applied to the lower extremities eA'ery other day ; the cystitis Avas treated by irrigating the bladder each day Avith Thiersch's solution. By August his appetite and general condition Avere much improved, and his Aveight had increased to 125 pounds, his tempera- ture being 99° or less each morning, and seldom as high as 100° at night. The cystitis had entirely disappeared, and he was able, with some effort, to pass his urine Avithout the aid of a catheter. Sensation in both extremities had slightly improved, and he Avas able to slightly move the toes of the right foot. This being his condition, an operation Avas proposed as the only means of further and permanent improA'ement, and to this he eagerly consented, and, accordingly, on the 25th of August, the 9th dorsal vertebra Avas trephined. " The cord Avas found to be compressed and greatly congested, but there AA'as no evidence of laceration. The lamina? and spinous processes of the 8th and 9th dorsal vertebra? Avere cut away, thus relieving all pressure on the cord ; the Avound Avas drained and sutured, and a plaster-of-Paris jacket applied, a hole being cut out OA'er the Avound for the purpose of changing the dressing Avhen necessary. By September 1st union Avas perfect, and for the next month the patient remained in excellent condition, but Avithout any sign of improvement as to sensation and motion. Early in October he avus able a 533, Nov. 24, 1894. INJURIES TO THE SPINAL CORD. 661 to slightly move both legs, and had full control of urination; from this time on his paralysis rapidly improved ; the battery was applied daily, with mas- sage morning and evening; and in November the plaster-of-Paris jacket Avas removed, and he propelled himself about the ward in a rolling chair, and shortly after Avas able to get about sloAvly on crutches. He Avas discharged December 23d, and Avhen I saAv him six months later he Avalked verv Avell and Avithout effort; he carried a cane, but this seemed more from habit than from necessity. At present date he Aveighs 150 pounds, and drives a hucks- ter Avagon for a living, shoAving very little loss of motion in his loAver extremities." Although few cases show such Avonderful improvement as this one, statis- tics prove that the results of this operation are sometimes most advantageous. Thorburn a collects statistics of 50 operations from 1814 to 1885, undertaken for relief of injuries of the spinal cord. Lloydb has compiled Avhat is possibly the most extensive collection of cases of spinal surgery, his cases including operations for both disease and injury. AVhite has collected 37 cases of recent date ; and Chipault0 reports Iavo cases, and collected 33 cases. Quite a tribute to the modern treatment by antisepsis is shoAvn in the results of laminectomy. Of his non-antiseptic cases Lloyd reports a mortality of 65 per cent.; those surviving the operation are distributed as follows : Cured, one ; partially cured, seven ; unknoAvn, two ; no improvement, five. Of those cases operated upon under modern antiseptic principles, the mortality Avas 50 percent.; those smwivingAvere distributed asfoiloAA's: Cured, four ; partially cured, 15 ; no improvement, 11. The mortality in White's cases, Avhich avc re all done under antiseptic precautions, Avas 38 per cent. Of those sur- viving, there Avere six complete recoA'eries, six Avith benefit, and 11 Avithout marked benefit. Pyled collects 52 cases of spinal disease and injury, in which laminectomy Avas performed. All the cases Ave re operated upon since 1890. Of the 52 cases there Avere 15 deaths (a mortality of 29.4 percent.), 26 recoA'eries with benefit, and five recoveries in Avhich the ultimate result has not been observed. It must be mentioned that seA'eral of the fatal cases reported Avere those of cervical fracture, Avhich is by far the most fatal variety. Injury to the Spinal cord does not necessarily cause immediate death. Mills and O'Hara, both of Philadelphia, have recorded instances of reco\-ery after penetrating Avound of the spinal marroAv.e EA'ef reports three cases of gunshot Avound in AA'hich the balls lodged in the A'ertebral canal, Iavo of the patients recovering. He adds some remarks on the division of the spinal cord Avithout immediate death. Ford 8 mentions a gunshot wound of the spinal cord, the patient living ten days ; after death the ball Avas found in the ascending aorta. Henley h speaks of a mulatto of twenty-four avIio avus stabbed in the back Avith a knife. The a 224, No. 1747, 1894. b U4, July, 1891. c 162, 1890, ii., 673. d 150, June, 1894. e 547, 1879, ix., 265. f 124, lvi., 103. K 744, 1866, i., 286. b 538, 1874, ix., 423. 662 SURGICAL ANOMALIES OF THORAX AND ABDOMEN. blade entered the body of the 6th dorsal vertebra, and Avas so firmly embedded that the patient could be raised entirely clear of the bed by the knife alone. An ultimate recoAery ensued. Although the Avord hernia can be construed to mean the protrusion of any viscus from its natural cavity through normal or artificial openings in the surrounding structures, the usual meaning of the Avord is protrusion of the abdominal contents through the parietes—Avhat is commonly spoken of as rupture. Hernia may be congenital or acquired, or may be single or multiple —as many as five having been seen in one individual.* More than hvo-thirds of cases of rupture suffer from inguinal hernia. In the oblique form of in- guinal hernia the abdominal contents descend along the inguinal canal to the outer side of the epigastric artery, and enter the scrotum in the male, and the labium majus in the female. In this form of hernia the size of the sac is sometimes enormous, the ac- companying illustration show- ing extreme cases of both scrotal and labial hernia845 (Plate 7). Umbilical hernia may be classed under three heads: congenital, infantile, and adult. Congenital um- bilical hernia occurs most frequently in children, and is brought about by the failure of the abdominal Avails to close. Fig. 223.—Congenital umbilical hernia. A, liver; C, intestine; When of large size it may COn- D, cord; E, pedicle. . . . . , tain not only the intestines, but various other organs, such as the spleen, liver, etc. (Fig. 223). In some monsters all the abdominal contents are contained in the hernia. Infantile umbilical hernia is common, and appears after the separation of the umbilical cord ; it is caused by the yielding of the cicatrix in this situation. It never reaches a large size, and shows a tendency to spontaneous cure. Adult umbilical hernia rarely commences in infancy. It is most commonly seen in persons Avith pendulous bellies, and is sometimes of enormous size, in addition to the ordinary abdominal contents, containing even the stomach and uterus. A few years since there was a man in Philadelphia past middle age, the victim of adult umbilical hernia so pendulous that while Avalking he had to support it with his arms and hands. It was said that this hernia did not enlarge until after his service as a soldier in the late Avar. a 224, 1874, i., 805. Fig. 1.—Largje scrotal hernia. Fig. 2.—Large labial hernia (Keen and White). HERNIA. 665 Abbott a recites the case of an Irish Avoman of thirtv-five who applied to knoAv if she Avas pregnant. Xo history of a hernia could be elicited. No pregnancy existed, but there was found a ventral hernia of the abdominal viscera through an opening which extended the entire length of the linea alba, and Avhich Avas four inches Avide in the middle of the abdomen. Pirn b saAv a colored Avoman of tAventy-four avIio, on December 29, 1858, was delivered normally of her first child, and Avho died in bed at 3 A. m. on February 12, 1859. The postmortem shoAved a tumor from the ensi- form cartilage to the symphysis pubis, which contained the omentum, liver (left lobe), small intestines, and colon. It rested upon the abdominal mus- cles of the right side. The pelvic A'iscera Avere normally placed and there Avas no inguinal nor femoral hernia. Hulkec reports a case remarkable for the immense size of the rupture Avhich protruded from a spot Aveakened by a former abscess. There Avas a partial absence of the peritoneal sac, and the obstruction readily yielded to a clyster and laxative. The rupture had a transverse diameter of 14J inches, Avith a vertical diameter of 11^ inches. The opening avus in the abdominal Avails outside of the internal inguinal ring. The writhings of the intestines avc re very conspicuous through the Avails of the pouch. Daded reports a case of prodigious umbilical hernia (Fig. 224). The pa- tient Avas a AvidoAV of fifty-eight, a native of Ireland. Her family history Avas good, and she had neA'er borne any children. The present dimensions of the tumor, Avhich for fifteen years had been accompanied Avith pain, and had progressively increased in size, are as folloAvs : Circumference at the base, 19J inches ; circumference at the ex- tremity, 11 \ inches; distance of extremity from abdominal aaiiII, 12| inches. Inspection showed a large tabulated tumor protruding from the abdominal Avail at the umbilicus. The veins covering it Avere prominent and distended. The circulation of the skin avus defective, giving it a blue appearance. Vermicular contractions of the small intestines could be seen at the dis- tance of ten feet. The tumor AA'as soft and velvety to the touch, and could only partially be reduced. Borborygmus could be easily heard. On per- cussion the note over the bulk Avas tympanitic, and dull at the base. The distal extremity contained a portion of the small intestine instead of the Fig. 224.—Prodigious umbilical hernia (Dade). a 21S, lxv., 161. c 476, 1878, 693. b703, xvii., 224. d Louisville Med. Monthly, Feb., 1895. 666 SURGICAL ANOMALIES OF THORAX AND ABDOMEN colon, Avhich Wood considered the most frequent occupant. The umbilicus avus completely obliterated. Dade believed that this hernia Avas caused bv the Aveakening of the abdominal Avails from a bloAV, and considered that the protrusion came from an aperture near the umbilicus and not through it, in this manner differing from congenital umbilical hernia. A peculiar form of hernia is spontaneous rupture of the abdominal walls, Avhich, however, is very rare. There is an account of such a case :i in a Avoman of seventy-tAVO living in Pittsburg, Avho, after a spasmodic cough, had a spontaneous rupture of the parietes. The rent Avas four inches in length and extended along the linea alba, and through it protruded a mass of omentum about the size of a child's head. It Avas successfully treated and the woman recovered. Wallace b reports a case of spontaneous rupture of the abdominal Avail, folloAving a fit of coughing. The skin avus torn and a large coil of ileum protruded, uncovered by peritoneum. After protracted exposure of the boAvel it Avas replaced, the rent Avas closed, and the patient recovered. a 545, 1862, Ani., 53. b 436) 1881, 340. CHAPTER XIII. SURGICAL ANOMALIES OF THE GEOTTO- TJMXAKY SYSTEM. Wounds of the kidney may be A'ery severe Avithout causing death, and even one entire kidney may be lost Avithout interfering Avith the functions of life. Marvand,a the Surgeon-Major of an Algerian regiment, reports the case of a young Arab Avoman Avho had been severely injured in the right lumbar region by a Aveapon called a " yataghan," an instrument AA'hich has only one cutting edge. On AvithdraAving this instrument the right kidney was extruded, became strangulated between the lips of the Avound, and caused considerable hemorrhage. A ligature was put around the base of the organ, and after some Aveeks the mass separated. The patient continued in good health the Avhole time, and her urinary secretion Avas normal. She was discharged in Iavo months completely recovered. Price b mentions the case of a groom Avho AA'as kicked over the kidney by a horse, and eighteen months later died of dropsy. Postmortem examination shoAved traces of a line of rupture through the substance of the gland ; the preparation Avas deposited in St. George's Hospital Museum in London. The case is singular in that this man, Avith granular degeneration of the kidney, recovered from so extensive a lesion, and, moreover, that he remained in perfect health for OA'er a year Avith his kidney in a state of destructive disease. BortliAvickc mentions a dragoon of thirty avIio was stabbed by a SAVord-thrust on the left side under the short rib, the SAvord penetrating the pelvis and Avounding the kidney. There Avas no hemorrhage from the external Avound, nor pain in the spermatic cord or tes- ticle. Under expectant treatment the man recovered. Castellanos d mentions a case of recovery from punctured Avound of the kidney by a knife that pene- trated the tubular and cortical substance, and entered the pelvis of the organ. The case Avas peculiar in the absence of two symptoms, viz., the escape of urine from the Avound, and retraction of the corresponding testicle. Dusen- burye reports the case of a corporal in the army Avho Avas Avounded on April 6, 1865, the bullet entering both the liver and kidney. Though there AA'as injury to both these important organs, there was no impairment of the patient's health, and he recovered. a Revue de Med. de Militaire, Oct., 1875. b 779, Feb., 1860, 140. c 149, 1799, 466. «l 809, 1874, 281. e 124, Oct., 1865, 399. 667 668 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. Bryant3 reports four cases of AA'ound of the kidney, with recovery. All of these cases Avere probably extraperitoneal lacerations or ruptures. Cock '' found a curious anomaly in a necropsy on the body of a boy of eighteen, Avho had died after a fall from some height. There Avas a compound, transverse rupture of the left kidney, Avhich avus tAvice as large as usual, the ureter also bein«; of abnormal size. Further search showed that the right kidney Avas rudimentary, and had no vein or artery. Ward0 mentions a case of ruptured kidney, caused by a fall of seven feet, the man recovering after appropriate treatment. Vernon d reports a case of serious injury to the kidney, resulting in recovery in nine Aveeks. The pa- tient fell 40 feet, landing on some rubbish and old iron, and received a Avound measuring six inches over the right iliac crest, through Avhich the loAver end of the right kidney protruded ; a piece of the kidney Avas lost. The case Avas remarkable because of the slight amount of hemorrhage. Nephrorrhaphy is an operation in Avhich a movable or floating kidney is fixed by suture through its capsule, including a portion of kidney-substance, and then through the adjacent lumbar fascia and muscles. The ultimate results of this operation haA'e been most successful. Nephrolithotomy is an operation for the remoA'al of stone from the kid- ney. The operation may be a very difficult one, OAving to the adhesions and thickening of all the perinephric tissues, or to the small size or remote loca- tion of the stone. There AA'as a recent exhibition in London,619 in Avhich Avere shoAvn the results of a number of recent operations on the kidney. There Avas one-half of a kidney that had been remoA'ed on account of a rapidlv-groAving sarcoma from a young man of nineteen, Avho had knoAvn of the tumor for six months ; there Avas a good recovery, and the man avus quite Avell in eigh- teen months afterAvard. Another specimen a\ as a right kidney removed at St. BartholomeAv's Hospital. It Avas much dilated, and only a small amount of the kidney-substance remained. A calculus blocked the ureter at its commencement. The patient Avas a Avoman of thirty-one, and made a good recoA'erv. From the Middlesex Hospital Avas a kidney containing a uric acid calculus Avhich Avas successfully remoA'ed from a man of thirty-five. From the Cancer Hospital at Brompton there Avere tAvo kidneys Avhich had been removed from a man and a Avoman respectively, both of Avhom made a good recovery. From the King's College Hospital there Avas a kidney Avith its pelvis enlarged and occupied by a large calculus, and containing little secreting substance, Avhich Avas remoA'ed from a man of forty-nine, Avho recovered. These are only a few of the examples of this most interesting collection. Large calculi of the kidney are mentioned in Chapter XV. Rupture of the ureter is a very rare injury. Polande has collected a 392, vii., 1861, 41. b 779, 1347, i., 293. <■• 224, 1*71, ii-, 292. dSt. Bart. Hosp. Reports, London, 1866, ii., 124. e 174. 400. WOUNDS OF THE URETER. 669 the histories of four cases, one of Avhich ended in recovery after the evacua- tion by puncture, at intervals, of about tAvo gallons of fluid resembling urine. The other cases terminated in death during the first, fourth, and tenth weeks respectively. Peritonitis Avas apparently not present in any of the cases, the urinary extravasation having occurred into the cellular tissue behind the peritoneum. There are a feAV recorded cases of uncomplicated wounds of the ureters. The only Avell authenticated case in Avhich the ureter alone Avas divided is the historic injury of the Archbishop of Paris,3, who Avas wounded during the Revolution of 1848, by a ball entering the upper part of the lumbar region close to the spine. Unsuccessful attempts Avere made to extract the ball, and as there Avas no urine in the bladder, but a quantity escaping from the Avound, a diagnosis of divided ureter was made. The Archbishop died in eighteen hours, and the autopsy shoAved that the ball had fractured the transverse process of the 3d lumbar vertebra, and divided the eauda equina just beloAv its origin; it had then changed direction and passed up toAvard the left kidney, dividing the ureter near the peh'is, and finally lodged in the psoas muscle. It occasionally happens that the ureter is Avounded in the removal of uterine, OA'arian, or other abdominal tumors. In such event, if it is impos- sible to transplant to the bladder, the divided or torn end should be brought to the surface of the loin or vagina, and sutured there. In cases of malignant growth, the ureter has been purposely diA'ided and transplanted into the bladder. Penrose,1* assisted by Baldy, has performed this operation after excision of an inch of the left ureter for carcinomatous involvement. The distal end of the ureter Avas ligated, and the proximal end implanted in the bladder according to ATan Hook's method, Avhich consists in tying the loAvered end of the ureter, then making a slit into it, and invaginating the upper end into the loAver through this slit. A perfect cure folloAved. Similar cases have been reported by Kelly, Krug, and Bache Emmet.0 Reed d reports a most interesting series in Avhich he has successfully transplanted ureters into the rectum. UreteroA'aginal fistulpe folloAving total extirpation of the uterus, opening of pelvic abscesses, or ulcerations from foreign bodies, are repaired by an operation termed by Bazy of Paris ureterocystoneostomy, and suggested by him as a substitute for nephrectomy in those cases in Avhich the renal organs are unaffected. In the repair of such a case after a vaginal hysterectomy Mayoe reports a successful reimplantation of the ureter into the bladder. Stricture of the ureter is also a very rare occurrence except as a result of compression of abdominal or pelvic neAV growths. Watsonf has, however, reported tAvo cases of stricture, in both of which a ureter Avas nearly or quite a 363, lSls. b Kansas City Medical Index, No. 5, 1894. c 843, 446. d 150, 1892. e 538, Feb. 10, 1894. f 845, 825. 670 SURGICAL ANOMALIES OF THE GENITOURINARYSYSTEM. obliterated by a dense mass of connectiA'e tissue. In one case there was a history of the passage of a renal calculus years previously. In both in- stances the condition Avas associated Avith pyonephrosis. AVatson has col- lected the reports of four other cases from medical literature. A remarkable procedure recently developed by gynecologists, particularly by Kelly of Baltimore, is catheterization and sounding of the ureters. McClellan a records a case of penetration of the ureter by the careless use of a catheter. Injuries of the Bladder.—Rupture of the bladder may result from violence Avithout any external Avound (such as a fall or kick) applied to the abdomen. Jones b reports a fatal case of rupture of the bladder by a horse falling on its rider. In this case there Avas but little extravasation of urine, as the vesical aperture was closed by omentum and bowel. Assmuth reports Iavo cases of rupture of the bladder from muscular action. Morris c cites the history of a case in which the bladder Avas twice ruptured : the first time by an injury, and the second time by the giving Avay of the cicatrix. The patient aaus a man of thirty-six Avho received a blow in the abdomen during a fight in a public house on June 6, 1879. At the hospital his condition avus diagnosed and treated expectantly, but he recovered perfectly and left the hospital July 10, 1879. He Avas readmitted on August 4, 1886, over seven years later, with symptoms of rupture of the bladder, and died on the 6th. The postmortem showed a cicatrix of the bladder which had given way and caused the patient's death. Rupture of the bladder is only likely to happen when the organ is dis- tended, as AA'hen empty it sinks behind the pubic arch and is thus protected from external injury. The rupture usually occurs on the posterior Avail, in- voking the peritoneal coat and allowing extravasation of urine into the peri- toneal cavity, a condition that is almost inevitably fatal unless an operation is performed. Bartels collected the data of 98 such cases, only four recovering. When the rent is confined to the anterior wall of the bladder the urine escapes into the pelvic tissues, and the prognosis is much more favorable. Bartels collected 54 such cases, 12 terminating favorably. When celiotomy is per- formed for ruptured bladder, in a manner suggested by the elder Gross, the mortality is much less. Ashhurst collected the reports of 28 cases thus treated, ten of AA'hich recovered—a mortality of 64.2 per cent. Aslihurst re- marks that he has seen an extraperitoneal rupture of the anterior AAall of the bladder caused by improper use of instruments, in the case of retention of urine due to the presence of a tight urethral stricture. There are a feAV cases on record in which the bladder has been ruptured by distention from the accumulation of urine, but the accident is a rare one, the urethra generally giving Avay first. Coats d reports tAvo cases of uncompli- cated rupture of the bladder. In neither case was a history of injury ob- a 526, 1850, 692. b 476, 1870, ii., 252. c 476, 1887, i., 418. a 224, July 21, 1S94. WOUNDS OF THE BLADDER. 671 tainable. The first patient was a maniac; the second had been intoxicated previous to his admission to the hospital, with symptoms of acute peritonitis. The diagnosis was not made. The first patient died in five days and the second in tAvo days after the onset of the illness. At the autopsies the rent was found to be in both instances in the posterior wall of the bladder a short distance from the fundus; the peritoneum was not inflamed, and there AAas absolutely no inflammatory reaction in the A'esical wound. From the statistics of Ferraton and Rivington it seems that rupture of the bladder is more common in intoxicated persons than in others—a fact that is probably explained by a tendency to over-distention of the bladder which alcoholic liquors bring about. The liquor imbibed increases the amount of urine, and the state of blunted consciousness makes the call to empty the bladder less appreciated. The intoxicated person is also liable to falls, and is not so likely to protect himself in falling as a sober person.3 Gunshot Wounds of the Bladder.—Jackson b relates the remarkable recovery of a private in the 17th Tennessee Regiment who Avas shot in the pelvis at the battle of Mill Springs or Fishing Creek, Ky. He AA'as left sup- posedly mortally wounded on the field, but was eventually picked up, and be- fore receiving any treatment hauled 164 miles, over mountainous roads in the midst of winter and in a Avagon Avithout springs. His urine and excre- tions passed out through the Avounds for several Aveeks and seA'eral pieces of bone came away. The two openings eventually healed, but for twenty-two months he passed pieces of bone by the natural channels. Evec records the case of a private in the Fifth Tennessee Cavalry who was shot in the right gluteal region, the bullet penetrating the bladder and making its exit through the pubis. He rode 30 miles, during Avhich the urine passed through the Avound. Urine avus afterAvard voided through the left pubic opening, and spicules of bone were discharged for tAvo years afterward ; ultimate recoA'cry ensued. Barkcsdale d relates the history of the case of a Confederate soldier who Avas shot at Fredericksburg in the median line of the body, 1J inches above the symphysis, the wound of exit being in the median line at the back, J inch loAver doAvn. Urine escaped from both wounds and through the urethra. There Avere no bad symptoms, and the Avounds healed in four Aveeks. The bladder is not ahvays injured by penetration of the abdominal Avail, but may be Avounded by penetration through the anus or vagina, or even by an instrument entering the buttocks and passing through the smaller sacrosciatic notch. Campere records the case of a sailor avIio fell from a mast and struck upon some fragments of Avood, one of Avhich entered the anus and penetrated the bladder, the result being a rectovesical fistula. About a year later the man consulted Camper, who unsuccessfully attempted a 843, 951. b 124, 1869, n. s. Ixii., 281. <= 579, 1867-68, 161. d Virginia Clin. Rec, 1873-74, iii., 367. e 641, 296. 672 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. to extract the piece of Avood; but by incising the fistula it Avas found that tAvo calculi had formed about the Avooden pieces, and Avhen these were ex- tracted the patient recoA'ered. Perrin a gives the history of a man of forty Avho, Avhile adjusting curtains, fell and struck an overturned chair; one of the chair-legs penetrated the anus. Its extraction AA'as followed by a gush of urine, and for several days the man suffered from incontinence of urine and feces. By the tenth day he Avas passing urine from the urethra, and on the twenty-fifth day there Avas a complete cicatrix of the parts ; fifteen days later he suffered from an attack of retention of urine lasting five days ; this Avas completely relieved after the expulsion of a small piece of trouser-cloth Avhich had been pushed into the bladder at the time of the accident. Postb reports the case of a young man who, in jumping OA'er a broomstick, was impaled upon it, the stick entering the anus Avithout causing any external wound, and penetrating the bladder, thus alloAving the escape of urine through the anus. A peculiar sequela was that the man suffered from a calculus, the nucleus of which Avas a piece of the seat of his pantaloons which the stick had carried in. Couper ° reports a fatal case of stab-wound of the buttocks, in Avhich the knife passed through the lesser sacrosciatic notch and entered the bladder close to the trigone. The patient Avas a man of twenty-three, a seaman, and in a quarrel had been stabbed in the buttocks with a long sailor's knife, Avith resultant symptoms of peritonitis which proved fatal. At the autopsy it Avas found that the knife had passed through the gluteal muscles and divided part of the great sacrosciatic ligament. It then passed through the small sacro- sciatic notch, completely dividing the pudic artery and nerve, and one vein, each end being closed by a clot. The knife entered the bladder close to the trigone, making an opening large enough to admit the index finger. There Avere Avell-marked eA'idences of peritonitis and cellulitis. Old-time surgeons had considerable difficulty in extracting arroAV-heads from persons Avho had received their injuries Avhile on horseback. Conrad Gesner records an ingenious device of an old surgeon avIio succeeded in ex- tracting an arroAv AA'hich had resisted all previous attempts, by placing the subject in the very position in which he was at the time of reception of the Avound. The folloAving noteworthy case shoAvs that the bladder may be penetrated by an arroAv or bullet entering the buttocks of a person on horse- back. Fonvood d describes the removal of a vesical calculus, the nucleus of Avhich Avas an iron arroAA'-head, as follows : " Sitimore, a Avild Indian, Chief of the KioAvas, aged forty-tAvo, applied to me at Fort Sill, Indian Territory, August, 1869, Avith symptoms of stone in the bladder. The folloAving his- tory Avas elicited : In the fall of 1862 he led a band of KioAvas against the PaAvnee Indians, and Avas Avounded in a fight near Fort Larned, Kansas. Being mounted and leaning over his horse, a PaAvnee, on foot and Avithin a a 368, No. 49, 1872. b 538, 1872, vii., 518. c 543, 1879, i., 646. d 847, 260. WO UNI) OF THE BLADDER THR 0 UGH THE B UTTO CKS. 673 feAV paces, drove an arroAv deep into his right buttock. The stick AA'as Avith- draAvn by his companions, but the iron point remained in his body. He passed bloody urine immediately after the injury, but the Avound soon healed, and in a feAV Aveeks he Avas able to hunt the buffalo Avithout inconvenience. For more than six years he continued at the head of his band, and traveled on horseback, from camp to camp, over hundreds of miles every summer. A long time after the injury he began to feel distress in micturating, AA'hich steadily increased "until he avus forced to reveal this sacred secret (as it is regarded by these Indians), and to apply for medical aid. His urine had often stopped for hours, at Avhich times he had learned to obtain relief bv elevating his hips, or lying in different positions. The urine avus loaded Avith blood and mucus and Avith a feAV pus globules, and the introduction of a sound indicated a large, hard calculus in the bladder. The Indians advised me approximately of the depth to Avhich the shaft had penetrated and the direction it took, and judging from the situation of the cicatrix and all the circumstances it Avas apparent that the arroAV-heacl had passed through the glutei muscles and the obturator foramen and entered the cavity of the bladder, Avhere it remained and formed the nucleus of a stone. Stone in the bladder is extremely rare among the Avild Indians, OAving, no doubt, to their almost exclusive meat diet and the very healthy condition of their digestive organs, and this fact, in connection with the age of the patient and the unobstructed condition of his urethra, Avent A'ery far to sustain this conclusion. On August 23d I removed the stone Avithout difficulty by the lateral operation through the perineum. The lobe of the prostate Avas enlarged, Avhich seemed to fiiA'or the extent of the incision beyond Avhat Avould otherAvise have been safe. The perineum Avas deep and the tuberosities of the ischii unnaturally approximated. The calculus of the mixed ammoniaco-magnesian variety was egg-shaped, and Aveighed 19 drams. The arrow-point Avas completely covered and imbedded near the center of the stone. It avus of iron, and had been originally about 2 J inches long, by | inch at its widest part, someAvhat reduced at the point and edges by oxidation. The removal of the stone Avas facilitated by the use of tAvo pairs of forceps,—one AA'ith broad blades, by Avhich I succeeded in bringing the small end of the stone to the opening in the prostate, Avhile the other, long and narroAV, seized and held it until the former Avas withdraAvn. In this Avay the forceps did not occupy a part of the opening Avhile the large end of the stone AA'as passing through it. The capacity of the bladder Avas reduced, and its inner AA'alls AA'ere in a state of chronic inflammation. The patient quickly recovered from the effects of the chloroform and felt great relief, both in body and mind, after the operation, and up to the eighth day di(i not present a single unfavorable symptom. The urine began to pass by the natural channel by the third day, and continued more or less until, on the seventh day, it had nearly ceased to Aoav at the Avound. But the restless 43 674 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. spirit of the patient's friends could no longer be restrained. Open hostility with the Avhites avus expected to begin at every moment, and thev insisted on his removal. He needed purgative medicine on the eighth day, which they refused to alloAv him to take. They assumed entire charge of the ease, and the folioAving day started Avith him to their camps (>0 miles aAvay. Nineteen days after he is reported to have died ; but his immediate relatives haA'e since assured me that his wound AA'as Avell and that no trouble arose from it. They described his symptoms as those of bilious remittent fever, a severe epidemic of Avhich Avas prevailing at the time, and from Avhich several Avhite men and many Indians died in that A'icinitv." The calculus Avas deposited in the Army Medical Museum at Washington, and is repre- Fig. 225.—Calculus having an arrow-head for a nucleus (Sp. 5931, A. M. M., Wash., D. C) (Forwood). sented in the accompanying photograph (Fig. 225), showing a cross-section of the calculus Avith the arroAV-head in situ. As quoted by Chelius,265 both Hennen and Cline relate cases in Avhich men have been shot through the skirts of the jacket, the ball penetrating the abdomen above the tuberosity of the ischium, and entering the bladder, and the men have afterAvard urinated pieces of clothing, threads, etc., taken in by the ball. In similar cases the bullet itself may remain in the bladder and cause the formation of a calculus about itself as a nucleus, as in three cases mentioned by McGuire of Richmond, or the remnants of cloth or spicules of bone may give rise to similar formation. FISTULA OF THE BLADDER. 675 McGuire a mentions the case of a man of twenty-three Avho was wounded at the Battle of McDowell, May 8, 1862. The ball struck him on the hori- zontal ramus of the left pubic bone, about an inch from the symphysis, passed through the bladder and rectum, and came out just beloAv the ri«-ht sacrosciatic notch, near the sacrum. The day after the battle the man Avas sent to the general hospital at Staunton, Va., Avhere he remained under treat- ment for four months. During the first month urine passed freely through the Avounds made by the entrance and exit of the ball, and was generally mixed Avith pus and blood. Fecal matter was frequently discharged through the posterior Avound. Some time during the third Aveek he passed several small pieces of bone by the rectum. At the end of the fifth Aveek the Avound of exit healed, and for the first time after his injury urine Avas discharged through the urethra. The Avound of entrance gradually closed after five months, but opened again in a feAV Aveeks and continued, at varying intervals, alternately closed and open until September, 1865. At this time, on sound- ing the man, it Avas found that he had stone ; this avus removed by lateral operation, and AA'as found to Aveigh 2\ ounces, having for its nucleus a piece of bone about J inch long. Dougherty b reports the operation of lithotomy, in Avhich the calculus removed Avas formed by incrustations about an iron bullet. In cases in Avhich there is a fistula of the bladder the subject may live for some time, in some cases passing excrement through the urethra, in others, urine by the anus. These cases seem to have been of particular interest to the older writers, and Ave find the literature of the last century full of examples. Benrvenius, Borellus, the Ephemerides, Tulpius, Zacutus Lusitanus, and others speak of excrement passing through the penis; and there are many cases of vaginal anus recorded. Langlet cites an instance in Avhich the intestine terminated in the bladder. Arand154 mentions re- covery after atresia of the anus Avith passage of excrement from the vuh-a. Bartholinus, the Ephemerides, Fothergill,c de la Croix,d Riedlin,683 Weber, and Zacutus Lusitanus mention instances in Avhich gas Avas passed by the penis and urethra. Campere records such a case from ulcer of the neigh- boring or connecting intestine ; Frank, from cohesion and suppuration of the rectum; Marcellus Donatus/ from penetrating ulcer of the rectum; and Petit/ from communication of the rectum and bladder in Avhich a cure Avas effected by the continued use of the catheter for the evacuation of urine. Flatus through the A-agina, A'ulva, and from the uterus is mentioned by Bartholinus, the Ephemerides, Meckel, Mauriceau, Paullini, Riedlin, Trnka, and many others in the older literature. Dickinsonh mentions a Burmese male child, four years old, Avho had an imperforate anus and urethra, but Avho passed feces and urine successfully through an opening at the base » S47, 24S. b 847. 259. c 524, ii., 200. d 367, 1788, No. 48. » 249, ii., 16. * 306, L. iv., c. xxix., 524. 8 625, T. ii., 94. b 476, 1859, i., 534. 676 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. of the glans penis. Dickinson cA'entually performed a successful operation on this case. Modern literature has many similar instances. In the older literature it Avas not uncommon to find accounts of persons passing worms from the bladder, no explanations being given to account for their presence in this organ. Some of these cases Avere doubtless instances of echinococcus, trichinae, or the result of rectovesical fistula, but Riverius11 men- tions an instance in Avhich, after drinking water containing Avonns, a person passed worms in the urine. In the old Journal de physique de Itozier is an account of a man of forty-five avIio enjoyed good health, but avIio periodically urinated small AA'onns from the bladder. They Avere described as being about 1 J lines long, and caused no incoiiA'enience. There is also mentioned '' the case of a Avoman avIio voided worms from the bladder. Tuppercdescribes a curious case of aAVoman of sixty-nine avIio complained of a severe, stinging pain that com- pletely overcame her after micturition. An ulceration of the neck of the blad- der AA'as suspected, and the usual remedies were applied, but Avithout effect. An examination of the urine Avas negative. On recommendation of her friends the patient, before going to bed, steeped and drank a decoction of knot-grass. During the night she urinated freely, and claimed that she had passed a Avorm about ten inches long and of the size of a knitting-needle. It exhibited motions like those of a snake, and Avas quite lively, liA'ing five or six days in Avater. The case seems quite unaccountable, but there is, of course, a possi- bility that the animal had already been in the chamber, or that it AAas passed by the boAvel. A rectovaginal or vesical fistula could account for the pres- ence of thisAVorm had it been voided from the boAvel ; nevertheless the Avoman adhered to her statement that she had urinated the Avorm, and, as confirmatory evidence, neA'er complained of pain after passing the animal. Foreign bodies in the bladder, other than calculi (which will be spoken of in Chapter XV.), generally gain entrance through one of the natural passages, as a rule being introduced, either in curiosity or for perverted satisfaction, through the urethra. Morand mentions an instance in Avhich a long wax taper Avas introduced into the bladder through the urethra by a man. At the University Hospital, Philadelphia, AVhite has extracted, by median cystotomy, a long Avax taper Avhich had been used in masturbation. The eystoscopic examination in this ease AA'as negative, and the man's statements Avere disbelieved, but the operation Avas performed, and the taper Avas found curled up and covered by mucus and folds of the bladder. It is not uncom- mon for needles, hair-pins, and the like to form nuclei for incrustations. Gross found three caudal vertebrae of a squirrel in the center of a vesical calculus taken from the bladder of a man of thirtv-five. It Ava- afterAvard elicited that the patient had practised urethral masturbation Avith the tail of this animal. Morand563 relates the history of a man of sixty-tAvo AA'ho intro- duced a sprig of Avheat into his urethra for a supposed therapeutic purpose. a 687, 660. b .-,50, ii., 3R5. c 130, 1864. 7*. FOREIGN BODIES IN THE BLADDER. 677 It slipped into the bladder and there formed the nucleus of a cluster calculus. Dayot:| reports a similar formation from the introduction of the stem of a plant. Terrilon b describes the case of a man of fifty-four avIio intro- duced a pencil into his urethra. The body rested fifteen days in this canal, and then passed into the bladder. On the twenty-eighth day he had a chill, and during tAvo days made successive attempts to break the pencil. FoIIoav- ing each attempt he had a violent chill and intense eA'ening fever. On the thirty-third day Terrilon removed the pencil by operation. Symptoms of perivesical abscess Ave re present, and seventeen days after the operation, and fifty days after the introduction of the pencil, the patient died. Caudmontc mentions a man of tAventy-six Avho introduced a pencil-case into his urethra, from Avhence it passed into his bladder. It rested about four years in this organ before A'iolent symptoms deA'eloped. Perforation of the bladder took place, and the patient died. Pouletd mentions the case of a man of seventy- eight, in Avhose bladder a metallic sound Avas broken off. The fractured piece of sound, Avhich measured 17 cm. in length, made its exit from the anus, and the patient recoA'ered. Wheeler e reports the case of a man of tAventy-one avIio passed a button-hook into his anus, from Avhence it escaped into his bladder. The hook, Avhich Avas subsequently spontaneously passed, measured 2^ inches in length and \ inch in diameter. Among females, Avhose urethrse are short and dilatable, foreign bodies arc often found in the bladder, and it is quite common for smaller articles of the toilet, such as hair-pins, to be introduced into the bladder, and there form calculi. Whiteside f describes a case in Avhich a foreign body introduced into the bladder Avas mistaken for pregnancy, and giving rise to correspond- ing symptoms. The patient Avas a young girl of seventeen Avho had several times missed her menstruation, and Avho Avas considered pregnant. The abdomen Avas more developed than usual in a young Avoman. The breasts AA'ere A'oluminous, and the nipples surrounded by a somber areola. At certain periods after the cessation of menstruation, she had incontinence of urine, and had also repeatedly vomited. The urine Avas of high specific grav- ity, albuminous, alkaline, and exhaled a disagreeable odor. In spite of the signs of pregnancy already noted, palpitation and percussion did not show any augmentation in the size of the uterus, but the introduction of a catheter into the bladder shoAved the existence of a large calculus. Under chloroform the calculus and its mudeus Avere disengaged, and proved to be the handle of a tooth-brush, the exact size of AA'hich is represented in the accompanying illustration (Fig. 226). The handle Avas covered Avith calcareous deposits, and AA-as tightly fixed in the bladder. At first the young Avoman Avould give no explanation for its presence, but afterward explained that she had several times used this instrument for relief in retention of urine, and one day it had fallen si 641. 5(52. b242. 1876, 651. e 242, 1850, 354. •1 641, 572. e 632, 1879, i., 262. f 476, Jan. 24, 1874, 127. 678 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. into the bladder. A short time after the operation menstruation returned for the first time in seven months, and AA'as afterAvard normal. BigeloAVa reports the case of a Avoman avIio habitually introduced hair-pins and common pins into her bladder. She acquired this mania after an attempt at dilatation of the urethra in the relief of an obstinate case of strangury. Rode 368 reports the case of a Avoman avIio had introduced a hog's penis into her urethra. It was removed by an incision into this canal, but the patient died in five days of septicemia. There is a curious case quoted b of a young domestic of four- teen avIio Avas first seen suffering Avith pain in the sides of the genital organs, retention of urine, and violent tenesmus. She Avas examined by a mkhvife Avho found nothing, but on the folloAving day the patient felt it neces- sary to go to bed. Her general symptoms persisted, and meanAvhile the bladder became much distended. The patient had made allusion to the loss of a hair-pin, a circumstance Avhich corresponded Avith the beginning of her trouble. Examination shoAved the orifice of the urethra to be swollen and painful to the touch, and from its canal a hair-pin 6.5 cm. long Avas extracted. The patient Avas unable to urinate, and it Avas necessary to resort to catheterization. By evening the general symp- toms had disappeared, and the next day the patient urin- ated as usual. There are peculiar cases of hair in the bladder, in which all history as to the method of entrance is denied, and which leaA'e as the only explanation the possibility that the bladder Avas in communication Avith some dermoid cyst. Hamelin c mentions a case of this nature. It is said d that all his life Sir William Elliot Avas annoyed by passing hairs in urination. They would lodge in the urethra and cause constant irritation. At his death a stone Avas taken from the bladder, covered Avith scurf and hair. Halle relates the case of a Avoman of sixty, from AA'hose bladder, by dilatation of the urethra, was removed a bundle of hairs tAvo inches long, Avhich, Hall says, Avithout a doubt had groAvn from the vesical Avails. Retention of Foreign Bodies in the Pelvis.—It is a peculiar fact that foreign bodies which once gain entrance to the pelvis may be tolerated in this location for many years. Baxterf describes a man who suffered an injury from a piece of white board which entered his pelvis, and remained in posi- tion for sixteen and a half years; at this time a piece of Avood 7\ inches Fig. 226.—Handle of a tooth-brush, removed from the bladder of a young girl. a 124, xxix., 57. a 629, 1700, iii., 164. b 641, 637. e476, 1860, ii., 461. c 302, iv., 432. f 218, 1883. FRACTURE OF THE PENIS. 679 long Avas discharged at stool, and the patient recovered. Jonesa speaks of a ease in which splinters of Avood Avere retained in the neighborhood of the rectum and vagina for sixteen years, and spontaneously discharged. Bar- well b mentions a case in Avhich a gum elastic catheter that had been passed into the vagina for the purpose of producing abortion became impacted in the pelvis for tAventy months, and was then removed. Rupture of the Male Urethra.—The male urethra is occasionally rup- tured in violent coitus. Frank351 and the Philosophical Transactions c are among the older authorities mentioning this accident. In Frank's case there Avas hemorrhage from the penis to the extent of five pounds. Colles d men- tions a man of thirty-eight, prone to obesity, and Avho had been married two months, avIio said that in sexual congress he had hurt himself by pushing his penis against the pubic bone, and added that he had a pain that felt as though something had broken in his organ. The integuments of the penis became livid and SAVollen and Avere extremely painful. His urine had to be draAvn by a catheter, and by the fifth day his condition was so bad that an incision AA'as made into the tumor, and pus, blood, urine, and air issued. The patient suffered intense rigors, his abdomen became tympanitic, and he died. Post- mortem examination revealed the presence of a ruptured urethra. Watsone relates an instance of coitus performed en postilion by a man while drunk, with rupture of the urethra and fracture of the corpus spongi- osum only. Loughlin mentions a rupture of the corpus spongiosum during coitus. Frank351 cites a curious case of hemorrhage from a fall Avhile the penis was erect. It is not unusual to find ruptured urethrse folioAving trau- matism, and various explanations are given for it in the standard Avorks on surgery. Fracture of the Penis.—A peculiar accident to the penis is fracture, which sometimes occurs in coitus. This accident consists in the laceration of the corpora cavernosa, folloAved by extensive extravasation of blood into the erectile tissue. It has also occurred from injury inflicted accidentally or maliciously, but ahvays happening Avhen the organ avus erect. An annoying sequel folloAving this accident is the tendency to curA'ature in erection, Avhich is sometimes so marked as to interfere AA'ith coitus, and even render the pa- tient permanently impotent.845 There is an accountf of a laborer of twenty-seven avIio, in attempting to micturate Avith his penis erect, pressed it doAvnward with considerable force and fractured the corpora caA'ernosa. Veazie g relates a case of fracture of the corpora caA'ernosa occurring in coitus. During the act the female sud- denly AvithdreAA', and the male, folloAving, A'iolently struck the pubes, Avith the resultant injury. Recovery ensued. M'Clellanh speaks of removing the a 218, 1856. b 650, 1874, viii., 280. e 218, 1885, cxiii., 463. g 593, 1884-85, xii., 321. c 629, No. 4. d 313, 1857. xxiii., 375. f Amer. Pract, & News, 1886, ii., 80. b Smith's Med. Jour., 1827, 256. 680 SURGICAL ANOMALIES OF THE GENITOURINARY S YSTEM. cavernous septum from a man of fifty-tAvo, in Avhom this part had become infiltrated Avith lime-salts and resembled a long, narroAV bone. When the penis AAas erect it Avas bent in the form of a semicircular bow. The Transactions of the South Carolina Medical Association a contain an account of a negro of sixty avIio had urethral stricture from gonorrhea, and avIio had been treated for fifteen years by caustics. The penis AA'as seven inches in circumference around the glans, and but little less near the scrotum. The glans was riddled AA'ith holes, and numerous fistulae existed on the inferior surface of the urethra, the meatus being impermeable. So great avus the Aveight and hypertrophy that amputation Avas necessary. John Hunter speaks of six strictures existing in one urethra at one time; Lallemand of seven ; Bolot of eight ; Dueamp of five ; Boyer thought three could never exist together; Leroy D'Etoilles found 11, and Rokitansky met AA'ith four. Sundry Injuries to the Penis.—Fabricius Hildanus334 mentions a curious case of paraphimosis caused by violent coitus Avith a virgin avIio had an extremely narroA\r vagina. Joyceb relates a history of a stout man who awoke Avith a A'igorous erection, and feeling much irritation, he scratched himself violently. He soon bled copiously, his shirt and underlying sheets and blankets being soaked through. On examination the penis AA'as found SAvollen, and on draAving back the foreskin a small jet of blood spurted from a small rupture in the frenum. The authors have knoAvledge of a case in AA'hich hemorrhage from the frenum proved fatal. The patient, in a drunken Avager, attempted to circumcise himself with a piece of tin, and bled to death before medical aid could be summoned. It sometimes happens that the virile member is amputated by an animal bite. Paullinifi20 and Celliezc men- tion amputation of the penis by a dog-bite. Morgand describes a boy of thirteen Avho Avas feeding a donkey AA'hich suddenly made a snap at him, un- fortunately catching him by the trousers and including the penis in one of the folds. By the violence of the bite the boy Avas throAvn to the ground, and his entire prepuce Avas stripped off to the root as if it had been done by a knife. There Avas little hemorrhage, and the prepuce AAas found in the trousers, looking exactly like the finger of a glove. Morgan stated that this AA'as the third case of the kind of Avhich he had knoAvledge. Bookey e records a case in Avhich an artilleryman was seized by the penis by an infuriated horse, and the tAvo crura were pulled out entire. Amputation of the penis is not always followed by loss of the sexual poAver and instinct, but sometimes has the mental effect of temporarily in- creasing the desire. Haslamf reports the case of a man AA'ho slipped on the greasy deck of a Avhaler, and falling fonvard Avith great A'iolence upon a large knife used to cut blubber, completely severed his penis, beside inflicting a wound in the abdomen through Avhich the intestines protruded. After re- a 1874-77, 90-92. b 224, 1869, i., 209. c 462, T. xx., 169. d536, 1869, vii., 31. « Indian Med. Jour., 1886, v., 647. f 476, 1828. WOUNDS OF THE PENIS. 681 covery there Avas a distinct increase of sexual desire and frequent nocturnal emissions. In the same report there is recorded the history of a man avIio had entirely lost his penis, but had supplied himself with an ivory succedaneum. This felloAV finally became so libidinous that it Avas necessary to exclude him from the Avorkhouse, of AA'hich he AA'as an inmate. Xorrisa gives an account of a prh'ate avIio received a gunshot wound of the penis Avhile it Avas partly erect. The Avound Avas acquired at the second battle of Fredericksburg. The ball entered near the center of the glans penis, and taking a slightly oblique direction, it passed out of the right side of the penis 1J inches beyond the glans ; it then entered the scrotum, and after striking the pelvis near the symphysis, glanced off around the innomi- nate bone, and finally made its exit tAvo inches above the anus. The after- effects of this injury Avere incontinence of urine, and inability to assume the erect position. Bookeyb cites the case of six wounds from one bullet Avith recovery. The bullet entered the sole and emerged from the dorsum of the foot. It then went through the right buttock and came out of the groin, only to penetrate the dorsum of the penis and emerge at the upper part of the glans. Rose c speaks of a case in which a man had his clothes caught in machinery, draAV- ing in the external genital organs. The testicles AA'ere found to be uninjured, but the penis Avas doubled out of sight and embedded in the scrotum, from whence it avus restored to its natural position and the man recovered. N6latond describes a case of luxation of the penis in a lad of six avIio fell from a cart. Nelaton found the missing member in the scrotum, Avhere it had been for nine days. He introduced Sir Astley Cooper's instrument for tying deeply-seated arteries through a cutaneous tube, and conducting the hook under the corporus caA'ernosum, seized this crossAvise, and by a to-and- fro movement succeeded in replacing the organ. Moldenhauer e describes the case of a farmer of fifty-seven AA'ho AA'as in- jured in a runaAvay accident, a Avheel passing OA'er his body close to the ab- domen. The glans penis could not be recognized, since the penis intotohad been torn from its sheath at the corona, and had slipped or been drh'en into the inguinal region. This author quotes Stromeyer's case/ Avhich AA'as that of a boy of four and a half years avIio Avas kicked by a horse in the external genital region. The sheath AA'as found empty of the penis, Avhich had been driven into the perineum. Raven * mentions a case of spontaneous retraction of the penis in a man of twenty-seven. While in bed he felt a sensation of coldness in the penis, and on examination he found the organ (a normal-sized one) rapidly retracting or shrinking. He hastily summoned a physician, Avho found that a 124, 1S64. b Indian Med. Jour., 1886, v., 647. c 476, 1866, i., 67. d36.'5, 1850, No. Hii. e 70:], 1876. 232. 11. s., xiii. 1 " Handbook of Surgery," ii., 771. 8 476, 1S86, ii.. 250 682 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. the penis had, in fact, almost disappeared, the glans being just perceptible under the pubic arch, and the skin alone visible. The next day the normal condition Avas restored, but the patient Avas Aveak and nerA'ous for several days after his fright. In a similar case, mentioned by Ivanhoff, the penis of a peasant of twenty-three, a married man, bodily disappeared, and was only captured by repeated effort. The patient Avas six days under treatment, and he finally became so distrustful of his virile member that, to be assured of its constancy, he tied a string about it above the glans. Injuries of the penis and testicles self-inflicted are grouped together and discussed in Chapter XIV. As a rule, spontaneous gangrene of the penis has its origin in some intense fever. Partridgea describes a man of forty Avho had been the victim of typhus fever, and Avhose penis mortified and dried up, becoming black and like the empty finger of a cast-off glove ; in a feAV days it dropped off. Bover h cites a case of edema of the prepuce, noticed on the fifteenth day of the fever, and Avhich AA'as folloAA'ed by gangrene of the penis. Rostan c men- tions gangrene of the penis from small-pox. Intermittent fever has been cited as a cause.d Koehler e reports a fatal instance of gangrene of the penis, caused by a prostatic abscess folioAving gonorrhea. In this case there Avas thrombosis of the pelvic A'eins. Hutchinsonf mentions a man Avho, thirty years before, after six days' exposure on a raft, had lost both legs by gan- grene. At the age of sixty-six he Avas confined to bed by subacute bronchitis, and during this period his Avhole penis became gangrenous and sloughed off. This is quite unusual, as gangrene is usually associated Avith feA'er; it is more than likely that the gangrene of the leg was not connected Avith that of the penis, but that the latter AA'as a distinct after-result. Possibly the prolonged exposure at the time he lost his legs produced permanent injury to the blood- vessels and nerves of the penis. There is a case on record in AA'hich, in a man of thirty-seA'en, gangrene of the penis folloAved delirium tremens, and AAas attributed to alcoholism.8 Quoted by Jacobson,44'' Troisfontaines records a case of gangrene of the skin and body of the penis in a young man, and Avithout any apparent cause. Schutz h speaks of regeneration of the penis after gangrenous destruction. Gangrene of the penis does not necessarily hinder the performance of marital functions. Chancex mentions a man Avhose penis sloughed off, lea\'- ing only a nipple-like remnant. HoAvever, he married four years later, and ahA'ays lived in harmony Avith his Avife. At the time of his death he Avas the father of a child, subsequent to AA'hose birth his Avife had miscarried, and at the time of report she Avas daily expecting to be again confined. WillettJ relates the instance of a horseman of thirty-three AA'ho, after a 779, xvi., 792. b " Traite des Mai. Chirurg." c 363,1853. d 260. Band., viii., 1-74. e 260, 1891. f 160, ii., 364. g Rev. Med. de la Suisse Eomande, 18-8. h736, ii., 53. i 313. xxxii. j Med. and Surg. Month., 1866, i., 102. PROLONGED PRIAPISM. 683 using a combination of refuse oils to protect his horse from gnats, Avas prompted to urinate, and, in so doing, accidentally touched his penis Avith the mixture. Sloughing phagedena rapidly ensued, but under medical treatment he eventu- ally recovered. Priapism is sometimes seen as a curious symptom of lesion of the spinal cord. In such cases it is totally unconnected with any voluptuous sensation, and is only found accompanied by motor paralysis. It may occur spontane- ously immediately after accident involving the cord, and is then probably due to undue excitement of the portion of the cord beloAv the lesion, which is de- prived of the regulating influence of the brain. Priapism may also deA'elop spontaneously at a later period, and is then due to central irritation from extra- vasation into the substance of the cord, or to some reflex cause. It may also occur from simple concussion, as shoAvn by a case reported by Le Gros Clark. Pressure on the cerebellum is supposed to account for cases of priapism observed in executions and suicides by hanging. There is an instance recorded of an Italian " eastrata " who said he provoked sexual pleasure by partially hanging himself. He accidentally ended his life in pursuance of this peculiar habit. The facts were elicited by testimony at the inquest. There are, hoAvever, in literature, records of long continued priapism in which either the cause is due to excessh'e stimulation of the sexual center, or in Avhich the cause is obscure or unknoAvn. There may or may not be accompanying voluptuous feelings. The older records contain instances of continued infantile priapism caused by the constant irritation of ascarides, and also records of prolonged priapism associated Avith intense agony and spasmodic cramps. Zacutus Lusitanus831 speaks of a Viceroy of India Avho had a long attack of stubborn priapism Avithout any A'oluptuous feeling. Gross refers to prolonged priapism, and remarks that the majority of cases seem to be due to excessh'e coitus. Moore a reports a case in a man of forty who had been married fifteen years, and Avho suffered spasmodic contractions of the muscles of the penis after an incomplete coitus. This pseudopriapism continued for tAventy-three davs, during which time he had unsuccessfully resorted to the application of cold, bleeding, and other treatment; but on the tAventy-sixth day, after the use of bladders filled with cold Avater, there Avas a discharge from the urethra of a glairy mucus, similar in nature to that in seminal debility. There Avas then complete relaxation of the organ. During all this time the man slept very little, only occasionally dozing. Donne b describes an athletic laborer of twenty-five Avho received a wound from a rifle-ball penetrating the cranial parietes immediately in the posterior superior angle of the parietal bone, and a feAV lines from the lambdoid suture. The ball did not make egress, but passed posteriorly downward. Reaction was established on the third day, but the inflammatory symptoms influenced the genitalia. Priapism began a 129, 1823. b 818> 1835, ii., 295. 684 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. on the fifth day, at Avhich time the patient became affected with a salacious appetite, and Avas rational upon every subject except that pertaining to ven- ery. He greAV Avorse on the sixth day, and his medical adviser was obliged to prohibit a female attendant. Priapism continued, but the man \vent into a soporose condition, with occasional intervals of satyriasis. In this condi- tion he survived nine days ; there AA'as not the slightest abatement of the priapism until a feAV moments before his death. Tripea relates the history of a seaman of twenty-five, in perfect health, avIio, arriving from Calcutta on April 12, 1884, lodged with a female until the 26th. At this time he ex- perienced an unusually fierce desire, Avith intense erection of the penis AA'hich, Avith pain, lasted throughout the night. Though coitus Avas frequently re- sorted to, these symptoms continued. He sought aid at the London Hospital, but the priapism Avas persistent, and Avhen he left, on May 10th, the peni> formed an acute angle Avith the pubes, and he again had free intercourse with the same female. At the time of leaA'ing England the penis made an angle of about 45° Avith the pubes, and this condition, he affirmed, lasted three months. On his return to England his penis was flaccid, and his symptoms had disappeared. Salzerb presents an interesting paper on priapism which Avas quoted in The Practitioner of London. Salzer describes one patient of forty-six avIio aAvoke one morning AA'ith a strong erection that could not be reduced by any means. Urine avus A'oided by jerks and AA'ith difficulty, and only when the subject AA'as placed in the knee and elboAV position. Despite all treatment this condition continued for seA'en Aveeks. At this time the patient's spleen AA'as noticed to be enormously enlarged. The man died about a year after the attack, but a necropsy AA'as unfortunately refused. Salzer, in discussing the theories Of priapism, mentions eight cases previously reported, and concludes, that such cases are attributable to leukemia. Kremine believes that continued priapism is produced by effusion of blood into the corpora caA'ernosa, AA'hich is impeded on its return. He thinks it corresponds to bleeding at the nose and rectum, Avhich often occurs in perfectly healthy per- sons. Longuet regards the condition of the blood in leukemia as the cause of such priapism, and considers that the circulation of the blood is retarded in the smaller vessels, Avhile, OAving to the great increase in the number of Avhite corpuscles, thrombi are formed. Xeidhart and Matthias conclude that the origin of this condition might be sought for in the disturbance of the nerve-centers. After reviewing all these theories, Salzer states that in his ease the patient Avas previously healthy and never had suffered the slightest hemorrhage in any part, and he therefore rejects the theory of extraA'asation. He is inclined to suppose that the priapism Avas due to the stimulation of the nervi erigentes, brought about either by anatomic change in the nerves them- selves, or by pressure upon them by enlarged lumbar glands, an associate condition of leukemia. a 476, 1845, ii., 8. b 199, X0. 11, 1879. INJURIES OF THE TESTICLES. 685 Burchard:i reports a most interesting case of prolonged priapism in an English gentleman of fifty-three. When he Avas called to see the man on July loth he found him suffering Avith intense pain in the penis, and in a state of extreme exhaustion after an erection AA'hich had lasted five hours uninter- ruptedly, during the Avhole of AA'hich time the organ Avas in a state of violent and continuous spasm. The paroxysm Avas controlled by § grain morphin and 3L grain atropin. Five hours later, after a troubled sleep, there Avas another erection, Avhich Avas again relieved by hypodermic medication. During the day he had tAvo other paroxysms, one lasting forty-five minutes, and another, three hours later, lasting eighteen minutes. Both these Avere controlled by morphin. There Avas no loss of semen, but after the paroxysms a small quantity of glairy mucus escaped from the meatus. The rigidity Avas remarkable, simulating the spasms of tetanus. No language could adequately describe the suffering of the patient. Burchard elicited the history that the man had suffered from nocturnal emissions and erotic dreams of the most lascivious nature, sometimes having three in one night. During the day he Avould have eight or ten erections, unaccompanied by any A'ol- uptuous emotions. In these there Avould rarely be any emission, but occa- sionally a small mucous discharge. This state of affairs had continued three years up to the time Burchard saAV him, and, chagrined by pain and his malady, the patient had become despondent. After a course of careful treat- ment, in Avhich diet, sponging, application of ice-bags, and ergot Avere features, this unfortunate man recoA'ered. Bruceb mentions the case of an Irishman of fifty-fiA'e avIio, Avithout ap- parent cause, Avas affected with a painful priapism Avhich lasted six Aveeks, and did not subside eA'en under chloroform. Boothc mentions a case of priapism in a married seaman of fifty-five, due to local inflammation about the muscles, constricting the bulb of the penis. The affection lasted fh'e weeks, and Avas extremely painful. There Avas a similar ease of priapism Avhich lasted for three Aveeks, and Avas associated Avith hydrocele in a man of forty-eight/1 Injuries of the testicle and scrotum may be productive of most serious issue. It is a Avell-knoAvn surgical fact that a major degree of shock accom- panies a contusion of this portion of the body. In fact, CheA'ers206 states that the sensitiveness of the testicles is so Avell knoAvn in India, that there are eases on record in Avhich premeditated murder has been effected by Cos- siah AA'omen, by violently squeezing the testicles of their husbands. He also mentions another case in Avhich, in frustrating an attempt at rape, death Avas caused in a similar manner. Stalkartte describes the case of a young man Avho, after drinking to excess AA'ith his paramour, AA'as either unable, or in- different in gratifying her sexual desire. The Avoman became so enraged that a 597, 1887, xlv., 66. b 476, 1873, i., 90. * 476, 18S7, i., 978. <1 476, 1863, ii., 162. e 224, 1890, ii., 1411 686 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. she seized the scrotum and Avrenched it from its attachments, exposing the testicles. The left testicle Avas completely denuded, and was hanging by the vas deferens and the spermatic vessels. There Avas little hemorrhage, and the Avound avus healed by granulation. Avulsion of the male external genitalia is not ahvays accompanied by serious consequences, and even in some cases the sexual poAver is preserved. Knoll a described a case in 1781, occurring in a peasant of thirty-six Avho fell from a horse under the Avheels of a carriage. He Avas first caught in the revolving Avheels by his apron, which dreAV him up until his breeches avc re entangled, and finally his genitals Avere torn off. Not feeling much pain at the time, he mounted his horse and Avent to his house. On examina- tion it Avas found that the injury Avas accompanied Avith considerable hemor- rhage. The Avound extended from the superior part of the pubes almost to the anus; the canal of the urethra Avas torn aAvay, and the penis up to the neck of the bladder. There Avas no A'estige of either the right scrotum or testicle. The left testicle avus hanging by its cord, enveloped in its tunica vaginalis. The cord AAas SAVollen and resembled a penis stripped of its in- tegument. The prostate was considerably contused. After Iavo months of suffering the patient recovered, being able to evacuate his urine through a fistulous opening that had formed. In ten weeks cicatrization AA'as perfect. In his " Memoirs of the Campaign of 1811," Larrey describes a soldier avIio, Avhile standing AA'ith his legs apart, Avas struck from behind by a bullet. The margin of the sphincter ani, the skin of the perineum, the bulbous portion of the urethra, some of the skin of the scrotum, and the right testicle Avere destroyed. The spermatic cord Avas divided close to the skin, and the skin of the penis and prepuce Avas torn. The soldier was left as dead on the field, but after four months' treatment he recoA'ered. Maddenb mentions a man of fifty avIio fell under the feet of a pair of horses, and suffered aA'ulsion of the testicles through the scrotum. The organs Avere mangled, the spermatic cord Avas torn and hung over the anus, and the penis Avas lacerated from the frenum down. The man lost his testi- cles, but otherAvise completely recovered. Brughc reports an instance of injury to the genitalia in a boy of eighteen Avho Avas caught in a threshing- machine. The skin of the penis and scrotum, and the tissue from the pubes and inguinal region Avere torn from the body. Cicatrization and recovery Avere complete. Brighamd cites an analogous case in a youth of se\renteen avIio AA'as similarly caught in threshing machinery. The skin of the penis and the scrotum Avas entirely torn aAvay ; both sphincters of the anus Avere lacerated, and the perineum Avas divested of its skin for a space 2h inches Avide. Recovery ensued, leaving a penis Avhich measured, Avhen flaccid, three inches long and 11 inches in diameter. a 682, vii., 594. b 54s, 1857, 260. c 545, 1877, 207. d West. Lancet, Cincin., 1875-76, iv., 517. AVULSION OF THE TESTICLES. 687 There is a case reported a of a man Avho had his testicles caught in ma- chinery Avhile ginning cotton. The skin of the penis avus stripped off to its root, the scrotum torn off from its base, and the testicles were contused and lacerated, and yet good recoA'ery ensued. A peculiarity of this case Avas the persistent erection of the penis Avhen cold avus not applied. Gibbsb mentions a case in AA'hich the entire scrotum and the perineum, together Avith an entire testicle and its cord attached, and nearly all the in- tegument of the penis Avere torn off, yet the patient recovered AA'ith preserva- tion of sexual poAvers. The patient was a negro of tAventy-tAvo Avho, Avhile adjusting a belt, had his coat (closely buttoned) caught in the shafting, and his clothes and external genitals torn off. On examination it Avas found that the Avhole scrotum avus Avrenched off, and also the skin and cellular tis- sue, from 2J inches above the spine of the pubes down to the edge of the sphincter ani, including all the breadth of the perineum, together Avith the left testicle with five inches of its cord attached, and all the integument and cellular covering of the penis except a rim nearly half an inch wide at the extremity and continuous Avith the mucous membrane of the prepuce. The right testicle was hanging by its denuded cord, and was apparently covered only by the tunica vaginalis as high up as the abdominal ring, Avhere the elastic feeling of the intestines avus distinctly perceptible. There aahs not more than half an ounce of blood lost. The raw surface was dressed, the gap in the perineum brought together, and the patient made complete recovery, with preservation of his sexual poAvers. Other cases of injuries to the external genital organs (self-inflicted) Avill be found in the next chapter. The preservation of the sexual power after injuries of this kind is not uncommon. There is a case reported c of a man Avhose testicles Avere completely torn away, and the perineal urethra so much injured that mictu- rition took place through the AA'ound. After a tedious process the wound healed and the man was discharged, but he returned in ten days with gonor- rhea, stating that he had neither lost sexual desire nor poAA'er of satisfaction. Robbinsd mentions a man of thirty-eight avIio, in 1874, had his left testicle removed. In the folio av ing year his right testicle became affected and Avas also removed. The patient stated that since the removal of the second gland he had regular sexual desire and coitus, apparently not differing from that in which he indulged before castration. For a feAV months previous to the time of report the cord on the left side, Avhich had not been completely extirpated, became extremely painful and Avas also removed. Atrophy of the testicle may follow venereal excess, and according to Larrey, deep wounds of the neck may produce the same result, with the loss of the features of virility. Guthrie e mentions a case of spontaneous absorp- tion of the testicle. According to Larrey, on the return of the French Army a 760, 1886-87, iv., 300. b 264, 1855, 154. c 224, 1885, 375. d Quoted 224, 1881, i., 171. e 476, 1832, ii., 670. 688 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. from the Egyptian expedition the soldiers complained of atrophy and disaj>- pearance of the testicle, Avithout any venereal affection. The testicle Avould lose its sensibility, become soft, and gradually diminish in size. One testicle at a time Avas attacked, and Avhen both Avere involved the patient Avas de- prived of the poAver of procreation, of Avhich he was apprised by the lack of desire and laxity of the penis. In this peculiar condition the general health seemed to fail, and the subjects occasionally became mentally deranged. Atrophy of the testicles has been knoAvn to folloAV an attack of mumps. In his description of the diseases of Barbadoes Hendy mentions several peculiar cases under his observation in which the scrotum sloughed, leaving the testicles denuded. Alix and Richtera mention a singular modification of rheumatic inflammation of the testicle, in Avhich the affection flitted from one testicle to the other, and alternated AA'ith rheumatic pains elseAvhcre. There is a case of retraction of the testicle reported15 in a young sol- dier of twenty-one avIio, Avhen first seen, complained of a SAvelling in the right groin. He stated that Avhile riding bareback his horse suddenly plunged and threAv him on the withers. He at once felt a sickening pain in the groin and became so ill that he had to dismount. On inspection an oval tumor Avas seen in the groin, tender to the touch and shoAving no impulse on coughing. The left testicle avus in its usual position, but the right AA'as absent. The patient stated posith'ely that both testicles were in situ before the accident. An at- tempt at reduction a\ as made, but the pain Avas so severe that manipulation could not be endured. A Avarm bath and laudanum Avere ordered, but unfor- tunately, as the patient at stool gave a sudden bend to the left, his testicle slipped up into the abdomen and Avas completely lost to palpation. Orchitis threatened, but the symptoms subsided ; the patient Avas kept under observa- tion for some Aveeks, and then as a tentative measure, discharged to duty. Shortly afterAvard he returned, saying that he Avas ill, and that Avhile lifting a sack of corn his testicle came partly doAvn, causing him great pain. At the time of report his left testicle Avas in position, but the right could not be felt. The scrotum on that side had retracted until it had almost disappeared ; the right external ring Avas A'ery patent, and the finger could be passed up in the inguinal canal; there a\ as no impulse on coughing and no tendency to hernia. A unique case of ectopia of the testicle in a man of tAventy-four is given by Popoff.c The scrotum AA'as normally developed, and the right tes- ticle in situ. The left half of the scrotum avus empty, and at the root of the penis there AA'as a swelling the size of a Avalnut, covered AA'ith normal skin, and containing an oval body about four-fifths the size of the testicle, but softer in constituency. The patient claimed that this SAvelling had been present since childhood. His sexual poAver had been normal, but for the past six month- he had been impotent. In childhood the patient had a small inguinal hernia, and Popoff thought this caused the displacement of the testicle. a 535, lxi. b 004, 1885. i., 536. c 812, Xo. 4, 1888. 75. INJURIES OF THE VAGINA. 689 A somewhat similar case occurred in the Hotel-Dieu, Paris. Through the agency of compression one of the testes Avas forced along the corpus eavcrnosum under the skin as far as the glans penis. It Avas easily reduced, and at a subsequent autopsy it was found that it had not been separated from the cord. Guiteras a cites a parallel case of dislocation of the testicle into the penis. It Avas the result of traumatism—a fall upon the wheel of a cart. It was reduced under anesthesia, after tAvo incisions had been made, the adhesions broken up, and the shrunken sac enlarged by stretching. Rupture of the spermatic arteries and veins has caused sudden death. Schleiserb is accredited Avith describing an instance in which a healthy man Avas engaged in a fray in the dark, and, suddenly crying out, fell into convulsions and died in five minutes. On examination the only injury found was the rupture of both spermatic arteries at the internal ring, produced by a violent pull on the scrotum and testicles by one of his antagonists. Shock Avas evidently a strong factor in this case. Fabricius Hildanus0 gh'es a case of impotency due to lesions of the spermatic vessels following a burn. There is an old record d of an aged man Avho, on marrying, found that he had erections but no ejaculations. He died of ague, and at the autopsy it was found that the verumontanum Avas hard and of the size of a Avalnut, and that the ejaculatory ducts contained calculi about the size and shape of peas. Hydrocele is a condition in which there is an abnormal quantity of fluid in the tunica A'aginalis. It is generally caused by traumatism, violent mus- cular efforts, or straining, and is much more frequent in tropic countries than elsewhere. It sometimes attains an enormous size. Leigh 483 mentions a hydrocele Aveighing 120 pounds, and there are records of hydroceles Aveigh- ing 40 e and 60 pounds/ Larrey speaks of a sarcocele in the coverings of the testicle which Aveighed 100 pounds. Mursinna577 describes a hy- drocele Avhich measured 27 inches in its longest and 17 in its transA'erse axis. Tedfords gives a curious case of separation of the ovary in a Avoman of twenty-eight. After suffering from invagination of the boAvel and inflam- mation of the OA'arian tissue, an OA'ary AAas discharged through an opening in the sigmoid flexure, and thence expelled from the anus. In discussing injuries of the vagina, the first to be mentioned Avill be a remarkable case reported by Curran.h The subject Avas an Irish girl of tAventy. While carrying a bundle of clothes that preA'ented her from seeing objects in front of her, she started to pass OA'er a stile, just opposite to Avhich a goat AA'as lying. The Avoman Avore no underclothing, and in the ascent her body AA'as partially exposed, and, Avhile in this enforced attitude, the goat, :l r,:)S, Jan. 4, 1896. b Casper's Wochenschrift, Oct, 22, 1842. c 334. cent, v., obs. xl. a 215, Ann. 2. e 106, 1725, 492. '' Mem. de la Acad, des Sciences de Paris, 1711, 30. g 701,1886. b 536,1837, i., 116. 44 690 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. frightened by her approach, suddenly started up, and in so doing thrust his horn forcibly into her anus and about tAvo or three inches up her rectum. The horn then passed through the boAvel and its coA'erings, just above the hymen, and was then Avithdrawn as she flinched and fell back. The resultant wound included the loAver part of the A'agina and rectum, the sphincter ani, the fourchet, and perineum. Hemorrhage AA'as profuse, and the wound caused excruciating pain. The subject fainted on the spot from hemorrhage and shock. Her modesty forbade her summoning medical aid for three da as, during Avhich time the Avound Avas undergoing most primitive treatment. After suturing, cicatrization folloAved Avithout delay. Tromperta mentions a case of rupture of the A'agina by the horn of a bull. There is a case recorded in the Pennsyh'ania Hospital Reports623 of a girl of nineteen avIio jumped out of a second-story AvindoAv. On reaching the ground, her foot turned under her as she fell. The high heel of a French boot avus driven through the perineum one inch from the median line, mid- way betAveen the anus and the posterior commissure of the labia majora. The Avound extended into the A'agina above the external opening, in which the heel, now separated from the boot, projected, and whence it Avas removed without difficulty. This Avound was the only injury sustained by the fall. Beckettb records a case of impalement in a woman of forty-five Avho, while attempting to obtain water from a hogshead, fell with one limb inside the cistern, striking a projecting stave three inches Avide and \ inch thick. The external labia Avere divided, the left crus of the clitoris separated, the nymphae lacerated, and the A'aginal wall penetrated to the extent of five inches; the patient recovered by the fourth Aveek. Homans c reports recoA'ery from extensive wounds acquired by a negress who fell from a roof, striking astride an upright barrel. There Avas a Avound of the perineum, and penetration of the posterior wall of the A'agina, Avith complete separation of the soft parts from the symphysis pubis, and extrusion of the bladder. Howe d reports a case of impalement Avith recovery in a girl of fifteen Avho slid down a hay-stack, striking a hay-hook Avhich penetrated her perineum and passed into her body, emerging two inches beloAv the umbilicus and one inch to the right of the median line. Injuries of the vagina may be so extensive as to alloAv protrusion of the intestines, and some horrible cases of this nature are recorded. In The Lancet for 1873e there is reported a murder or suicide of this description. The Avoman Avas found with a Avound in the vagina, through Avhich the intes- tines, Avith clean-cut ends, protruded. Over 7| feet of the intestines had been cut off in three pieces. The cuts Avere all clean and carefully separated from the mesentery. The woman surviA'ed her injuries a Avhole week, finally a 587, xix., 311. b Med. Annals, Albany, 1881, ii., 136. c 218, 1883, cviii., 344. d 218, 1840, xxii., 71. e 476, 1873, i., 673. INJURIES DURING COITUS. 691 succumbing to loss of blood and peritonitis. Her husband Avas tried for murder, but Avas acquitted by a GlasgoAv jury. Taylor756 mentions similar cases of two Avomen murdered in Edinburgh some years since, the Avounds having been produced by razor slashes in the vagina. Taylor remarks that this crime seems to be quite common in Scotland. Starkey a reports an in- stance in Avhich the body of an old colored Avoman Avas found, with evidences of A'omiting, and her clothing stained AA'ith blood that had evidently come from her A'agina. A postmortem showed the abdominal caA'ity to be full of blood ; at Douglas' culdesac there Avas a tear large enough to admit a man's hand, through Avhich protruded a portion of the omentum ; this Avas at first taken for the membranes of an abortion. There were distinct signs of acute peritonitis. After investigation it Avas proA'ed that a drunken glass-bloAver had been seen leaving her house Avith his hand and arm stained with blood. In his drunken frenzy this man had thrust his hand into the A'agina, and through the junction of its posterior wall Avith the uterus, up into the abdom- inal cavity, and grasped the uterus, trying to drag it out. Outside of obstet- ric practice the injury is quite a rare one. There is a case of death from a ruptured clitoris reported by Gutteridge. b The Avoman AA'as kicked while in a stooping position and succumbed to a pro- fuse hemorrhage, estimated to be between three and four pounds, and proceed- ing from a rupture of the clitoris. Discharge of Vaginal Parietes.—Longhic describes the case of a woman of twenty-seven, an epileptic, with metritis and copious eatamenia twice a month. She Avas immoderately addicted to drink and sexual indulgence, and in Feb- ruary, 1835, her menses ceased. On May 8th she AAas admitted to the hospital with a severe epileptic convulsion, and until the 18th remained in a febrile condition, Avith abdominal tenderness, etc. On the 21st, Avhile straining as if to discharge the contents of the rectum, she felt a A'oluminous body pass through the vagina, and fancied it Avas the expected fetus. After Avashing this mass it Avas found to be a portion of the A'aginal parietes and the fleshy body of the neck of the uterus. The Avoman believed she had miscarried, and still persisted in refusing medicine. Cicatrization Avas someAvhat delayed ; immediately on leaA'ing the hospital she returned to her old habits, but the pain and hemorrhage attending copulation Avas so great that she had finally to desist. The vagina, however, gradually yielding, ceased to interfere Avith the gratification of her desires. ToAvard the end of June the menses reap- peared and floAved Avith the greatest regularity. The portions discharged are preserved in the Milan Hospital. The injuries received during coitus have been classified by Spaeth as folloAvs : Deep tears of the hymen Avith profuse hemorrhage ; tears of the clitoris and of the urethra (in cases of atresia hymenis); vesicoA'aginal fistula ; laceration of the vaginal fornices, posteriorly or laterally ; laceration a 453, 1889-90. b 476, 1846, ii., 478. c 376, No. 22. 692 SURGICAL ANOMALIES OF THE GENITOURINAR Y SYSTEM. of the septum of a duplex vagina ; injuries following coitus after perineor- rhaphy. In the last century Plazzoni reports a case of vaginal rupture occurring during coitus. Green of Boston ; Mann of Buffalo ; Sinclair and Munro of Boston, all mention lacerations occurring during coitus. 'There is an instance recordeda of extensive laceration of the vagina in a Avoman, the result of coitus Avith a large dog. Haddon and Rossb both mention cases of rupture of the vagina in coitus ; and Martin0 reports a similar case result- ing in a young girl's death. Spaeth d speaks of a AA'oman of thirty-one Avho, a feAV days after marriage, felt violent pain in coitus, and four days later she noticed that fecal matter escaped from the A'agina during stool. Examina- tion shoAved that the columns of the posterior Avail Ave re torn from their at- tachment, and that there Avas a rectovaginal fistula admitting the little finger. Hofmokle cites an instance in Avhich a poAverful young man, in coitus with a Avidow of fifty-eight, caused a tear of her fornix, followed by violent hemor- rhage. In another case by the same author, coitus in a sitting posture pro- duced a rupture of the posterior fornix, involving the peritoneum ; although the patient lost much blood, she finally recovered. In a third instance, a young girl, whose lover had violent connection Avith her while she Avas in an exaggerated lithotomy position, suffered a large tear of the right vaginal Avail. Hofmokl also describes the case of a young girl with an undeveloped vagina, absence of the uterus and adnexa, avIio during a forcible and unsuccessful at- tempt at coitus, had her left labium majus torn from the vaginal Avail. The tear extended into the mons A'eneris and (Ioavii to the rectum, and the finger could be introduced into the vaginal Avound to the depth of tAvo inches. The patient recovered in four Aveeks, but Avas still anemic from the loss of blood. Crandallf cites instances in AA'hich hemorrhage, immediately after coitus of the marriage-night, Avas so active as to almost cause death. One of his pa- tients AA'as married three weeks previously, and Avas rapidly becoming exhausted from a constant floAving AA'hich started immediately after her first coitus. Examination shoAved this to be a case of active intrauterine hemorrhage excited by coitus soon after the menstrual Aoav had ceased and Avhile the uterus and ovaries Avere highly congested. In another case the patient commenced flooding Avhile at the dinner table in the Metropolitan Hotel in Ncav York, and from the same cause1 an almost fatal hemorrhage ensued. Hirst of Phila- delphia has remarked that brides have been found on their marital beds completely covered Avith blood, and that the hemorrhage may have been so profuse as to soak through the bed and fall on the floor. Lacerations of the urethra from urethral coitus in instances of vaginal atresia or imperforate hymen may also excite serious hemorrhage. Foreign Bodies in the Vagina.—The elasticity of the vagina alloAvs the presence in this passage of the most voluminous foreign bodies. When Ave a St. Louis Med. Review, April, 1893. b 052, 1876. c 435, 1873. d 832, Baud xix. e International Klin., Rundschau, 1890. f 545, 187(1. LONG RETENTION OF PESSARIES 693 consider the passage of a fetal head through the vagina the ordinary foreign bodies, none of Avhich ever approximate this size, seem quite reasonable. Goblets, hair-pins, needles, bottles, beer glasses, compasses, bobbins, pessaries, and many other articles have been found in the vagina. It is quite possible for a phosphatic incrustation to be found about a foreign body tolerated in this location for some time. Hubbauer a speaks of a young girl of nineteen in Avhose vagina there was a glass fixed by incrustations Avhich held it solidly in place. It had been there for six months and Avas only removed Avith great difficulty. Holmes b cites a peculiar case in Avhich the neck of a bottle was found in the vagina of a Avoman. One point of the glass had penetrated the bladder and a calculus had formed on this as Avell as on the A'aginal end. When a foreign body remains in the vagina for a long time and if it is composed of material other than glass, it becomes influenced by the corrosive action of the vaginal secretion. For instance, Cloquet removed a foreign bod}' which Avas incrusted in the vagina, and found the cork pessary Avhich had formed its nucleus completely rotted. A similar instrument found by Gos- seiin c had remained in the A'agina thirty-six years, and Avas incrus- tated with calcareous salts. Metal is ahvays attacked by the A'aginal secretions in the most marked manner. Cloquet mentions that at an autopsy of a Avoman avIio had a peAvter goblet in her A'agina, lead \ # Fig. 227.—Pessary incrusted with phosphates after long Oxid AVaS found in the gangrenOUS sojourn in the vagina (after Poulet). debris. Long Retention of Pessaries, etc.—The length of time during which pessaries may remain in the vagina is sometimes astonishing. The accom- panying illustration (Fig. 227) sIioavs the phosphatic deposits and incrustations around a pessary after a long sojourn in the vagina. The specimen is in the Musee Dupuytren. Pinet mentions a pessary that remained in situ for tAventy- five years. Gerould of Massilon, Ohio, reports a case in Avhich a pessary had been Avorn by a German Avoman of eighty-four for more than fifty years. She had forgotten its existence until reminded of it by irritation some years before death. It Avas remarkable that when the pessary was removed it Avas found to have largely retained its original wax covering. Hurxthald mentions the a 841, 613. b 490, 1854. ° 363, 1846. d 612, 1851. 694 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. remoA'al of a pessary Avhich had been in the pelvis for forty-one years. Jacksona speaks of a glove-pessary remaining in the A'agina thirty-five years. Mackeyb reports the remoA'al of a glass pessary after fifty-five years' incarceration. There is an account0 of a young girl addicted to onanism avIio died from the presence of a peAvter cup in her vagina ; it had been there fourteen months. Shame had led her to conceal her condition for all the period during Avhich she suffered pain in the hypogastrium, and diarrhea. She had steadily refused examination. Bazzanella of Innsbruck removed a drinking glass from the vagina by means of a pair of small obstetric forceps. The glass had been placed there ten years previously by the Avoman's husband. Szigethy d reports the case of a Avoman of seventy-five who, some thirty years before, introduced into her vagina a ball of string previously dipped in wax. The ball Avas effectual in relieving a prolapsed uterus, and Avas worn Avith so little discom- fort that she entirely forgot it until it Avas forced out of place by a violent effort. The ball Avas seven inches in circumference, and covered Avith mucus, but otherwise unchanged. Breisky644 is accredited Avith the report of a case of a Avoman suffering Avith dysmenorrhea, in whose vagina Avas found a cotton reel which had been introduced seven years before. The Avoman made a good recovery. Pearsee mentions a Avoman of thirty-six who had suffered monor- rhagia for ten days, and was in a state of great prostration and suffering from strong colicky pains. On examination he found a silk-bobbin about an inch from the entrance, which the patient had introduced fourteen years before. She had already had attacks of peritonitis and hemorrhage, and a urethro- vaginal fistula Avas found. The bobbin itself was black. This patient had been married twice, and had been cared for by physicians, but the existence of a body f inch long had never been noticed. Poulet quotes tvA'o curious cases :f in one a pregnant Avoman was examined by a doctor Avho diagnosti- cated carcinomatous degeneration of the neck of the uterus. Capuron, who aaiis consulted relative to the case, did not believe that the state of the Avoman's health Avarranted the diagnosis, and on further examination the groAvth was found to have been a sponge which had previously been introduced by the AA'oman into the A'agina. The other case, reported by Guyon, exemplified another error in diagnosis. The patient was a woman who suffered from con- tinuous vaginal hemorrhage, and had been given extensive treatment Avithout success. Finally, Avhen the Avoman was in extreme exhaustion, an injection of vinegar-water Avas ordered, the use of Avhich Avas followed by the expulsion from the vagina of a live leech of a species very abundant in the country. The hemorrhage immediately ceased and health returned. There is a recordg of a Avoman of tAventy-eight Avho was suddenly sur- prised by some one entering her chamber at the moment she Avas introducing a 437, 1882, iii., 83. b 771 j 1888. c 789, March 4, 1848. d 614, 1890. e 224, June 28, 1873. f 641, 621. 8 550, xxix., 15. FOREIGN BODIES IN THE UTERUS. 695 a cedar pencil into her vagina. With the purpose of covering up her act and dissembling the Avoman sat doAvn, and the shank of the Avood Avas pushed through the posterior Avail of the vagina into the peritoneal cavity. The in- testine Avas, Avithout doubt, pierced in tAvo of its curves, Avhich Avas demon- strated later by an autopsy. A plastic exudation had evidently agglutinated the intestine at the points of penetration, and prevented an immediate fatal issue. Erichsen practised extraction eight months after the accident, and a pencil 5J inches long, having a strong fecal odor, was brought out. The patient died the fourth day after the operation, from peritonitis, and an au- topsy shoAved the perforation and agglutination of the tAvo intestinal curva- tures. Getchell a relates the description of a calculus in the vagina, formed about a hair-pin as a nucleus. It is reported that a country girl came to the Hotel-Dieu to consult Dupuytren, and stated that several years before she had been violated by some soldiers, who had introduced an unknown foreign body into her vagina, which she never could extract. Dupuytren found this to be a small metallic pot, two inches in diameter, with its concavity toward the uterus. It contained a solid black substance of a most fetid odor. Foreign bodies are generally introduced in the uterus either accident- ally in vaginal applications, or for the purpose of producing abortion. Zuhmeister720 describes a case of a woman AA'ho shortly after the first mani- festations of pregnancy used a twig of a tree to penetrate the matrix. She thrust it so strongly into the uterus that the wall Avas perforated, and the twig became planted in the region of the kidneys. Although six inches long and of the volume of a goose feather, this branch remained five months in the pelvis Avithout causing any particular incouAenience, and was finally discharged by the rectum. Brignatellib mentions the case of a woman who, in culpable practices, introduced the stalk of a reed into her uterus. She suffered no incoiiA'enience until the next menstrual epoch which was accompanied by violent pains. She presented the appearance of one in the pains of labor. The matrix had augmented in volume, and the orifice of the uterine cervix Avas closed, but there was hypertrophy as if in the second or third month of pregnancy. After examination a piece of reed three cm. long Avas extracted from the uterus, its external face being incrusted Avith hard calcareous mate- rial. Meschede of Schwetz, Germany, mentions death from a hair-pin in the uterine cavity. Crouzitc Avas called to see a young girl who had attempted criminal abor- tion by a darning-needle. When he arrived a fetus of about three months had already been expelled, and had been wounded by the instrument. It Avas impossible to remove the needle, and the placenta was not expelled for two days. Eleven days afterward the girl commenced to have pains in the inguinal region, and by the thirty-fifth day an elevation was formed, and the pains increased in violence. On the seventy-ninth day a needle six inches a 547, 1873, iii., 635. b 64i; 628. c 162, 1823, T. iii. 696 SURGICAL ANOMALIES OF THE GENITOURINARY SYSTEM. long AAas expelled from the SAvelling in the groin, and the patient rccovenKl. Lisfranc extracted from the uterus of a Avoman avIio supposed herself to be pregnant at the third month, a fragment of a large gum-elastic sound which during illicit maneuvers had broken off within fh'e cm. of its extremity, and penetrated the organ. Lisfranc found there was not the slightest sign of pregnancy, despite the Avoman's belief that she Avas AA'ith child. CHAPTER XIV. MISCELLANEOUS SURGICAL ANOMALIES. Marvelous Recoveries from Multiple Injuries.—There are injuries so numerous or so great in extent, and so marvelous in their recovery, that they are Avorthy of record in a section by themselves. They are found particularly in military surgery. In the Medical and Philosophical Commentaries for 1770 a is the report of the case of a lieutenant avIio AAas Avounded through the lungs, liver, and stomach, and in whose armpit lodged a ball. It Avas said that Avhen the Avound in his back AA'as injected, the fluid Avould immediately be coughed up from his lungs. Food would pass through the wound of the stomach. The man avus greatly prostrated, but after eleven months of con- valescence he recovered. In the brutal capture of Fort GrisAvold, Connecticut, in 1781, in which the brave occupants Avere massacred by the British, Lieu- tenant Avery had an eye shot out, his skull fractured, the brain-substance scattering on the ground, AA'as stabbed in the side, and left for dead ; yet he recovered and lived to narrate the horrors of the day forty years after. A French iiiA'alid-artillery soldier, from his injuries and a peculiar mask he used to hide them, AAas knoAvn as " L'homme & la ttte de cireP The Lan- cet gives his history briefly as folloAvs : During the Franco-Prussian War, he was horribly Avounded by the bursting of a Prussian shell. His Avhole face, including his Iavo eyes, Avere literally bloAvn aAvay, some scanty remnants of the osseous and muscular systems, and the skull covered Avith hair being left, His Avounds healed, giA'ing him such a hideous and ghastly appearance that he Avas virtually ostracized from the sight of his felloAvs. For his relief a dentist by the name of Delalain constructed a mask Avhich included a false palate and a set of false teeth. This apparatus avus so perfect that the func- tions of respiration and mastication were almost completely restored to their former condition, and the man AA'as able to speak distinctly, and even to play the flute. His sense of smell also returned. He wore tAvo false eyes sim- ply to fill up the cavities of the orbits, for the parts representing the eyes were closed. The mask Avas so well-adapted to Avhat remained of the real face, that it Avas considered by all one of the finest specimens of the prothetic art that could be devised. This soldier, Avhose name Avas Moreau, was living and in perfect health at the time of the report, his bizarre face, Avithout expression, and his sobriquet, as mentioned, making him an object of great a 534, 1779, v., 188. 697 698 MISCELLANEOUS SURGICAL ANOMALIES. curiosity. He Avore the Cross of Honor, and nothing delighted him more than to talk about the Avar. To augment his meager pension he sold a pamph- let containing in detail an account of his injuries and a description of the skilfully devised apparatus by Avhich his declining life Avas made endurable. A somewhat similar case is mentioned on page 585. A most remarkable case of a soldier suffering numerous and almost in- credible injuries and recovering and pursuing his vocation Avith undampened ardor is that of Jacques Roellinger, Company B, 47th Ncav York Volunteers. a He appeared before a pension board in New York, June 29, 1865, Avith the folloAving history : In 1862 he suffered a sabre-cut across the quadriceps extensor of the left thigh, and a sabre-thrust betAveen the bones of the fore- arm at the middle third. Soon afterAvard at Williamsburg, Va., he Avas shot in the thigh, the ball passing through the middle third external to the femur. At Fort AVagner, 1863, he had a sAvord-cut, severing the spinal muscles and overlying tissue for a distance of six inches. Subsequently he Avas captured by guerillas in Missouri and tortured by burning splinters of Avood, the cicatrices of which he exhibited ; he escaped to Florida, Avhere he Avas struck by a fragment of an exploding shell, which passed from without inAvard, be- hind the hamstring on the right leg, and remained embedded and could be plainly felt. When struck he fell and was fired on by the retiring enemy. A ball entered between the 6th and 7th ribs just beneath the apex of the heart, traversed the lungs and issued at the right 9th rib. He fired his re- volver on reception of this shot, and Avas soon bayonetted by his OAvn com- rades by mistake, this Avound also penetrating the body. He shoAved a de- pressed triangular cicatrix on the margin of the epigastrium. If the scars are at all indicative, the bayonet must have passed through the left lobe of the liver and border of the diaphragm. Finally he was struck by a pistol-ball at the lower angle of the left lower jaw, this bullet issuing on the other side of the neck. As exemplary of the easy manner in which he bore his many injuries during a somewhat protracted convalescence, it may be added that he amused his comrades by bloAving jets of water through the apertures on both sides of his neck. Beside the foregoing injuries he received many minor ones, Avhich he did not deem worthy of record or remembrance. The greatest dis- ability he suffered at the time of applying for a pension resulted from an ankylosed knee. Not satisfied with his experience in our war, he stated to the pension examiners that he Avas on his Avay to join Garibaldi's army. This case is marvelous Avhen we consider the proximity of several of the Avounds to a vital part; the slightest deviation of position Avould surely have resulted in a fatal issue for this apparently charmed life. The following table shows the man's injuries in the order of their reception :— (1) Sabre-cut across the quadriceps femoris of right leg, dividing the tendinous and muscular structures. a 538, 1875, i., 688. MARVELOUS RECOVERIES. 699 (2) Sabre-thrust betAveen the bones in the middle third of the right forearm. (3) Shot in the right thigh, the ball passing through the middle third. (4) A SAVord-cut across the spinal muscles covering the lower dorsal vertebras. (5) Tortured by guerillas in Indian fashion by having burning splinters of wood applied to the surface of his right thorax. (6) An exploded shell passed through the hamstring muscles of the right thigh and embedded itself in the ligamentous tissues of the internal condyle of the femur. (7) Shot by a ball between the 6th and 7th ribs of the left side. (8) Bayonetted through the body, the steel passing through the left lobe of the liver and penetrating the posterior border of the diaphragm. (9) Pistol-ball shot through the sternocleido muscle of one side of the neck, emerging through the corresponding muscle of the other side of the neck. (10) Sabre-thrust betAveen the bones of the left forearm. (11) Pistol-shot through the left pectoralis major and left deltoid muscles. (12) Deep cut dividing the commissure between the left thumb and fore- finger doAvn to the carpal bones. SomeAvhat analogous to the foregoing is a case reported in 1834 by McCosh from Calcutta. The patient Avas a native Avho had been dreadfully butchered in the Chooar campaign. One of his hands Avas cut off above the wrist. The remaining stump was nearly amputated by a second bloAV. A third blow penetrated the shoulder-joint. Beside these and several other slashes, he had a cut across the abdomen extending from the umbilicus to the spine. This cut divided the parietes and severed one of the coats of the colon. The intestines escaped and lay by his side. He Avas then left on the ground as dead. On arrival at the hospital his Avounds were dressed and he speedily convalesced, but the injured colon ruptured and an artificial anus AA'as formed and part of the feces Avere discharged through the Avound. This man Avas subsequently seen at Midnapore healthy and lusty although his body avus bent to one side in consequence of a large cicatrix; a small portion of the feces occasionally passed through the open wound. There is an account a of a private soldier, aged twenty-seven, who suffered a gunshot Avound of the skull, causing compound fracture of the cranium, and avIio also received compound fractures of both bones of the leg. He did not present himself for treatment until ten days later. At this time the head- injury caused him no inconvenience, but it Avas necessary to amputate the leg and remove the necrosed bones from the cranial wounds ; the patient recovered. Recovery After Injuries by Machinery, with Multiple Fractures, etc.—Persons accidentally caught in some portions of poAverful machinery a 597, 1866, 219. 700 MISCELLANEOUS SURGICAL ANOMALIES. usually suffer several major injuries, any one of which might have been fatal, yet there are marvelous instances of recovery after Avounds of this nature. Phares a records the case of a boy of nine Avho, Avhile playing in the saAv-gate of a cotton-press, was struck by the lever in revolution, the IiIoav fracturing both bones of the leg about the middle. At the second revolution his shoulder avus crushed ; the third passed over him, and the fourth, Avith maxi- mum momentum struck his head, carrying aAvay a large part of the integument, including one eyebroAV, portions of the skull, membranes, and brain-substance. A piece of cranial bone Avas found sticking in the lever, and there Avere stains of brain on all the 24 posts around the circumference of the hole. Possibly from 1J to two ounces of cerebral sub- stance were lost. A physician Avas called, but thinking the case hopeless he declined to offer surgical interference. Undaunted, the father of the injured lad straightened the leg, adjusted the various fractures, and administered calomel and salts. The boy progressh'cly recoA'ered, and in a feAV Aveeks his shoulder and legs avc re Avell. About this time a loosened fragment of the skull AA'as removed almost the size and shape of a dessertspoon, Avith the handle attached, leaving a circular opening directly OA'er the eye as large as a Mexican dollar, through which cerebral pulsation Avas visible. A peculiar feature of this case Avas that the boy never lost consciousness, and while one of his playmates ran for assistance he got out of the hole himself, and moved to a spot ten feet distant before any help arrh'ed, and eA'en then he declined proffered aid from a man he disliked. This boy stated that he remembered each revolution of the lever and the individual injuries that each inflicted. Three years after his injury he aa-us in eA'ery respect Avell. Fraserb mentions an instance of a boy of fifteen avIio AA'as caught in the crank of a balance- wheel in a shingle-mill, and Avas taken up insensible. His skull was frac- tured at the parietal eminence and the pericranium stripped off, leaA'ing a bloody tumor near the base of the fracture about tAvo inches in diameter. The right humerus Avas fractured at the external condyle; there Avas a frac- ture of the coronoid process of the ulna, and a backAvard dislocation at the elbow. The annular ligament was ruptured, and the radius Avas separated from the ulna. On the left side there AAas a fracture of the anatomic neck of the humerus, and a dislocation doAviiAvard. The boy Avas trephined, and the comminuted fragments removed ; in about six Aveeks recovery Avas nearly com- plete. Gibson c reports the history of a girl of eight AA'ho AAas caught by her clothing in a perpendicular shaft in motion, and carried around at a rate of 150 or 200 times a minute until the machinery could be stopped. Although she AAas found in a state of shock, she was anesthetized, in order that imme- diate attention could be given to her injuries, Avhich were found to be as fol- lows :— (1) An oblique fracture of the middle third of the right femur. a Richmond Med. Jour., 1868. b 124, 1869. c 21S, 1881, 61. MULTIPLE FRACTURES. 701 (2) A transverse fracture of the middle third of the left femur. (3) A slightly comminuted transverse fracture of the middle third of the left tibia and fibula. (4) A transverse fracture of the lower third of the right humerus. (5) A fracture of the loAver third of the right radius. (6) A partial radiocarpal dislocation. (7) Considerable injuries of the soft parts at the seats of fracture, and con- tusions and abrasions all over the body. During convalescence the little patient suffered an attack of measles, but after careful treatment it Avas found by the seA'cnty-eightli clay that she had recovered Avithout bony deformity, and that there Avas bony union in all the fractures. There avus slight tilting upAvard in the left femur, in Avhich the fracture had been transA'crse, but there avus no perceptible shortening. Hulke a describes a silver-polisher of thirty-six av1io, Avhile standing near a machine, had his sleeve caught by a rapidly-turning Avheel, Avhich dreAV him in and Avhirled him round and round, his legs striking against the ceiling and floor of the room. It was thought the Avheel had made 50 revolutions before the machinery Avas stopped. After his removal it Avas found that his left humerus Avas fractured at its loAver third, and apparently comminuted. There Avas no pulse in the wrist in either the radial or ulnar arteries, but there Avas pulsation in the brachial as Ioav as the ecchymosed SAvelling. Those parts of the hand and fingers supplied by the median and radial nerves were insen- sible. The right humerus Avas broken at the middle, the end of the upper fragment piercing the triceps, and almost protruding through the skin. One or more of the middle ribs on the right side were broken near the angle, and there Avas a large transverse rent in the quadriceps extensor. Despite this terrible accident the man made a perfect recovery, Avith the single exception of limitation of flexion in the left elboAV-joint. DeAvevb details a description of a girl of six avIio aahs carried around the upright shaft of a flour mill in Avhich her clothes became entangled. Some part of the body struck the bags or stones Avith each revolution. She sus- tained a fracture of the left humerus near the insertion of the deltoid, a frac- ture of the middle third of the left femur, a compound fracture of the left femur in the upper third, Avith protrusion of the upper fragment and consider- able venous hemorrhage, and fracture of the right tibia and fibula at the upper third. When taken from the shafting the child Avas in a moribund state, with scarcely perceptible pulse, and all the accompanying symptoms of shock. Her injuries Avere dressed, the fractures reduced, and starch ban- dages applied ; in about six Aveeks there AA'as perfect union, the right leg being slightly shortened. Six months later she Avas playing about, with only a slight halt in her gait, Miscellaneous Multiple Fractures.—Westmorelandc speaks of a man a 767 1878. b 124. 1854. c Atlanta Acad, of Med., 1874. 702 MISCELLANEOUS SURGICAL ANOMALIES. who avus pressed between tAvo cars, and sustained a fracture of both collar- bones and of the sternum ; in addition, six or eight ribs Avere fractured, driven into and lacerating the lung. The heart Avas displaced. In spite of these terrible injuries, the man Avas rational Avhen picked up, and lived nearly half a day. In comment on this case Battey mentions an instance in Avhich a mill-saAvyer Avas run over by 20 or 30 logs, Avhich produced innu- merable fractures of his body, constituting him a surgical curiosity. He afterward completely recovered, and, as a consequence of his miraculous escape, became a soothsayer in his region. Westa reports a remarkable recovery after a compound fracture of the femur, fracture of the jaAV, and of the radius, and possibly injury to the base of the skull, and injury to the spine. There is on record b an account of a Avoman of forty-three Avho, by mus- cular action in lifting a stone, fractured her pubes, external to the spine, on the left side. Not realizing her injury she continued hard work all that day, but fell exhausted on the next. She recovered in about a month, and Avas able to Avalk as Avell as eA'er. Yinnedge c reports recoAery after concussion of the brain and extreme shock, associated Avith fracture of the left femur, and comminuted fractures of the left tibia and fibula. Tufnelld mentions recovery after compound comminuted fracture of the leg, Avith simple fracture of both collar-bones, and dislocation of the thumb. Nankivelle speaks of a remarkable recovery in an individual Avho suffered compound comminuted fracture of both legs, and fracture of the skull. It was found necessary to amputate the right thigh and left leg. Erichsen f effected recovery by rest alone, in an individual whose ribs and both clavicles were fractured by being squeezed. Gilman g records recoA'ery after injuries consisting of fracture of the frontal bone near the junction Avith the right parietal; fracture of the right radius and ulna at the middle third and at the Avrist; and compound fracture of the left radius and ulna, 14; inches above the wrist, Boultingh reports a case of an individual Avho suffered compound fractures of the skull and humerus, together Avith extensh'e laceration of the thigh and chest, and yet recovered. BanvellJ mentions recovery after amputation of the shoulder-joint, in an individual Avho had suffered fracture of the base of the skull, fracture of the juav, and compound fracture of the right humerus. There Avas high delirium folloAved by imbecility in this case. Bonnetj reports a case of fracture of both thighs, tAvo right ribs, luxation of the clavicle, and accidental club-foot Avith tenotomy, Avith good recovery from all the complications. Beach k speaks a 476, 1879. b 672, Sept. 30, 1868. d 312, xlvi., 337. e 476, 1873, ii., 264. g 218, 1881, 275. b 543, 1879, i., 702. j Bull. Soc. de Med. de Poitiers, 1854, 305. c Toledo Med. and Surg. Jour., 1880. f 476, 1861, ii., 229. i 548, 1879, ii., 64. 1^218, cii., 35. REMARKABLE FALLS. 703 of an individual Avho suffered fracture of both thighs, and compound com- minuted fracture of the tibia, fibula, and tarsal bones into the ankle-joint, necessitating amputation of the leg. The patient not only survived the operation, but recovered Avith good union in both thighs. As illustrative of the numerous fractures a person may sustain at one time, the London Medical Gazette* mentions an injury to a girl of fourteen, which resulted in 31 frac- tures. Remarkable Falls.—In this connection it is of interest to note from hoAV great a height a person may fall without sustaining serious injury. A remarkable fall of a miner doAvn 100 meters of shaft (about 333 feet) without being killed is recorded by M. Reumeaux in the Bulletin de 1'In- dustrie Min6rale. Working AA'ith his brother in a gallery Avhich issued on the shaft, he forgot the direction in which he Avas pushing a truck ; so it went over, and he after it, falling into some mud with about three inches of water. As stated in Nature, he seems neither to have struck any of the wood debris, nor the sides of the shaft, and he shoAved no contusions AA'hen he was helped out by his brother after about ten minutes. He could not, hoAvever, recall any of his impressions during the fall. The velocity on reaching the bottom Avould be about 140 feet, and time of fall 4.12 seconds; but it is thought he must have taken longer. It appears strange that he should have escaped simple suffocation and loss of consciousness during a time sufficient for the Avater to have drowned him. While intoxicated Prh'ate Gough of the 42d Royal Highlandersb at- tempted to escape from the castle at Edinburgh. He fell almost perpendicu- larly 170 feet, fracturing the right frontal sinus, the left clavicle, tibia, and fibula. In five months he had so far recovered as to be put on duty again, and he served as an efficient soldier. There is an account0 of recovery after a fall of 192 feet, from a cliff in County Antrim, Ireland. Manzinid men- tions a man avIio fell from the dome of the Invalides in Paris, without sus- taining any serious accident, and there is a record from Madrid9 of a much higher fall than this Avithout serious consequence. In 1792 f a bricklayer fell from the fourth story of a high house in Paris, landing with his feet on the dirt and his body on stone. He bled from the nose, and lost consciousness for about forty-five minutes ; he Avas carried to the Hotel-Dieu Avhere it Avas found that he had considerable difficulty in breathing ; the regions about the external malleoli Avere contused and SAvollen, but by the eighth day the patient had recoA'ered. In the recent reparation of the Hotel Raleigh in Washington, D. C, a man fell from the top of the building, AA'hich is above the average height, fracturing several ribs and rupturing his lung. He AA'as taken to the Emergency Hospital Avhere he Avas put to bed, and persistent treatment for shock Avas pursued ; little hope of the man's recovery AAas a Quoted 124, 1833. b i24, 1837. c 312, 1850. d 363, 1841. e 354, 1846, ii. f 302, iv., 248. 704 MISCELLANEOUS SURGICAL ANOMALIES. entertained. His friends Avere told of his apparently hopeless condition. There Avere no external signs of the injury Avith the exception of the emphy- sema folloAA'ing rupture of the lung. Respiration Avas limited and thoracic movement diminished by adhesive straps and a binder; under careful treat- ment the man recovered. Kartulus* mentions an English boy of eight avIio, on June 1, 1879, while playing on the terrace in the third story of a house in Alexandria, in attempting to fly a kite in company with an Arab servant, slipped and fell 71 feet to a granite pavement beloAv. He AAas picked up conscious, but both legs avc re fractured about the middle. He had so far recovered by the 24th of July that he could hobble about on crutches. On the 15th of November of the same year he avus seen by Kartulus racing across the playground Avith some other boys ; as he came in third in the race he had evidently lost little of his agility. Parrott b reports the history of a man of fifty, Aveighing 196 pounds, avIio fell 110 feet from the steeple of a church. In his descent he broke a scaffold pole in tAvo, and fell through the Avooden roof of an engine-house below, breaking several planks and two strong joists, and landing upon some sacks of cement inside the house. When picked up he avus unconscious, but regained his senses in a short time, and it Avas found that his injuries Avere not serious. The left metacarpal bones avc re dislocated from the carpal bones, the left tibia was fractured, and there Avere contusions about the back and hips. TAveh'e days later he left for home Avith his leg in plaster. Farber and McCassyc report a ease in AA'hich a man fell 50 feet perpendicularly through an elevator shaft, fracturing the skull. Pieces of bone at the supe- rior angle of the occipital bone Avere removed, leaving the dura exposed for a space one by four inches. The man Avas unconscious for four days, but en- tirely recovered in eighteen days, with only a slightly subnormal hearing as an after-effect of his fall. For many years there haA'e been persons who have given exhibitions of high jumps, either landing in a net or in the Avater. Some of these hazardous individuals do not hesitate to dive from enormous heights, being satisfied to strike head first or to turn a somersault in their descent. Nearly all the noted bridges in this country have had their " divers." ^The death of Odium in his attempt to jump from Brooklyn bridge is Avell knoAvn. Since then it has been claimed that the feat has been accomplished Avithout any serious injury, i i is reported that on June 20, 1896, a youth of nineteen made a head- long dive from the top of the Eads bridge at St. Loujs, Mo., a distance of 125 feet. He is said to have sAvum 250 feet to a Availing tug, and Avas taken on board without having been hurt. Probably the most interesting exhibition of this kind that Avas ever seen was at the Royal Aquarium, London, in the summer of 1895. A part of the regular nightly performance at this Hall, AA'hich is familiar on account of its immens- a 476, 1880, i., 486. b 224, 1886, ii., 451. c Laucet-Clinic, Feb. 22, 1896. VITALLTY IN CHILDREN. 705 ity, was the jump of an individual from the rafters of the large arched roof into a tank of Avater about 15 by 20 feet, and from eight to ten feet deep, sunken in the floor of the hall. Another performer, dressed in his ordinary street clothes, Avas tied up in a bag and jumped about two-thirds of this height into the same tank, breaking open the bag and undressing himself before com- ing to the surface. In the same performance a female acrobat made a back- ward dive from the topmost point of the building into a net stretched about ten feet above the floor. Nearly every large acrobatic entertainment has one of these individuals who seem to experience no difficulty in duplicating their feats night after night. It is a common belief that people falling from great heights die in the act of descent. An interview Avith the sailor who fell from the top-gallant of an East Indiaman, a height of 120 feet, into the water, elicited the fact that during the descent in the air, sensation entirely disappeared, but returned in a slight degree Avhen he reached the Avater, but he Avas still unable to strike out when rising to the surface. By personal observation this man stated that he believed that if he had struck a hard substance his death Avould have been painless, as he was sure that he AAas entirely insensible during the fall.a A Avriter in the Pall Mall Gazette,b in speaking of the accidents which had happened in connection Avith the Forth Bridge, tells of a man Avho trusted himself to Avork at the height of 120 feet above the Avaters of the Firth, sim- ply grasping a rope. His hands became numb with cold, his grasp relaxed, and he fell backAvard down into the Avater, but was brought out alive. In another instance a spanner fell a distance of 300 feet, knocked off a man's cap, and broke its way through a four-inch plank. Again, another spanner fell from a great height, actually tearing off a man's clothes, from his Avaist- eoat to his ankle, but leaving him uninjured. On another occasion a stag- ing Avith a number of workmen thereon gave way. Tavo of the men were killed outright by striking some portion of the Avork in their descent; tAvo others fell clear of the girders, and were rescued from the Firth little Avorse for their great fall. Resistance of Children to Injuries.—It is a remarkable fact that young children, Avhose bones, cartilages, and tissues are remarkably elastic, are some- times able to sustain the passage over their bodies of vehicles of great weight Avithout apparent injury. There is a record early in this century c of a child of five who Avas run over across the epigastrium by a heavy tAVO-Avheeled cart, but recovered Avithout any bad symptoms. The treatment in this case is quite interesting, and AA'as as folloAvs : A'enesection to faintness, castor oil in infusion of senna until there Avas a free evacuation of the boAvels, 12 leeches to the abdomen and spine, and a saline mixture every tAvo hours ! Sneh depleting therapeutics Avould in themselves seem almost sufficient to a 476. 1S89, ii., 466. b gept., 1888. c 476, 1829, 652. 45 706 MISCELLANEOUS SURGICAL ANOMALIES. proA'oke a fatal issue, and AA'ere gh'en in good faith as the means of effecting a recovery in such a case. In a similar instance11 a Avagon Aveighing 1200 pounds passed over a child of five, Avith no apparent injury other than a bruise near the ear made by the Avheel. Infant-vitality is sometimes quite remarkable, a neAvly-born child some- times surviving extreme exposure and major injuries. There AA'as a remark- able instance of this kind brought to light in the Mullings vs. Midlings di- vorce-case, recorded in The Lancet.b It appeared that Mrs. Mullings, a feAV hours after her confinement at Torquay, packed her neAvly-born infant boy in a portmanteau, and started for London. She had telegraphed Dr. J. S. Tul- loch to meet her at Paddington, Avhere he found his patient apparently in good condition, and not Aveak, as he expected in a Avoman shortly to be confined. On the Avay to her apartments, Avhich had been proA'ided by Dr. Tulloch, Mrs. Mullings remarked to the Doctor that she had already borne her child. Dr. Tulloch Avas greatly surprised, and immediately inquired what she had done Avith the baby. She replied that it Avas in a box on top of the cab. When the box AA'as opened the child Avas found alive. The Lancet comments on the remarkable fact that, shortly after confinement, a Avoman can travel six or seven hours in a railroad train, and her neAvly-born babe coiiAeyed the same distance in a portmanteau, Avithout apparent injury, and Avithout attracting attention. Booth c reports a remarkable case of vitality of a newly-born child Avhich came under his observation in October, 1894. An illegitimate child, aban- doned by its mother, Avas left at the bottom of a cesspool vault; she claimed that ten hours before Booth's visit it had been accidentally dropped during an attempt to micturate. The infant lived despite the folloAving facts : Its delivery from an ignorant, inexperienced, unattended negress; its cord not tied ; its fall of 12 feet dovra the pit; its ten hours' exposure in the cesspool; its smothering by foul air, also by a hea\-y covering of rags, paper, and straw ; its pounding by three bricks AA'hich fell in directly from eight feet above (some loose bricks Avere accidentally dislodged from the sides of the A'ault, in the maneuA'ers to extricate the infant); its loAvered temperature previous to the application of hot bottles, blankets, and the administration of cardiac stimulants. Booth adds that the morning after its discovery the child appeared perfectly Avell, and some Iavo months afterward Avas brought into court as evidence in the case. A remarkable case of infant vitality is given on page 117. Operations in the Young and Old.—It might be of interest to men- tion that such a major operation as OA'ariotomv has been successfully performed in an infant. In a paper on infant OA'ariotomyd several instances of this nature are mentioned. Roemer successfully performed ovariotomy on a child one year and eight months old; SAvartz, on a child of four; Barker, on a 218, 1847. b 476, 1874, ii., 169. c 792, Feb., 1895. d 224, 1884, i., 234. REPEA TED OPERA TIONS. 707 a child of four ; KnoAvsley Thornton, on a child of seven, and Spencer AVells, Cupples, and ChenoAveth, on children of eight. Rein performed ovariotomy on a girl of six, suffering from a miiltilocular cyst of the left ovary. He expresses his belief that childhood and infancy are favorable to laparotomy. Ividd a removed a dermoid from a child of two years and eleven months; Hooks b performed the same operation on a child of thirty months. Chiene c extirpated an ovary from a child of three ; Neville d duplicated this operation in a child one month younger; and Alcocke performed ovariotomy on a child of three. Successful ovariotomies are infrequent in the extremely aged. Bennett £ mentions an instance in a Avoman of seventy-five, and Davies^ records a simi- lar instance. Borsini h and Terrieri cite instances of successful ovariotomy in patients of seventy-seven. Carmichaelj performed the operation at seventy- four. OAvens k mentions it at eighty ; and Homans] at eighty-two years and four months. DeAvees m records a successful case of ovariotomy in a Avoman over sixty-seven ; McNuttn reports a successful instance in a patient of sixty- seven years and six months ; the tumor weighed 60 pounds, and there were extensive adhesions. Maury removed a monocystic ovarian tumor from a woman of seATenty-four, his patient recovering. Pippingskold mentions an ovariotomy at eighty. Terrier ° describes double ovariotomy for fibromata in a Avoman of seventy-seven. Aron p speaks of an operation for pilous dermoid of the ovary in a woman of seventy-five. Shepherd q reports a case of recur- rent proliferous cyst in a Avoman of sixty-three, on Avhom successful ovariotomy was performed twice within nine months. Wells r mentions an ovarian cyst in a Avoman of sixty-five, from AA'hich 72 pints of fluid were remo\'ed. HaAvkins s describes the case of a musician, M. Rochard, Avho at the age of one hundred and seven Avas successfully operated on for strangulated hernia of upAvard of thirty hours' duration. The Avound healed by first in- tention, and the man Avas Avell in tAvo Aveeks. Fowler* operated successfully for strangulated umbilical hernia on a patient of sixty-eight. Repeated Operations.—Franzolini11 speaks of a Avoman of fifty on Avhom he performed six celiotomies betAveen June, 1879, and April, 1887. The first operation AAas for fibrocystic disease of the uterus. Since the last opera- tion the Avoman had had remarkably good health, and there AA'as every indi- cation that Avell-merited recoA'ery had been effected. The Ephemerides contains an account of a case in Avhich cystotomy Avas repeated four times, and there is another record of this operation having been done five times on a man.v Instances of repeated Cesarean section are mentioned on page 130. a 610, 18*0, 241. b 125, 1886, 1022. c 318, 1883-84, 1132. d Proc. Dublin Obst. Soc, 1879-80, 16. e 476, 1871, ii., 850. * 130, 1861. g 223, 1887. b688, 1881. i 653, 1888. J 590,1883. k 223, 1889. 1 538, 1888. m54S, 1864, i., 560. n West. Lancet, San Francisco, 1879-80, viii., 485. o 653, 1888, vii., 466. P 363, xlvi., 1065. q 476, 1886, i., 1162. r 779, x., 189. s 490, Dec. 9, 1842. t 224, 1884, i., 555. "361, 1889. * 708, 1718, 1985. 708 MISCELLANEOUS SURGICAL ANOMALIES. Before leaving this subject, Ave mention a marvelous operation per- formed by Billroth'1 on a married Avoman of tAventy-nine, after her sixth pregnancy. This noted operator performed, synchronously, double ovari- otomy and resections of portions of the bladder and ileum, for a large medul- lary carcinomatous groAvth of the ovary, AA'ith surrounding invoh'ement. Menstruation returned three months after the operation, and in fifteen months the patient Avas in good health in every Avay, aa ith no apparent danger of recurrence of the disease. Self-performed Surgical Operations.—There haA'e been instances in which surgeons and even laymen have performed considerable operations upon themselves. On the battlefield men have amputated one of their oavu limbs that had been shattered. In such cases there Avould be little pain, and premeditation Avould not be brought into play in the same degree as in the case of M. Clever de Maldigny, a surgeon in the Royal Guards of France, avIio successfully performed a lithotomy on himself before a mirror. He savs that after the operation Avas completed the urine floAvcd in abundance ; he dressed the Avound Avith lint dipped in an emollient solution, and, being per- fectly relieA'ed from pain, fell into a sound sleep. On the folloAving day, M. Maldigny says, he Avas as tranquil and cheerful as if he had neA'er been a suf- ferer. A Dutch blacksmith and a German cooper each performed lithotomy on themselves for the intense pain caused by a stone in the bladder. Tul- pius,842 Walther,81i5 and the Ephemerides each report an instance of self-per- formed cystotomy. The folloAving case is probably the only instance in Avhich the patient, suffering from vesical calculus, tried to crush and break the stone himself. b J. B., a retired draper, born in 1828, Avhile a youth of seventeen, sustained a fracture of the leg, rupture of the urethra, and laceration of the perineum, by a fall down a Avell, landing astride an iron bar. A permanent perineal fistula AA'as established, but the patient Avas aA'erse to any operative remedial measure. In the year 1852 he became aAA'are of the presence of a calculus, but not until 1872 did he ask for medical assistance. He explained that he had introduced a chisel through his perineal fistula to the stone, and at- tempted to comminute it himself and thus remove it, and by so doing had remoA'ed about an ounce of the calculus. The physician started home for his forceps, but during the interval, Avhile Avalking about in great pain, the man \A-as relieved by the stone bursting through the perineum, falling to the floor, and breaking in tAvo. Including the ounce already chiselled off, the stone Aveighed 14J ounces, and Avas lOf inches in its long circumference. B. recovered and lived to December, 1883, still believing that he had another piece of stone in his bladder. In Holden's " Landmarks " Ave are told that the operation of dividing the Achilles tendon Avas first performed by an unfortunate upon himself, by means a Wiener Med. Wocbenscbrift, Nos. ii. and iii., 1883. b 381, 1.-89. i., 408. EXTENSIVE LOSS OF BLOOD. 709 of a razor. According to Patterson,a the late Mr. Synies told of a patient in North Scotland avIio, for incipient hip-disease, had the cautery applied at the Edinburgh Infirmary Avith resultant great relief. After returning home to the country he experienced considerable pain, and despite bis vigorous efforts he AA'as unable to induce any of the men to use the cautery upon him ; they termed it " barbarous treatment." In desperation and fully believing in the efficacy of this treatment as the best means of permanently alleviating his pain, the crippled Scotchman heated a poker and applied the cautery himself. We have already mentioned the marvelous instances of Cesarean sections self-performed (page 131), and in the literature of obstetric operations many of the minor type haA'e been done by the patient herself. In the foregoing cases it is to be understood that the operations haA'e been performed solely from the inability to secure surgical assistance or from the incapacity to endure the pain any longer. These operations Avere not the self-mutilations of maniacs, but Avere performed by rational persons, driven to desperation by pain. Possibly the most remarkable instances of extensive loss of blood, with recoveries, are to be found in the older records of A'enesection. The chroni- cles of excessive bleeding in the olden days are avcII knoAvn to everybody. Perhaps no similar practice Avas so universally indulged in. Both in sickness and in health, depletion Avas indicated, and it is no exaggeration to say that about the hospital rooms at times the floors Avere coA'ered Avith blood. The reckless Avay in which venesection Avas resorted to, led to its disuse, until to-dav it has so A'anished from medical practice that eA'en its benefits are overlooked, and depletion is brought about in some other manner. Turn- ing to the older Avriters, Ave find Burton b describing a patient from whom he took 122 ounces of blood in four days. Dover speaks307 of the re- moval of 111 and 190 ounces ; Galen, of six pounds ; and Haen,395 of 114 ounces. Taylorc relates the history of a case of asphyxia in Avhich he pro- duced a successful issue by extracting one gallon of blood from his patient during twelve hours. Lucasd speaks of 50 venesections being practised during one pregnancy. Van der Wiele performed A'enesection 49 times dur- ing a single pregnancy. Balmesf mentions a case in AA'hich 500 venesections were performed in tAventy-five years. Laugier s mentions 300 venesections in tAventv-six months. Osiander speaks of 8000 ounces of blood being taken aAvav in thirtv-five years. Pechlin622 reports 155 A'enesections in one person in sixteen years, and there is a record of 1020 repeated A'enesections.h The loss of blood through spontaneous hemorrhage is sometimes re- markable. Fabricius Hildanus1 reports the loss of 27 pounds of blood in a feAV days; and there is an older record of 40 pounds being lost in four days. J florstius, Fabricius Hildanus, and Schenck, all record instances of death from ;1 381, 1889, i., 408. b American Med. Repository. c 476, 1827. 718. 'I M«l. Obs. & Inquiries. e Cent, i., obs. 65. t 462, T. lxxi., 233. g 462, T. xv. >> Samml. Med. AVuhrnehm, Band 6, 408. i 334, cent, vi., obs. 13. J 470, 1683. 710 MISCELLANEOUS SURGICAL ANOMALIES hemorrhage of the gums. Tulpius842 speaks of hemoptysis lasting chronic- ally for thirty years, and there is a similar record of forty years' duration in the Ephemerides. Chapman" gives several instances of extreme hemorrhage from epistaxis. He remarks that Bartholinus has recorded the loss of 48 pounds of blood from the nose ; and Rhodius, 18 pounds in thirty-six hours. The Ephemerides contains an account of epistaxis Avithout cessation for six Aveeks. Another Avriter in an old journal106 speaks of 75 pounds of blood from epistaxis in ten days. Chapman also mentions a case in AA'hich, by in- testinal hemorrhage, eight gallons of blood Avere lost in a fortnight, the patient recovering. In another case a pint of blood Avas lost daily for fourteen days, with recovery. The loss of eight quarts in three days caused death in another case; and Chapman, again, refers to the loss of three gallons of blood from the boAvel in tAventy-four hours. In the case of Michelotti, recorded in the Transactions of the Royal Society, a young man suffering from enlarge- ment of the spleen vomited 12 pounds of blood in tAvo hours, and recovered. In hemorrhoidal hemorrhages, Lieutaud speaks of six quarts being lost in tAvo days; Hoffman, of 20 pounds in less than tAventy-four hours, and Pana- roli, of the loss of one pint daily for tAvo years. Arrow-Wounds.—According to Otis b the illustrious Baron Percy Avas wont to declare that military surgery had its origin in the treatment of wounds inflicted by darts and arroAVs ; he used to quote Book XI. of the Iliad in behalf of his belief, and to cite the eases of the patients of Chiron and Machaon, Menelaus and Philoctetes, and Eurypiles, treated by Patroclus ; he Avas eA'en tempted to believe Avith Sextus c that the name larpoq, medicus, avus derived from loq, Avhich in the older times signified " sagitta," and that the earliest function of our professional ancestors was the extraction of arroAvs and darts. An instrument called beluleum was invented during the long Peloponnesian War, over four hundred years before the Christian era. It was a rude extracting-forceps, and AAas used by Hippocrates in the many campaigns in which he served. His immediate successor, Diocles, invented a complicated instrument for extracting foreign bodies, called graphiscos, Avhich consisted of a canula Avith hooks. Otis states that it was not until the Avars of Augustus that Heras of Cappadocia designed the famous duck-bill forceps Avhich, aa ith every conceivable modification, has continued in use until our time. Celsus d instructs that in extracting arrow-heads the entrance-AVOund should be dilated, the barb of the arroAV-head crushed by strong pliers, or protected betAveen the edges of a split reed, and thus Avithdrawn Avithout laceration of the soft parts. According to the same authority, Paulus Aegineta also treated fully of Avounds by arroAV-heads, and described a method used in his time to re- moA'e firmly-impacted arroAvs. Albucasius115 and others of the Arabian school did little or nothing toward aiding our knoAvledge of the means of a "Eruptive Fevers." b 847, 144. c Ad vers. Math., L. I., cap. ii. d 259, L. vii., cap. v. ARROW-WOUNDS. 711 extracting foreign bodies. After the fourteenth century the attention of surgeons was directed to wounds from projectiles impelled by gunpoAvder. In the sixteenth century arroAvs were still considerably used in Avarfare, and we find Parea delineating the treatment of this class of injuries with the sovereign good sense that characterized his Avritings. As the use of firearms became prevalent the literature of Avounds from arrows became meager, and the report of an instance in the present day is very rare. Billb has collected statistics and thoroughly discussed this subject, remark- ing upon the rapidity with Avhich American Indians discharge their arroAvs, and states that it is exceptional to meet with only a single Avound. It is commonly believed that the Indian tribes make use of poisoned arrows, but from the reports of Bill and others, this must be a very rare custom. Aslihurst states that he was informed by Dr. Schell, who Avas stationed for some time at Fort Laramie, that it is the universal custom to dip the arrows in blood, which is alloAved to dry on them; it is not, therefore, improbable that septic material may thus be inoculated through a wound. Many savage tribes still make use of the poisonous arrow. The Dyak uses a sumpitan, or blow-tube, which is about seven feet long, and haA'ing a bore of about half an inch. Through this he blows his long, thin dart, anointed on the head with some vegetable poison. Braid Avood c speaks of the physiologic action of Dajaksch, an arroAV-poison used in Borneo. Arnottd has made observations relath'e to a substance produced near Aden, which is said to be used by the Somalies to poison their arroAvs. Messer of the Brit- ish Navy has made inquiries into the reputed poisonous nature of the arrows of the South Sea Islanders. Otise has collected reports of arroAV-Avounds from surgical cases occurring in the U. S. Army. Of the multiple arrow-wounds, six out of the seven cases Avere fatal. In five in which the cranial cavity Avas wounded, four pa- tients perished. There Avere tAvo remarkable instances of recovery after pene- tration of the pleural cavity by arroAvs. The great fatality of arroAV-Avounds of the abdomen is avcII known, and, according to Bill, the Indians ahvays aim at the umbilicus; when fighting Indians, the Mexicans are accustomed to envelop the abdomen, as the most vulnerable part, in many folds of a blanket. Of the arrow-wounds reported, nine Avere fatal, with one exception, in which the lesion implicated the soft parts only. The regions injured were the scalp, face, and neck, in three instances; the parietes of the chest in six; the long muscles of the back in two; the abdominal muscles in two; the hip or buttocks in three ; the testis in one ; the shoulder or arm in 13 ; forearm or hand in six ; the thigh or leg in seven. The force with Avhich arrows are projected by Indians is so great that it a 618, 445, et seq. b 124, xliv., 365 and 439, ii. c 318, 1864, x., 123. d 777, 1855, ii., 314. e 847, 144. 712 MISCELLANEOUS SURGICAL ANOMALIES. has been estimated that the initial A'elocitv nearly equals that of a musket- ball. At a short distance an arroAv Avill perforate the larger bones Avithout comminuting them, causing a slight fissure only, and resembling the effect of a pistol-ball fired through a AvindoAA'-glass a feAV yards off. Among extraordinary eases of recovery from arrow-wounds, several of the most striking will be recorded. Tremaine a mentions a sergeant of thirty- four avIio, in a fray Avith some hostile Indians, received seven arroAV-Avounds : tAvo on the anterior surface of the right arm ; one in the right axilla; one on the right side of the chest near the axillary border; tAvo on the posterior sur- face of the left arm near the elboAv-joint, and one on the left temple. On June 1st he Avas admitted to the Post Hospital at Fort Dodge, Kan. The wound on the right arm near the deltoid discharged, and there Avas slight ex- foliation of the humerus. The patient was treated AA'ith simple dressings, and AA'as returned to duty in July, 1870. Goddard b mentions an arroAv-AA'ound by Avhich the body AA'as transfixed. The patient AAas a sutler's helper at Fort Rice, Dakota Territory. He AA'as accidentally Avounded in February, 1868, by an arroAv AA'hich entered the back three inches to the right of the 5th lumbar vertebra, and emerged about tAvo inches to the right of the ensiform cartilage. During the folloAving evening the patient lost about eight ounces of blood externally, Avith a small amount internally. He Avas confined to his bed some two weeks, suffering from circumscribed peritonitis Avith irritative fever. In four Aveeks he Avas Avalking about, and by July 1st Avas actively employed. The arroAv Avas deposited in the Army Medical Museum. Midlerc gh'es a report of an arroAv-wound of the lung Avhich Avas produc- tive of pleurisy but Avhich avus folloAved by recovery. Kuglerd recites the description of the case of an arrow-wound of the thorax, complicated by fright- ful dyspnea and blood in the pleural cavity and in the bronchi, Avith recovery. Smarte extracted a hoop-iron arroAV-head, If inches long and J inch in breadth, from the brain of a private, about a month after its entrance. About a dram of pus folloAved the exit of the arroAV-head. After the operation the right side Avas observed to be paralyzed, and the man could not remember his name. He continued in a varying condition for a month, but died on May 13, 1866, fifty-tAvo days after the injury. At the postmortem it Avas found that the brain-tissue, to the extent of £ inch around the track of the arroAv as a center, Avas softened and disorganized. The track itself Avas filled with thick pus Avhich extended into the ventricles. Peabody reports a most remarkable case of recovery from multiple arroAv- Avounds.f In a skirmish Avith some Indians on June 3,1863, the patient had been Avounded by eight distinct arroAvs Avhich entered different parts of the body. They Avere all extracted with the exception of one, Avhich had entered at the outer and loAver margin of the right scapula, and had passed imvard a 847, 156. b 847, 153. c 847, 151. d ibid. e 847, 147. t 847, 145. SERIOUS INSECT-STINGS 713 and upward through the upper lobe of the right lung or trachea. The hem- orrhage at this time was so great that all hope AA'as abandoned. The patient, however, rallied, but continued to experience great pain on SAvalloAving, and occasionally spat blood. In July, 1866, more than three years after the in- jury, he called on Dr. Pea body to undergo an examination Avith a vieAV of applying for a pension, stating that his health was affected from the presence of an arroAV-head. He Avas much emaciated, and expressed himself as tired of life. Upon probing through a small fistulous opening just above the superior end of the sternum, the point of the arroAv Avas found resting against the bone, about 11 inches beloAv, the head lying against the trachea and eso- phagus, Avith the carotid artery, jugular vein, and nerves overlying. After some little difficulty the point of the arroAv AA'as raised above the sternum, and it Avas extracted Avithout the loss of an ounce of blood. The edge grazed against the sheath of the innominate artery during the operation. The missile measured an inch at the base, and Avas four inches long. The health of the patient underwent remarkable improvement immediately after the operation. Serious Insect-stings.—Although in this country the stings of insects are seldom productive of serious consequences, in the tropic climates death not unfrequently results from them. Wounds inflicted by large spiders, centi- pedes, tarantulse, and scorpions have proved fatal. Even in our country deaths, preceded by gangrene, have sometimes folloAved the bite of a mosquito or a bee, the location of the bite and the idiosyncrasy of the individual prob- ably influencing the fatal issue. In some cases, possibly, some vegetable poison is introduced AA'ith the sting. Hulse, IT. S. N.,a reports the case of a man avIio avus bitten on the penis by a spider, and Avho subsequently exhibited vio- lent symptoms simulating spinal meningitis, but ultimately recovered. Kunstb mentions a man of thirty-six Avho received several bee-stings while taking some honey from a tree, fell from the tree unconscious, and for some time afterAvard exhibited signs of cerebral congestion. Chaumetonc mentions a young man who did not perceive a Avasp in a glass of sweet Avine, and sAval- loAvcd the insect. He was stung in the throat, followed by such intense in- flammation that the man died asphyxiated in the presence of his friends, avIio could do nothing to relieve him. In connection with this case there is men- tioned an English agriculturist Avho saA'ed the life of one of his friends Avho had inadA'ertently swalloAved a Avasp with a glass of beer. Alarming symp- toms manifested themselves at the moment of the sting. The farmer made a kind of paste from a solution of common salt in as little AA'ater as possible, Avhich he gave to the young man, and, after several swalloAvs of the potion, the symptoms disappeared as if by enchantment. There is a recent account from Bridgeport, Conn., of a AA'oman Avho, Avhile eating a pear, SAvallowed a hornet that had alighted on the fruit. In going down the throat the insect a 124, 1839, 69. b 545, 1878, 130. c 302, i. 714 MISCELLANEOUS SURGICAL ANOMALIES. stung her on the tonsil. Great pain and inflammation followed, and in a short time there Avas complete deprivation of the poAver of speech. Mease a relates the case of a corpulent farmer avIio, in July, 1835, Avas stung upon the temple by a common bee. He Avalked to a fence a short dis- tance away, thence to his house, 20 yards distant, lay doAA'ii, and expired in ten minutes. A second case, AA'hich occurred in June, 1811, is also mentioned by Mease.b A vigorous man Avas stung in the septum of the nose by a bee. Supported by a friend he Avalked to his house, a feAV steps distant, and lav doAvn. He rose immediately to go to the well, stepped a feAV paces, fell, and expired. It Avas thirty minutes from the time of the accident to the man's death. A third case is reported by the same author from Kentucky. A man of thirty-five was stung on the right superior palpebrum, and died in tAventy minutes. Mease reports a fourth case from Connecticut, in which a man of twenty-six Avas stung by a bee on the tip of the nose. He recovered after treatment with ten-grain doses of Dover's Powder, and persistent application of plantain leaves. A fifth case was that of a farmer in Pennsylvania avIio Avas stung in the left side of the throat by a Avasp Avhich he had SAvallowed in drinking cider. Notwithstanding medical treatment, death ensued tAventy- seven hours afterward. A sixth case, which occurred in October, 1834, is given by the same author. A middle-aged man was stung by a yellow AA'asp on the middle finger of the right hand, and died in less than tAventy minutes after having received his Avound. A seA'enth case Avas that of a New York farmer who, while hoeing, was bitten on the foot by a spider. NotAvith- standing medical treatment, principally bleeding, the man soon expired. Desbrestc mentions the sting of a bee above the eyebrow followed by death. Zacutus saw a bee-sting which was followed by gangrene. Delaistre d men- tions death from a hornet-sting in the palate. Nivison e relates the case of a farmer of fifty who was stung in the neck by a bee. The usual SAvelling and dis- coloration did not follow, but notwithstanding vigorous medical treatment the man died in six days. Thompson f relates three cases of bee-sting, in all of Avhich death supervened Avithin fifteen minutes,—one in a farmer of fifty-eight avIio Avas stung in the neck beloAv the right ear ; a second in an inn-keeper of fifty who AAas stung in the neck, and a third of a woman of sixty-four Avho avus stung on the left brow. "Chirurgus"s recalls the details of a case of a Avasp-sting in the middle finger of the right hand of a man of forty, depriv- ing him of all sense and of muscular power. Ten minutes after receiving it he was unconscious, his heart-beats were feeble, and his pulse only perceptible. Syphilis from a Flea-bite.—Jonathan Hutchinson, in the October, 1895, number of his unique and valuable Archives of Surgery, reports a primary lesion of most unusual origin. An elderly member of the profession presented himself entirely covered with an evident syphilitic eruption, which a 124, 1836-37, xix., 265. b ibid. c 462, 1765. d Gaz. de Sante, 1776. e 594, 1857, 3 s., ii., 339. t 224, 1869, i., 374. g 535, 1819, xl., 479. SNAKE-BITES. 715 rapidly disappeared under the use of mercury. The only interest about the case Avas the question as to hoAV the disease had been acquired. The doctor Avas evidently anxious to give all the information in his poAver, but AA'as posi- tive that he had never been exposed to any sexual risk, and as he had retired from practice, no possibility of infection in that manner existed. He will- ingly stripped, and a careful examination of his entire body surface revealed no trace of lesion Avhatever on the genitals, or at any point, except a dusky spot on one leg, Avhich looked like the remains of a boil. This, the doctor stated, had been due to a small sore, the dates of the appearance and duration of Avhich avc re found to fit exactly Avith those of a primary lesion. There had also been some enlargement of the femoral glands. He had neA'er thought of the sore in this connection, but remembered most distinctly that it folloAved a flea-bite in an omnibus, and had been caused, as he supposed, by his scratch- ing the place, though he could not understand why it lasted so long. Mr. Hutchinson concludes that all the evidence tends to sIioav that the disease had probably been communicated from the blood of an infected person through the bite of the insect. It thus appears that even the proverbially trivial flea- bite may at times prove a serious injury. Snake-bites.—A writer in an Indian paper asserts that the traditional immunity of Indian snake-charmers is due to the fact that having been accidentally bitten by poisonous serpents or insects more than once, and having survived the first attack, they are subsequently immune. His asser- tion is based on personal acquaintance Avith Madari Yogis and Fakirs, and an actual experiment made Avith a Mohammedan Fakir avIio Avas immune to the bites of scorpions provided by the writer. The animals Avere from five to seven inches long and had lobster-like cIuavs. Each bite dreAV blood, but the Fakir was none the Avorse. The venom of poisonous snakes may be considered the most typ- ical of animal poisons, being unrivaled in the fatality and rapidity of its ac- tion. Fortunately in our country there are feAV snake-bites, but in the tropic countries, particularly India, the mortality from this cause is frightful. Not only are there numerous serpents in that country, but the natives are lightly dressed and unshod, thus being exposed to the bites of the reptiles. It is estimated by capable authorities that the deaths in India each year from snake- bites exceed 20,000. It is stated that there Avere 2893 human beings killed by tigers, leopards, hyenas, and panthers in India during the year 1894, and in the same year the same species of beasts, aided by snakes, killed 97,371 head of cattle. The number of human lives destroyed by snakes in India in 1894 was 21,538. The number of Avild beasts killed in the same year was 13,447, and the number of snakes killed Avas 102,210. Yarrow of Washington, avIio has been a close student of this subject, has found in this country no less than 27 species of poisonous snakes, belonging to four genera. The first genus is the Crotalus, or rattlesnake proper ; the second 716 MISCELLANEOUS SURGICAL ANOMALIES. is the Caudisona, or ground-rattlesnake; the third is the Ancistrodon, or moc- casin, one of the species of Avhich is a AA'ater-snake ; and the fourth is the Flaps, or harlequin snake. There is some dispute over the exact degree of the toxic qualities of the venom of the Heloderma suspectum, or Gila monster. In India the cobra is the most deadly snake. It groAVs to the length of 5| feet, and is most active at night. The Ophiophagus, or hooded cobra, is one of the largest of venomous snakes, sometimes attaining a length of 15 feet; it is both poAverful, active, and aggressive. The common snakes of the deadly variety in the United States are the rattlesnake, the "copperhead," and the moccasin ; and it is from the bites of one of these varieties that the great majority of reported deaths arc caused. But in looking over medical literature one is struck Avith the scarcity of reports of fatal snake-bites. This is most likely attributable to the fact that, except a feAV army-surgeons, physicians rarely see the cases. The natural abode of the serpents is in the Avild and uninhabited regions. The venom is delivered to the victim through the medium of a long fang Avhich is connected AA'ith a gland in AA'hich the poison is stored. The supply may be readily exhausted ; for a time the bite would then be harmless. Con- trary to the general impression, snake-venom AA'hen swalloAved is a deadly poison, as proved by the experiments of Fayrer, Mitchell, and Reiehert. Death is most likely caused by paralysis of the vital centers through the cir- culation. In this country the wounds invariably are on the extremities, Avhile in India the cobra sometimes strikes on the shoulder or neck. If called on to describe accurately the symptoms of snake-venom poi- soning, few medical men could respond correctly. In most cases the Avound is painful, sometimes exaggerated by the mental condition, AA'hich is Avrought up to a pitch rarely seen in other equally fatal injuries. It is often difficult to discern the exact point of puncture, so minute is it. There is SAvelling due to effusion of blood, active inflammation, and increasing pain. If the poison has gained full entrance into the system, in a short time the SAvelling extends, vesicles soon form, and the disorganization of the tissues is so rapid that gangrene is liable to intervene before the fatal issue. The patient be- comes prostrated immediately after the infliction of the Avound, and his con- dition strongly indicates the use of stimulants, even if the medical attendant Avere unfamiliar Avith the history of the snake-bite. There may be a slight delirium ; the expression becomes anxious, the pulse rapid and feeble, the respiration labored, and the patient complains of a sense of suffocation. Coma folloAvs, and the respirations become sloAver and sloAver until death results. If the patient lives long enough, the discoloration of the extremity and the savcII- ing may spread to the neck, chest and back. Loss of speech after snake-bite is discussed in Chapter XVIL, under the head of Aphasia. A peculiar complication is a distressing inflammation of the mouth of in- dividuals that have sucked the Avounds containing venom. This custom is CASES OF SNAKE-BITE. Ill still quite common, and is preferred by the laity to the surer and much Aviser method of immediate cauterization by fire. There is a curious case reported a of a young man avIio Avas bitten on the ankle by a viper; he had not sucked the Avound, but he presented such an enormous SAvelling of the tongue as to be almost provocative of a fatal issue. In this case the lingual SAvelling was a local effect of the general constitutional disturbance. Cases of Snake-bite.—The folloAving case illustrative of the tenacity of virulence of snake-venom Avas reported by Mr. Temple, Chief Justice of Honduras, and quoted by a London authority.b Wrhile Avorking at some Avood-cutting a man Avas struck on a heavy boot by a snake, Avhich he killed Avith an axe. He imagined that he had been efficiently protected by the boot, and he thought little of the incident. Shortly afterAvard he began to feel ill, sank into a stupor, and succumbed. His boots Avere sold after his death, as they Avere quite Avell made and a luxury in that country. In a feAV hours the purchaser of the boots Avas a corpse, and every one attributed his death to apoplexy or some similar cause. The boots Avere again sold, and the next unfortunate OAvner died in an equally short time. It AA'as then thought wise to examine the boots, and in one of them Avas found, firmly embedded, the fang of the serpent. It Avas supposed that in pulling on the boots each of the subsequent owners had scratched himself and became fatally inoculated Avith the venom, Avhich avus unsuspected and not combated. The case is so strange as to appear hypothetic, but the authority seems reliable. The folloAving are three cases of snake-bite reported by surgeons of the United States Army, two followed by recovery, and the other by death : Middleton0 mentions a private in the Fourth Cavalry, aged tAventy-nine, Avho AA'as bitten by a rattlesnake at Port Concho, Texas, June 27, 1866. The bite opened the phalangeal joint of the left thumb, causing violent inflamma- tion, and resulted in the destruction of the joint. Three years afterAvard the joint SAvelled and became extremely painful, and it Avas necessary to ampu- tate the thumb. Campbelld reports the case of a private of the Thirteenth Infantry avIio Avas bitten in the throat by a large rattlesnake. The Avound Avas immediately sucked by a comrade, and the man reported at the Post Hospital, at Camp Cooke, Montana, three hours after the accident. The only noticeable appearance Avas a slightly Avild look about the eyes, although the man did not seem to be the least alarmed. The region of the Avound AA'as hard and someAvhat painful, probably from haA'ing been bruised by the teeth of the man who sucked the Avound ; it remained so for about three hours. The throat AA'as bound up in rancid olive oil (the only kind at hand) and no internal remedy Avas administered. There Avere no other bad consequences, and the patient soon returned to duty. Le Carpentier e sends the report of a fatal case of rattlesnake-bite : A pri- a Repert, di Medicina, Torino, 1828. b 548, 1856, ii., 597. c 847, 164. d Ibid. e Ibid. 718 MISCELLANEOUS SURGICAL ANOMALIES. vate, aged thirty-seven, remarkable for the singularity of his conduct, Avas knoAvn in his Company as a snake-charmer, as he had many times, Avithout injury, handled poisonous snakes. On the morning of July 13,1869, he Avas detailed as guard Avith the herd at Fort Cummings, Ncav Mexico, AA'hen, in the presence of the herders, he succeeded in catching a rattlesnake and prov- ing his poAver as a sorcerer. The performance being over and the snake killed, he caught sight of another of the same class, and tried to duplicate his previous feat; but his dexterity failed, and he Avas bitten in the middle finger of the right hand. He avus immediately admitted to the Post Hospital, com- plaining only of a little pain, such as might folloAV the sting of a bee or Avasp. A ligature avus applied above the Avound; the tAvo injuries made by the fangs Avere enlarged by a bistoury ; ammonia and the actual cautery were applied ; large doses of Avhiskey avc re repeated frequently, the constitution of the patient being broken and poor. Vomiting soon came on but Avas stopped Avithout trouble, and there Avere doubts from the beginning as to his recoA'erv. The SAvelling of the hand and arm gradually increased, showing the particular livid and yellowish tint following the bites of poisonous snakes. A blister Avas applied to the bitten finger, tincture of iodin used, and tAA'o ounces of whiskey given every tAvo hours until inebriety was induced. The pulse, which Avas very much reduced at first, gained gradually under the influence of stimulants; two grains of opium Avere given at night, the patient slept Avell, and on the next day complained only of numbness in the arm. The SAvelling had extended as far as the shoulder-joint, and the blood, which AA'as very fluid, was incessantly running from the Avound. Carbolic acid and cerate were applied to the arm, with stimulants internally. On the 15th his condition Avas good, the SAvelling had someAvhat augmented, there Avas not so much lividity, but the yellowish hue had increased. On the 16th the man complained of pain in the neck, on the side of the affected limb, but his general condition was good. Examining his genitals, an iron ring £ inch in diameter was discovered, imbedded in the soft tissues of the penis, con- stricting it to such a degree as to have produced enormous enlargement of the parts. Upon inquiry it seemed that the ring had been kept on the parts A'ery long, as a means of preservation of chastity ; but under the influence of the snake's venom the SAvelling had increased, and the patient having much trouble in passing AA'ater Avas obliged to complain. The ring Avas filed off Avith some difficulty. Gangrene destroyed the extremity of the bitten finger. From this date until the 30th the man's condition improved someAvhat. The progress of the gangrene AA'as stopped, and the injured finger avus disar- ticulated at the metacarpal articulation. Anesthesia Avas readily obtained, but the appearance of the second stage Avas hardly perceptible. Le Carpen- tier AA'as called early on the next morning, the patient having been observed to be sinking ; there Avas stertorous respiration, the pulse Avas Aveak and sIoav, and the man Avas only partly conscious. Electricity Avas applied to the HYDROPHOBIA. 719 spine, and brandy and potassium bromid were given, but death occurred about noon. A necropsy was made one hour after death. There Avas general softening of the tissues, particularly on the affected side. The blood Avas black and very fluid,—not coagulable. The ventricles of the brain AA'ere filled Avith a large amount of serum; the brain was somewhat congested. The lungs were healthy, Avith the exception of a few crude tubercles of recent formation on the left side. The right ventricle of the heart Avas empty, and the left filled Avith dark blood, Avhich had coagulated. The liver and kid- neys Avere healthy, and the gall-bladder very much distended Avith bile. The intestines presented a few livid patches on the outside. Hydrophobia.—The bite of an enraged animal is always of great danger to man, and death has folloAved a wound inflicted by domestic animals or even foAvls; a human bite has also caused a fatal issue. Rabies is frequently ob- served in herbivorous animals, such as the ox, coav, or sheep, but is most com- monly found in the carnivora, such as the dog, wolf, fox, jackal, hyena, and cat and other members of the feline tribe. Fox a reports several cases of death from symptoms resembling those of hydrophobia in persons Avho were bitten by skunks. SAvine, birds, and eA'en domestic poultry have caused hydrophobia by their bites. Le Cat b speaks of the bite of an enraged duck causing death, and Thiermeyer mentions death shortly folloAving the bite of a goose, as avcII as death in three days from a chicken-bite. Camerarius c describes a case of epilepsy which he attributed to a horse-bite. Among the older Avriters speaking of death folloAving the bite of an enraged man, are van Meek'ren,560 Wolff,d Zacutus Lusitanus,831 and Glandorp.380 The Ephe- merides contains an account of hydrophobia caused by a human bite. Jones e reports a ease of syphilitic inoculation from a human bite on the hand. Hydrophobia may not necessarily be from a bite ; a previously-existing wound may be inoculated by the saliva alone, conveyed by licking. Pliny, and some subsequent Avriters, attributed rabies to a Avorm under the ani- mal's tongue Avhich they called " lytta." There is said to be a superstition in India that, shortly after being bitten by a mad dog, the victim conceives pups in his belly; at about three months these move rapidly up and down the patient's intestines, and being mad like their progenitor, they bite and bark incessantly, until they finally kill the unfortunate victim. The natives of Nepaul firmly believe this theory.f All sorts of curious remedies have been suggested for the cure of hydrophobia. Crabs-claAvs, Spanish fly, and dragon roots, given three mornings before the new or full moon, was suggested as a specific by Sir Robert Gordon. Theodore De Yaux remarks that the person bitten should immediately pluck the feathers from the breech of an old cock and apply them bare to the bites. If the dog was mad the cock Avas sup- posed to sAvell and die. If the dog Avas not mad the cock would not sAvell; a 481, 1872, vi., 119. b 462, T. ii., 90. c Diss, de Epilep., 15. d Observ. deMed. Chirurg., ii., No. 5. e 224, 1872, i., 313. ' 433, 1834, i., 202. 720 MISCELLANEOUS SURGICAL ANOMALIES. in either case the person so treated AA'as immune. Mad-stones, as avcII as snake-stones, are believed in by some persons at the present day. According to Curran,a at one time in Ireland the fear of hydrophobia Avas so great that any person supposed to be suffering from it could be legally smothered. According to French statistics, hydrophobia is an extremely fatal disease, although the proportion of people bitten and escaping Avithout infection is OA'erAvhelmingly greater than those avIio acquire the disease. The mortality of genuine hydrophobia is from 30 to 80 per cent, influenced by efficient and early cauterization and scientific treatment. There is little doubt that many of the cases reported as hydrophobia are merely examples of general systemic infection from a local focus of sepsis, made possible by some primitive and uncleanly treatment of the original Avound. There is much superstition rela- tive to hydrophobia ; the majority of Avounds seen are filled Avith the hair of the dog, soot, ham-fat, and also Avith particles of decayed food and saliva from the mouth of some person avIio has practised sucking the Avound. Ordinarily, the period of incubation of hydrophobia in man is before the end of the second month, although rarely cases are seen as many as six months from the reception of the bite. The first symptoms of the disease are melancholia, insomnia, loss of appetite, and occasionally shooting pains, radia- ting from the Avound. There may be seA'ere pain at the back of the head and in the neck. Difficulty in SAvalloAving soon becomes a marked symptom. The speech assumes a sobbing tone, and occasionally the expression of the face is Avild and haggard. As regards the crucial diagnostic test of a glass of Avater, the folloAving account of a patient's attempt to drink is given by Curtis and quoted by AVarren :843 " A glass of Avater Avas offered the patient, Avhich he refused to take, saying that he could not stand so much as that, but Avould take it from a teaspoon. On taking the AA'ater from the spoon he evinced some dis- comfort and agitation, but continued to raise the spoon. As it came Avithin a foot of his lips, he gagged and began to gasp violently, his features Avorked, and his head shook. He finally almost tossed the Avater into his mouth, los- ing the greater part of it, and staggered about the room gasping and groan- ing. At this moment the respirations seemed Avholly costal, and were per- formed Avith great effort, the elbows being jerked upAvard with every inspira- tion. The paroxysm lasted about half a minute. The act of SAvalloAving did not appear to cause distress, for he could go through the motions of deglutition Avithout any trouble. The approach of liquid toward the mouth would, hoAA'ever, cause distress." It is to be remarked that the spasm affects the mechanism of the respiratory apparatus, the muscles of mastication and deglutition being only secondarily contracted. Pasteur discovered that the virulence of the virus of rabies could be at- tenuated in passing it through different species of animals, and also that inoculation of this attenuated virus had a decided prophylactic effect on the a 536, 1879, xxviii., 576. SHARK-BITES. 721 disease ; hence, 1 >y cutting the spinal cord of inoculated animals into fragments a feAV' centimeters long, and drying them, an emulsion could be made con- taining the virus. The patients are first inoculated Avith a cord fourteen days old, and the inoculation is repeated for nine days, each time with a cord one day fresher. The intensive method consists in omitting the Aveakest cords and giving the inoculations at shorter intervals. As a curious coincidence, Pliny and Pasteur, the ancient and modern, both discuss the particular viru- lence of saliva during fasting. There is much discussion over the extent of injury a shark-bite can pro- duce. In fact some persons deny the reliability of any of the so-called cases of shark-bites. Elisor a reports an interesting case occurring at Port Elizabeth, South Africa. While bathing, an expert SAvimmer felt a sharp pain in the thigh, and before he could cry out, felt a horrid crunch and Avas dragged be- Ioav the surface of the Avater. He struggled for a minute, Avas tAvisted about, shaken, and then set free, and by a supreme effort, reached the landing stairs of the jetty, where, to his surprise, he found that a monstrous shark had bitten his leg off. The leg had been seized obliquely, and the teeth had gone across the joints, wounding the condyles of the femur. There Avere three marks on the left side showing where the fish had first caught him. The amputation Avas completed at once, and the man recovered. Macgrigor b reports the case of a man at a fishery, near Manaar, avIio Avas bitten by a shark. The upper jaAV of the animal was fixed in the left side of the belly, forming a semicircular wound of which a point one inch to the left of the umbilicus Avas the upper boundary, and the loAver part of the upper third of the thigh, the lower boundary. The abdominal and lumbar muscles Avere divided and turned up, exposing the colon in its passage across the belly. Several convolutions of the small intestines were also laid bare, as Avere also the three loAvest ribs. The gluteal muscles Avere lacerated and torn, the tendons about the trochanter divided, laying the bone bare, and the vastus extern us and part of the rectus of the thigh Avere cut across. The wound Avas 19 inches in length and four or fh'e inches in breadth. When Dr. Kennedy first saAv the patient he had been carried in a boat and then in a palanquin for over five miles, and at this time, three hours after the reception of theAvound, Kennedy freed the abdominal cavity of salt water and blood, thoroughly cleansed the Avound of the hair and the clots, and closed it Avith adhesive strips. By the sixteenth day the abdominal wound had perfectly closed, the lacerations granulated healthily, and the man did Avell. Boylec reports re- covery from extensive lacerated wounds from the bite of a shark. Both arms were amputated as a consequence of the injuries. Fayrerd mentions shark- bites in the Hooghley. Leprosy from a Fish-bite.—Ashmeade records the curious case of a a 476, 1883, i., 1160. b 550, ix. c 490, 1828-29, iii., 502. d 548, 1871, i., 5. e 450, March 16,1895. 46 722 MISCELLANEOUS SURGICAL ANOMALIES. man that had lived many years in a leprous country, and Avhile dressing a fish had received a Avound of the thumb from the fin of the fish. Swelling of the arm followed, and soon after bullae upon the chest, head, and face. In a few months the blotches left from this eruption became leprous tubercles, and other well-marked signs of the malady followed. The author asked if in this case we have to do with a latent leprosy AA'hich AAas evoked by the Avound, or if it were a case of inoculation from the fish ? Cutliffe a records recoA'ery after amputation at the elboAV-joint, as a conse- quence of an alligator-bite nine days before admission to the hospital. The patient exhibited a compound comminuted fracture of the right radius and ulna in their loAver thirds, compound comminuted fractures of the bones of the carpus and metacarpus, Avith great laceration of the soft parts, laying bare the wrist-joint, besides several penetrating wounds of the arm and fore-arm. Mourray b gives some notes on a case of crocodile-bite with removal of a large portion of omentum. Sircar speaks of recoA'ery from a crocodile-bite. Dudgeonc reports two cases of animal-bites, both fatal, one by a bear, and the other by a camel. There is mention d of a compound dislocation of the wrist-joint from a horse-bite. Fayrere speaks of a wolf-bite of the fore- arm, followed by necrosis and hemorrhage, necessitating ligature of the brachial artery and subsequent excision of the elboAv-joint. Injuries from Lightning.—The subject of lightning-stroke, with its diverse range of injuries, is of considerable interest, and, though not uncom- mon, the matter is surrounded by a veil of superstition and mystery. It is well known that instantaneous or temporary unconsciousness may result from lightning-stroke. Sometimes superficial or deep burns may be the sole result, and again paralysis of the general nerA'es, such as those of sensation and motion, may be occasioned. For many years the therapeutic effect of a lightning-stroke has been believed to be a possibility, and numerous instances are on record. The object of this article will be to record a sufficient number of cases of lightning-stroke to enable the reader to judge of its various effects, and form his own opinion of the good or evil of the injury. It must be mentioned here that half a century ago Le Contef Avrote a most extensive article on this subject, which, to the present time, has hardly been improved upon. The first cases to be recorded are those in which there has been complete and rapid recovery from lightning-stroke. CraAvford * mentions a woman Avho, while sitting in front of her fireplace on the first floor of a two-story frame building, heard a crash about her, and realized that the house had been struck by lightning. The lightning had torn all the Aveather-boarding off the house, and had also followed a spouting Avhich terminated in a AA'ooden trough a 435, 1870, v., 36. b 435, 1877, xii., 245. c Customs Gaz. Med. Rep., Shanghai, 1874, iv., 12. d548, xv., 351. e 548. 1869. i., 5. f 594, 1844, iii. g 579, 1*70, 12. LIGHTNING-STR OKE. 723 in a pig-sty, ten feet back of the house, and killed a pig. Another branch of the fluid passed through the inside of the building and, running alone the upper floor to directly over where Mrs. F. was sitting, passed through the floor and descended upon the top of her left shoulder. Her left arm Avas lying across her abdomen at the time, the points of the fingers resting on the crests of the ilium. There was a rent in the dress at the top of the shoulder, and a red line half an inch Avide running from thence along the inside of the arm and fore-arm. In some places there AA'as complete vesication, and on its palmar surface the hand lying on the abdomen Avas completely de- nuded. The abdomen, for a space of four inches in length and eight inches in breadth, was also blistered. The fluid then passed from the fingers to the crest of the ilium, and doAvn the outside of the leg, bursting open the shoes, and passing then through the floor. Again a red line half an inch wide could be traced from the ilium to the toes. The clothing was not scorched, but only slightly rent at the point of the shoulder and where the fingers rested. This woman was neither knocked off her chair nor stunned, and she felt no shock at the time. After ordinary treatment for her burns she made rapid and complete recovery. Halton a reports the history of a case of a Avoman of sixty-fh'e who, about thirty-five minutes before he saAV her, had been struck by lightning. While she AA'as sitting in an outbuilding a stroke of lightning struck and shattered a tree about a foot distant. Then, leaving the tree about seven feet from the ground, it penetrated the wall of the building, Avhich was of unplastered frame, and struck Mrs. P. on the back of the head, at a point Avhere her hair aa:is done up in a knot and fastened by two ordinary hair-pins. The hair was much scorched, and under the knot the skin of the seal]) was seA'erely burned. The fluid crossed, burning her right ear, in which Avas a gold ear-ring, and then passed over her throat and doAvn the left sternum, leaving a burn three inches wide, covered by a blister. There was another burn, 12 inches long and three inches Avide, passing from just above the crest of the ilium forAvard and doAvnward to the symphysis pubis. The next burn began at the patella of the right knee, extending to the bottom of the heel, upon reaching Avhich it wound around the inner side of the leg. About four inches beloAv the knee a sound strip of cuticle, about 1J inches, was left intact. The lightning passed off the heel of the foot, bursting open the heel of a strongly seAved gaiter-boot. The Avoman Avas rendered unconscious but sub- sequently recovered. A remarkable feature of a lightning-stroke is the fact that it very often strips the affected part of its raiment, as in the previous case in which the shoe Avas burst open. In a discussion before the Clinical Society of London, October 24, 1879,b there Avere several instances mentioned in Avhich clothes had been strip- ped off by lightning. In one case mentioned by Sir James Paget, the clothes a 124, 1869. b 476, 1879, ii., 656. 724 MISCELLANEOUS SURGKAL ANOMALIES. Avere wet and the man's skin Avas reeking with perspiration. In its course the lightning traveled doAvn the clothes, tearing them posteriorly, and completely stripping the patient. The boots were split up behind and the laces torn out. This patient, however, made a good recovery. Beatson ;i mentions an instance in which an explosion of a shell completely tore off the left leg of a sergeant instructor, mkhvay between the knee and ankle. It Avas found that the foot and lower third of the leg had been completely denuded of a boot and avooIcu stocking, without any apparent abrasion or injury to the skin. The stocking was found in the battery and the boot struck a person some distance off. The stocking Avas much torn, and the boot had the heel missing, and in one part the*sole AAas separated from the upper. The laces in the upper holes were broken but Avere still present in the lower holes. The explanation of- fered in this case is similar to that in analogous cases of lightning-stroke, that is, that the gas generated by the explosion found its Avay betAveen the limb and the stocking and boot and stripped them off. There is a curious collection of relics, consisting of the clothes of a man struck by lightning, artistically hung in a glass case in the Museum of the Royal College of Surgeons, London, and the history of the injury, of Avhich these remnants are the result, is given by Professor StcAvart, the curator, as folloAvs : At half past four on June 8, 1878, James Orman and others Avere at work near SnaA'e, in Komncy Marsh, about eight miles from Ashford. The men Avere engaged in lopping avUIoavs, when the violence of the rain compelled them to take refuge under a hedge. Three of the men entered a shed near by, but Orman remained by the AvilloAv, close to the Avindow of the shed. Scarcely Avere the three inside Avhen a lightning-stroke entered the door, crossed the shed, and passed out the window, which it blew before it into the field. The men noticed that the tree under which Orman stood Avas stripped of its bark. Their companion's boots stood close to the foot of the tree, while the man himself lay almost perfectly naked a feAV yards further on, calling for help. When they left him a feAV moments previously, he Avas completely clad in a cotton shirt, cotton jacket, flannel vest, and cotton trousers, secured at the Avaist with leather straps and buckles. Orman also Avore a pair of stout hobnail boots, and had a watch and chain. After the lightning-stroke, however, all he had on him Avas the left arm of his flannel vest. The field was streAvn for some distance Avith fragments of the unfortunate man's clothing. Orman Avas throAvn doAvn, his eyebroAvs burned off, and his Avhiskers and beard much scorched. His chest was covered with superficial burns, and he had sustained a fracture of the leg. His strong boots Avere torn from his feet, and his Avatch had a hole burned right through it, as if a soldering iron had been used. The watch-chain Avas almost completely destroyed, only a feAV links remaining. Together AA'ith some fused coins, these were found close by, and are deposited in a closed box in the Museum. According to Orman's account a 224, 1890, i., 514. LIGHTNINGS TR OKE. 725 of the affair, he first felt a violent bloAV on the chest and shoulders, and then he Avas involved in a blinding light and hurled into the air. He said he never lost consciousness ; but Avhen at the hospital he seemed very deaf and stupid. He Avas discharged perfectly cured twenty Aveeks after the occurrence. The scientific explanation of this amazing escape from this most eccentric vagary of the electric fluid is given,—the fact that the AA'et condition of the man's clothing increased its power of conduction, and in this Avay saved his life. It is said that the electric current passed doAvn the side of Orman's body, caus- ing everyAvhere a sudden production of steam, Avhich by its expansion tore the clothing off and hurled it aAvay. It is a curious fact that where the flannel covered the man's skin the burns Avere merely superficial, Avhereas in those parts touched by the cotton trousers they Avere very much deeper. This case is also quoted and described by Dr. Wilks.439 There Avas a curious case of lightning-stroke reported at Cole Harbor, Halifax. A diver, Avhile at Avork far under the surface of the AA'ater, was seriously injured by the transmission of a lightning-stroke, which first struck the communicating air pump to Avhich the diver avus attached. The man AAas brought to the surface insensible, but he afterAA'ard recoA'ered. Permanent Effect of Lightning on the Nervous System.—Mac- Donalda mentions a Avoman of seventy-eight Avho, some forty-tAvo years previous, Avhile ironing a cap Avith an Italian iron, Avas stunned by an extremely vivid flash of lightning and fell back unconscious into a chair. On regaining consciousness she found that the cap Avhich she had left on the table, remote from the iron, Avas reduced to cinders. Her clothes Avere not burned nor Avere there any marks on the skin. After the stroke she felt a creeping sensation and numbness, particularly in the arm Avhich AAas next to the table. She stated positively that in consequence of this feeling she could predict Avith the greatest certainty Avhen the atmosphere Avas highly charged Avith electricity, as the numbness increased on these occasions. The Avoman averred that shortly before or during a thunder storm she ahvays became nauseated. MacDonald offers as a physiologic explanation of this case that probably the impression produced forty-tAvo years before implicated the right brachial plexus and the afferent branches of the pneumogastric, and to some degree the A'omiting center in the medulla; hence, Avhen the atmosphere Avas highly charged Avith electricity the structures affected became more readily impressed. Camby b relates the case of a neuropathic Avoman of thirty-eight, tAvo of Avhose children Avere killed by lightning in her presence. She herself was unconscious for four days, and Avhen she recovered consciousness, she Avas found to be hemiplegic and hemianesthetic on the left side. She fully re- covered in three Aveeks. Tavo years later, during a thunder storm, Avhen there AA'as no evidence of a lightning-stroke, she had a second attack, and three years later a third attack under similar circumstances. a 655, 1886, 348. b Soc. Med. des Hop., Paris, May 25, 1894. 726 MISCELLANEOUS SURGICAL ANOMALIES. There are some ocular injuries from lightning on record. In these cases the lesions have consisted of detachment of the retina, optic atrophy, cataract, hemorrhages into the retina, and rupture of the choroid, paralysis of the oculomotor muscles, and paralysis of the optic nerve. According to Buller of Montreal, such injuries may arise from the mechanic violence sustained by the patient rather than by the thermal or chemic action of the current. Buller describes a case of lightning-stroke in Avhich the external ocular muscles, the crystalline lens, and the optic nerve Avere involved. Godfrey ■ reports the case of Daniel Brown, a seaman on H. M. S. Cambrian. AVhile at sea on February 21, 1799, he aahs struck both dumb and blind by a lightning-stroke. There AA'as evidently paralysis of the optic nerve and of the oculomotor muscles ; and the muscles of the glottis Avere also in some manner deprh'ed of motion. That an amputation can be perfectly performed by a lightning-stroke is exemplified in the case of Syevanko of CracoAV, Poland.b The patient AA'as a boy of tAveh'e, Avhose right knee Avas ankylosed. While riding in a field in a A'iolent storm, a loud peal of thunder caused the horse to run away, and the child fell stunned to the ground. On coming to his senses the boy found that his right leg Avas missing, the parts haA'ing been divided at the upper end of the tibia. The wound Avas perfectly round and the patella and femur Avere intact. There Avere other signs of burns about the body, but the boy recovered. Some days after the injury the missing leg Avas found near the place Avhere he Avas first throAvn from the horse. The therapeutic effect of lightning-stroke is verified by a number of cases, a feAV of AA'hich will be given. Tilesius367 mentions a peculiar case AA'hich AAas extensiA'ely quoted in London.0 Tavo brothers, one of Avhom Avas deaf, were struck by lightning. It avus found that the inner part of the right ear near the tragus and anti-helix of one of the individuals Avas scratched, and on the folloAving day his hearing returned. Olmsteadd quotes the history of a man in Carteret County, N. C, avIio Avas seized Avith a paralytic affection of the face and eyes, and Avas quite unable to close his lids. While in his bedroom, he AAas struck senseless by lightning, and did not recover until the next day, Avhen it Avas found that the paralysis had disappeared, and during the fourteen years which he afterward lived his affection never returned. There is a record of a young colliere in the north of England AA'ho lost his sight by an explosion of gunpoAA'der, utterly destroying the right eye and fracturing the frontal bone. The vision of the left eye was lost Avithout any serious damage to the organ, and this Avas attributed to shock. On returning from Ettingshall in a severe thunder storm, he remarked to his brother that he had seen light through his specta- cles, and had immediately afterward experienced a piercing sensation AA'hich a 535, 1822, 369. b 548, 1869, i., 363. c 550, 1825. d594, 1844, 308. ^ e 470. 1888. ii., 178. LIGHTNINGSTR OKE. 727 had passed through the eye to the back of the head. The pain Avas brief, and he was then able to see objects distinctly. From this occasion he stead- ily improved until he Avas able to Avalk about without a guide. Le Conte mentions the case of a negress Avho was struck by lightning August 19, 1842, on a plantation in Georgia. For years before the reception of the shock her health had been very bad, and she seemed to be suffering from a progressh'e emaciation and feebleness akin to chlorosis. The diffi- culty had probably followed a protracted amenorrhea, subsequent to labor and a retained placenta. In the course of a week she had recovered from the effects of lightning and soon experienced complete restoration to health; and for two years had been a remarkably healthy and vigorous laborer. Le Conte quotes five similar cases, and mentions one in which a lightning-shock to a Avoman of twenty-nine produced amenorrhea, whereas she had previously suffered from profuse menstruation, and also mentions another case of a Avoman of seventy 'who Avas struck unconscious ; the catamenial discharge Avhich had ceased twenty years before, Avas now permanently reestablished, and the shrunken mammae again resumed their full contour. A peculiar feature or superstition as to lightning-stroke is its photographic properties. In this connection Strieker of Frankfort quotes the case of Raspaila of a man of twenty-two Avho, Avhile climbing a tree to a bird's nest, was struck by lightning, and afterAvard shoAved upon his breast a picture of the tree, Avith the nest upon one of its branches. Although in the majority of cases the photographs resembled trees, there Avas one case in Avhich it resembled a horse-shoe; another, a cow; a third, a piece of furniture ; a fourth, the whole surrounding landscape. This' theory of lightning-photo- graphs of neighboring objects on the skin has probably arisen from the resemblance of the burns due to the ramifications of the blood-vessels as con- ductors, or to peculiar electric movements which can be demonstrated by positive charges on lycopodium poAvder. A lightning-stroke does not exhaust its force on a few individuals or objects, but sometimes produces serious manifestations over a large area, or on a great number of people. It is saidb that a church in the village of Chateauneuf, in the Department of the LoAver Alps, in France, Avas struck by three successive lightning strokes on July 11, 1819, during the installa- tion of a neAV pastor. The company were all thrown down, nine Avere killed and 82 Avounded. The priest, Avho was celebrating mass, was not affected, it is believed, on account of his silken robe acting as an insulator. Bryantc of Charlestown, Mass., has communicated the particulars of a stroke of lightning on June 20, 1829, Avhich shocked several hundred persons. The effect of this discharge was felt over an area of 172,500 square feet with nearly the same degree of intensity. Happily, there Avas no permanent injury recorded. Le Conte reports that a person may be killed Avhen some distance a 161, xxii. b 139, T. xii. c 126, 1830. 728 MISCELLANEOUS SURGICAL ANOMALIES. —even as far as 20 miles aAvay from the storm—by Avhat Lord Mahon calls the " returning stroke." Skin-grafting is a subject Avhich has long been more or less familiar to medical men, but Avhich has only recently been developed to a practicallv successful operation. The older surgeons kneAV that it Avas possible to re- unite a resected nose or an amputated finger, and in Hunter's time tooth- replantation was quite Avell knoAvn. Smcllie739 has recorded an instance in Avhich, after avulsion of a nipple in suckling, restitution AA'as effected. It is not alone to the skin that grafting is applicable; it is used in the cornea, nerves, muscles, bones, tendons, and teeth. Wolfer has been success- ful in transplanting the mucous membranes of frogs, rabbits, and pigeons to a portion of mucous membrane previously occupied by cicatricial tissue, and avus the first to sIioav that on mucous surfaces, mucous membrane remains mucous membrane, but AA'hen transplanted to skin, it becomes skin. Attempts have been made to transplant a button of clear cornea of a dog, rabbit, or cat to the cornea of a human being, opaque as the result of oph- thalmia, and von Hippel has devised a special method of doing this. Re- cently Fuchsa has reported his experience in cornea-grafting in sections, as a substitute for A'on Hippel's method, in parenchymatous keratitis and corneal staphyloma, and though not eminently successful himself, he considers the operation worthy of trial in cases that are without help, and doomed to blindness. John Hunter Avas the first to perform the implantation of teeth ; and Younger the first to transplant the teeth of man in the jaAvs of man ; the initial operation should be called replantation, as it Avas merely the replace- ment of a tooth in a socket from AA'hich it had accidentally or intentionally been remoA'ed. Hunter drilled a hole in a cock's comb and inserted a tooth, and held it by a ligature. Younger drilled a hole in a man's jaw and im- planted a tooth, and proA-ed that it Avas not necessary to use a fresh tooth. Ottolengnib mentions the case of a man Avho Avas struck by a ruffian and had his tAvo central incisors knocked out. He searched for them, Avashed them in Avarm AA'ater, carefully washed the teeth-sockets, and gently placed the teeth back in their position, where they remained firmly attached. At the time of report, six years after the accident, they were still firmly in position. Pettyjohn0 reports a successful case of tooth-replantation in his young daugh- ter of two, avIio fell on the cellar stairs, completely excising the central incis- ors. The alveolar process of the right jaw Avas fractured, and the gum lacerated to the entire length of the root. The teeth Avere placed in a tepid normal saline solution, and the child chloroformed, narcosis being in- duced in sleep; the gums were cleaned antiseptically, and 3| hours afterAvard the child had the teeth firmly in place. They had been out of the mouth fully an hour. Four weeks afterward they were as firm as eA'er. By their » 838, Nov., 1894. b 007, 1889, viii., 65. c 632, Jan., 1896. SKIN- GRAFTING. 729 experiments Gluck and Magnus prove that there is a return of activity after transplantation of muscle. After excision of malignant tumors of mus- cles, Helferich of Munich, and Lange of Ncav York, have filled the gap left by the excision of the muscle affected by the tumor Avith transplanted mus- cles from dogs. Gluck has induced reproduction of lost tendons by grafting them with cat-gut, and according to Aslihurst, Peyrot has filled the gaps in retracted tendons by transplanting tendons, taken in one case from a dog, and in another from a cat. Nerve-grafting, as a supplementary operation to neurectomy, has been practised, and Gersung has transplanted the nerves of loAver animals to the nerve stumps of man. Bone-grafting is quite frequently practised, portions from a recently am- putated limb, or portions removed from living animals, or bone-chips, may be used. Senn proposed decalcified bone-plates to be used to fill in the gaps. Shifting of the bone has been done, e. g., by dividing a strip of the hard palate covered with its soft parts, parallel to the fissure in cleft palate, but leaA'ing unsevered the bony attachments in front, and partially fracturing the pedicle, drawing the bony flaps together Avith sutures ; or, Avhen forming a neAV nose, by turning doAvn with the skin and periosteum the outer table of the frontal bone, split off Avith a chisel, after cutting around the part to be removed.841 Trueheart reports a case of partial excision of the clavicle, successfully fol- loAved by the grafting of periosteal and osseous material taken from a dog. Robson and Hayes of Rochester, N. Y., have successfully supplemented ex- cision of spina bifida by the transplantation of a strip of periosteum from a rabbit. Poncet hastened a cure in a case of necrosis with partial destruction of the periosteum by inserting grafts taken from the bones of a dead infant and from a kid. Ricketts speaks of bone-grafting and the use of h'ory, and remarks that Poncet of Lyons restored a tibia in nine months by grafting to the superior articular surface. Recently amalgam fillings have been used in bone-cavities to supplant grafting. In destructive injuries of the skin, various materials Avere formerly used in grafting, none of Avhich, hoAvever, have produced the same good effect as the use of skin by the Thiersch Method, Avhich will be described later. Podgers, U. S. N.,a reports the case of a Avhite man of thirty-eight Avho suffered from gangrene of the skin of the buttocks caused by sitting in a pan of caustic potash. When seen the man Avas intoxicated, and there Avas a gan- grenous patch four by six inches on his buttocks. Rodgers used grafts from the under Aving of a young foAvl, as suggested by Redard,b with good result. Yanmetcr of Colorado0 describes a boy of fourteen with a severe extensive burn ; a portion beneath the chin and loAver jaAA', and the right arm from the elboAv to the fingers, formed a granulating surface Avhich Avould not heal, and grafting Avas resorted to. The neck-grafts Avere supplied by the skin of the a 269, 1888. b 538, March 10, 1888. c Annals of Surgery, St. Louis, 1890. 730 MISCELLANEOUS SURGICAL ANOMALIES. father and brother, but the arm-grafts Avere taken from tAvo young puppies of the Mexican hairless breed, AA'hose soft, Avhite, hairless skin seemed to offer itself for the purpose AA'ith good prospect of a successful result. The outcome AA'as all that could be desired. The puppy-grafts took faster and proved them- selves to be superior to the skin-grafts. There is a case reported a in Avhich the skin of a greyhound seven days old, taken from the abdominal Avail and even from the tail, Avas used with most satisfactory results in grafting an cx- tensh'e ulcer following a burn on the left leg of a boy of ten. Masterman has grafted with the inner membrane of a hen's egg, and a Mexican surgeon, Al- tramirano, used the gills of a cock. FoAvler of St. Louis b has grafted AA'ith the skin from the back and abdo- men of a large frog. The patient Avas a colored boy of sixteen, Avho Avas extensively burned by a kerosene lamp. The burns Avere on the legs, thighs, buttocks, and right ankle, and the estimated area of burnt surface Avas 247.9.1 square inches. The frog skin was transferred to the left buttocks, and on the right buttocks eight long strips of Avhite skin Avere transferred after the man- ner of Thiersch. A strip of human skin Avas placed in one section over the frog skin, but became necrotic in four days, not being attached to the granu- lating surface. The man was discharged cured in six months. The frog skin was soft, pliable, and of a reddish hue, Avhile the human white skin was firm and rapidly becoming pigmented. Leale c cites the successful use of common warts in a case of grafting on a man of tAventy who Avas burned on the foot by a stream of molten metal. Leale remarks that as common Avails of the skin are collections of vascular papillae, admitting of separation Avith- out injury to their exceptionally thick layer of epidermis, they are probably better for the purposes of skin-grafting than ordinary skin of less vitality or vascularity. Ricketts d has succeeded in grafting the skin of a frog to that of a tortoise, and also grafting frog skin to human skin. Ricketts remarks that the prepuce of a boy is remarkably good material for grafting. Sponge- grafts are often used to hasten cicatrization of integumental Avounds. There is recorded e an instance in Avhich the breast of a croAV and the back of a rat Avere grafted together and grew fast. The crow dragged the rat along, and the two did not seem to care to part company. Relath'e to skin-grafting proper, Bartens f succeeded in grafting the skin of a dead man of seA'enty on a boy of fourteen. Symonds g reports cases of skin-grafting of large flaps from amputated limbs, and says this method is particularly aA'ailable in large hospitals Avhere they ha\Te amputations and grafts on the same day. Martin has shown that, after many hours of exposure in the open air at a temperature of nearly 32° F., grafts could be successfully applied, but in such temperatures as 82° F., exposure of from six to seven hours destroyed their vitality, so that if kept cool, the limb of a healthy a 476, March 6, 1890. b Annals of Surgery, St. Louis, 1889. e 538, 1879. xiv. d 773, 1890. e 548, I860, i., 282. f 199, 1888. S 224, 1889, ii., 1331. SELF-MUTILA TION 731 Fig. 228.—Extensive burn of the thigh, with skin-graft,—early stage (Harte). individual amputated for some accident, may be utilized for grafting pur- poses. Reverdin originated the procedure of epidermic grafting. Small grafts the size of a pin-head doing quite as well as large ones. Unfortunately but little diminution of the cicatricial contraction is effected by Reverdin's method. Thiersch contends that healing of a granulated surface results first from a conA'ersion of the soft, vascular granulation-pa- pilla?, by contraction of some of their elements into young connective- tissue cells, into " dry, cicatricial papillae," actu- ally approximating the surrounding tissues, thus diminishing the area to be covered by epidermis; and, secondly, by the covering of these papilla? by epidermic cells. Thiersch therefore recommends that for the prevention of cicatricial contraction, the grafting be performed Avith large strips of skin. Harte a giA'cs illustrations of a case of extensive skin-grafting on the thigh from six inches above the great trochanter Avell over the median line anteriorly and OA'er the buttock. This extent is shoAvn in Figure 228, taken five months after the accident, Avhen the gran- ulations had groAvn over the edge about an inch. Figure 229 sIioavs the surface of the wound, six and one-half months after the accident and three months after the applications of numerous skin-grafts. Cases of self-mutila- tion may be divided into three classes:—those in Avhich the injuries are inflicted in a moment of temporary insanity from hallucinations or melan- cholia ; Avith suicidal intent; and in religious frenzy or emotion. Self- mutilation is seen in the lower animals, and Kennedy,b in mentioning the case of a hydrocephalic child Avho ate off its entire under lip, speaks also of a dog, of cats, and of a lioness who ate off their tails. Kennedy Fig. 229.—Extensive burn of the thigh, with skin-graft,—late stage. a 792, Nov., ls<)-2. b536, 1885, i., 211. 732 MISCELLANEO US SUR GK'. 1L A NOMA L IEs. mentions the habit in young children of biting the finger-nails as an evidence of infantile trend toAA'ard self-mutilation. In the same di-cussion Collins states that he kneAV of an instance in India in Avhich a horse lay down, deliberately exposing his anus, and alloAving the ci-oavs to pick and cat his Avhole rectum. In temporary insanity, in fury, or in grief, the lower animals have been noticed by naturalists to mutilate themselves. Self-mutilation in man is almost invariably the result of meditation over the generative function, and the great majority of cases of this nature arc avulsions or amputations of some parts of the genitalia. The older records are full of such instances. Benivenius,198 Blanchard,213 Knackstedt, and Schenck cite cases. Smetius a mentions castration Avhich Avas effected by using the finger-nails, and there is an old record in Avhich a man avulsed his OAvn genitals.b Scottc mentions an instance in Avhich a man amputated his genitals and recovered Avithout subsequent symptoms. Goekelius speaks of self-castration in a ruptured man, and Golding,d Guyon, Louis,e Laugier,f the Ephemerides, Alix, Marstral,s and others, record instances of self-castra- tion. In his Essays Montaigne mentions an instance of complete castration performed by the individual himself. Thiersch11 mentions a case of a man avIio circumcised himself Avhen eigh- teen. He married in 1870, and upon being told that he Avas a father he slit up the hypogastrium from the symphysis pubis to the umbilicus, so that the omentum protruded ; he said his object Avas to obtain a vieAV of the interior. Although the knife a\;is dirty and blunt, the Avound healed after the removal of the extruding omentum. A year later he laid open one side of the scrotum. The prolapsed testicle AA'as replaced, and theAvound healed Avithout serious effect. He again laid open his abdomen in 1880, the Avound again healing notAvithstanding the prolapse of the omentum. In May of the same year he removed the right testicle, and sewed the Avound up himself. Four days later the left Avas treated the same Avay. The spermatic cord hoAvever escaped, and a hematoma, the size of a child's head, formed on account of Avhich he had to go to the hospital. This man acted under an uncontrollable impulse to mutilate himself, and claimed that until he castrated himself he had no peace of mind. There is a similar report in an Italian journal360 which aahs quoted in London.1 It described a student at laAv, of delicate complexion, who at the age of fourteen gave himself up to masturbation. He continually studied until the age of nineteen, Avhen he fell into a state of dulness, and complained that his head felt as if compressed by a circle of fire. He said that a voice kept muttering to him that his generative organs Avere abnormally deformed or the- seat of disease. After that, he imagined that he heard a cry of "amputation! amputation!" Driven by this hallucination, he made his a 730, 525. b 458, T. xvii., 401. c .-,04, ii., \(). 7. d fy28. vii.. No. 6. e 462, T. ix. * Ibid. g 462, T. viii. b 49^ issl, 253. i 54-*. 1-54. ii., 94. SELF- CASTRA TION. 733 first attempt at self-mutilation ten days later. He Avas placed in an Asylum at Astino Avhere, though closely Avatched, he took advantage of the first op- portunity and cut off two-thirds of his penis, Avhen the delirium subsided. Campa describes a stout German of thirty-fiA'e avIio, Avhile suffering from de- lirium tremens, fancied that his enemies were trying to steal his genitals, and seizing a sharp knife he amputated his penis close to the pubes. He threAv the severed organ violently at his imaginary pursuers. The hemorrhage was profuse, but ceased spontaneously by the formation of coagulum over the mouth of the divided vessels. The Avound avus quite healed in six Aveeks, and he Avas discharged from the hospital, rational and apparently content with his surgical feat. Richards b reports the case of a Brahman boy of sixteen Avho had con- tracted syphilis, and convinced, no doubt, that " nocit empta dolore volup- tus," he had taken effective means of avoiding injury in the future by com- pletely amputating his penis at the root. Some days after his admission to the hospital he asked to be castrated, stating that he intended to become an ascetic, and the loss of his testes as well as of his penis appeared to him to be an imperatiA'e condition to the attainment of that happy consummation. Chevers266 mentions a someAvhat similar case occurring in India. Sands c speaks of a single man of thirty avIio amputated his penis. He gave an incomplete history of syphilis. After connection Avith a Avoman he became a confirmed syphilophobe and greatly depressed. While laboring under the hallucination that he was possessed of two bodies he tied a string around the penis and amputated the organ one inch beloAv the glans. On loosening the string, three hours afterAvard, to enable him to urinate, he lost three pints of blood, but he eventually recovered. In the Pennsylvania Hospital Reports623 there is an account of a married man avIio, after drinking several weeks, developed mania a potu, and was found in his room covered Avith blood. His penis Avas completely cut off near the pubes, and the skin of the scrotum was so freely incised that the testicles were entirely denuded, but not injured. X small silver cap was made to cover the sensitive urethra on a line Avith the abdominal Avail. There is a record d of a tall, powerfully-built Russian peasant of twenty- nine, of morose disposition, aaIio on April 3d, while reading his favorite book, Avithout uttering a cry, suddenly and with a single pull tore away his scrotum together Avith his testes. He then arose from the bank Avhere he had been sitting, and quietly handed the avulsed parts to his mother Avho was sitting near by, saying to her : " Take that; I do not want it any more." To all questions from his relatives he asked pardon and exemption from blame, but gave no reason for his act. This patient made a good recovery at the hos- pital. Alcxccf,1' another Russian, speaks of a similar injury occurring dur- ing an attack of delirium tremens. a 593, 1852. <> 435, xii. o 127, 1871. d 697, 1887, 93, No. 5. e 556, 1882, No. 22. 734 MISCELLANEOUS SURGICAL ANOMALIES. Black a details the history of a young man of nineteen avIio Avent to his bath- room and deliberately placing his scrotum on the edge of the tub he cut it crossAvays doAvn to the AA'ood. He besought Black to remove his testicle, and as the spermatic cord was cut and much injured, and hemorrhage could only be arrested by ligature, the testicle avus removed. The reason assigned for this act of mutilation Avas that he had so frequent nocturnal emissions that he became greatly disgusted and depressed in spirit thereby. He had prac- ticed self-abuse for two years and ascribed his emissions to this cause. Al- though his act AA'as that of a maniac, the man AA'as perfectly rational. Since the injury he had had normal and frequent emissions and erections. Orwin b mentions the case of a laborer of forty who, in a fit of remorse after being several days with a prostitute, atoned for his unfaithfulness to his Avife by opening his scrotum and cutting away his left testicle Avith a pocket knife. The missing organ Avas found about six yards aAvay covered Avith dirt. At the time of infliction of this injury the man Avas calm and perfectly rational. Warrington c relates the strange case of Isaac Brooks, an unmar- ried farmer of tAventy-nine, Avho was found December 5, 1879, Avith extensive mutilations of the scrotum ; he said that he had been attacked and injured by three men. He swore to the identity of two out of the three, and these Avere transported to ten years' penal servitude. On February 13, 1881, he AA'as again found Avith mutilation of the external genitals, and again said he had been set upon by four men who had inflicted his injury, but as he wished it kept quiet he asked that there be no prosecution. Just before his death on December 31, 1881, he confessed that he had perjured himself, and that the mutilations were self-performed. He Avas not aware of any morbid ideas as to his sexual organs, and although he had an attack of gonorrhea ten years before he seemed to worry A'ery little over it. There is an accountd of a Scotch boy who Avished to lead a " holy life," and on tAvo occasions sought the late Mr. Liston's skilful aid in pursuance of this idea. He returned for a third time, having himself unsuccessfully performed castration. A case of self-mutilation by a soldier avIio Avas confined in the guard- house for drunkenness is related by Beck.e The man borrowed a knife from a comrade and cut off the whole external genital apparatus, remarking as he flung the parts into a corner : " Any-----fool can cut his throat, but it takes a soldier to cut his privates off! " Under treatment he recovered, and then he regretted his action. Sinclairf describes an Irishman of twenty-five Avho, maniacal from in- temperance, first cut off one testicle with a wire nail, and then the second Avith a trouser-buckle. Not satisfied with the extent of his injuries he droA'e a nail into his temple, first through the skin by striking it Avith his hand, and then by butting it against the Avail,—the latter maneuver causing his death. a 536, 1889, ii, 32. b 224, 1882, L, 105. c 224, 1882, i., 72. d476, 1882, i., 118. e 124, 1847, 265. t 178, Jan., 1886. "NEEDLE-GIRLS." 735 There is on record a the history of an insane medical student in Dublin who extirpated both eyes and threAv them on the grass. He Avas in a state of acute mania, and the explanation offered Avas that as a " grinder " before examination he had been diligently studying the surgery of the eye, and par- ticularly that relating to enucleation. Another Dublin case quoted bv the same authority Avas that of a young girl Avho, upon being arrested and com- mitted to a police-cell in a state of furious drunkenness, tore out both her eyes. In such cases, as a rule, the finger-nails are the only instrument used. There is a French case also quoted of a Avoman of thirty-nine avIio had borne children in rapid succession. While suckling a child three months old she became much excited, and even fanatical, in reading the Bible. Coming to the passage, " If thy right eye offend thee, pluck it out, etc.," she was so im- pressed Avith the necessity of obeying the diA'ine injunction that she enucleated her eye with a meat-hook. There is mentioned b the case of a young Avoman who cut off her right hand and cast it into the fire, and attempted to enucleate her eyes, and also to hold her remaining hand in the fire. Haslam c reports the history of a female who mutilated herself by grinding glass betAveen her teeth. Channing d gives an account of the case of Helen Miller, a German JeAV- ess of thirty, Avho Avas admitted to the Asylum for Insane Criminals at Au- burn, N. Y., in October, 1872, and readmitted in June, 1875, suffering from simulation of hematemesis. On September 25th she cut her left Avrist and right hand; in three weeks she became again " discouraged " because she Avas refused opium, and again cut her arms below the elboAvs, cleanly severing the skin and fascia, and completely hacking the muscles in every direction. Six Aveeks later she repeated the latter feat OA'er the seat of the recently healed cicatrices. The right arm healed, but the left shoAved erysipelatous inflam- mation, culminating in edema, Avhich affected the glottis to such an extent that tracheotomy was performed to save her life. FiA'e Aveeks after convales- cence, during which her conduct Avas exemplary, she again cut her arms in the same place. In the folloAving April, for the merest trifle, she again re- peated the mutilation, but this time leaA'ing pieces of glass in the Avounds. Six months later she inflicted a Avound seven inches in length, in Avhich she inserted 30 pieces of glass, seven long splinters, and five shoe-nails. In June, 1877, she cut herself for the last time. The folloAving articles Avere taken from her arms and preserved : Ninety-four pieces of glass, 34 splinters, two tacks, five shoe-nails, one pin, and one needle, besides other things which Avere lost,—making altogether about 150 articles. " Needle-girls," etc.—A peculiar type of self-mutilation is the habit sometimes seen in hysteric persons of piercing their flesh Avith numerous needles or pins. Herbolt of Copenhagene tells of a young JeAvess from whose a 536, 1888, ii., 260. b 476, 1851. c Quoted 465, July, 1875. d 123. xxxiv. 368. e Journal des Debats, 1823. 736 MISCELLANEOUS SURGICAL ANOMALIES. body, in the course of eighteen months, avc re extracted 217 needles. Sometime after 100 more came from a tumor on the shoulder. As all the symptoms in this case Avere abdominal, it Avas supposed that during an epileptic seizure this girl had SAvalloAved the needles ; but as she Avas of an hysteric nature it seems more likely they had entered the body through the skin. There is an instance a in Avhich 132 needles were extracted from a young lady's person. Caen b describes a woman of twenty-six, Avhile in prison aAvaiting trial, suc- ceeding in committing suicide by introducing about 30 pins and needles in the chest region, over the heart. Her method Avas to gently introduce them, and then to press them deeper Avith a prayer-book. An autopsy showed that some of the pins had reached the lungs, some Avere in the mediastinum, on the back part of the right auricle ; the descending vena cava AA'as perforated, the anterior portion of the left ventricle AA'as transfixed by a needle, and several of the articles Avere found in the liver. Andrewsc removed 300 needles from the bodv of an insane female. The Lancet,x records an account of a suicide by the penetration of a darning-needle in the epigastrium. There were nine punctures in this region, and in the last the needle Avas left in situ and fixed by Avorsted. In 1851 the same journal spoke of an instance in which 30 pins Avere removed from the limbs of a serA'ant girl. It was said that while hanging clothes, Avith her mouth full of pins, she was slapped on the shoulder, causing her to start and savuIIoav the pins. There is another reporte of a Avoman AA'ho SAvallowed great numbers of pins. On her death one pound and nine ounces of pins were found in her stomach and duodenum. There are individuals knoAvn as " human pin-cushions," who publicly introduce pins and needles into their bodies for gain's sake. The wanderings of pins and needles in the body are quite Avell knoAvn. Schenck records the finding of a sav alio wed pin in the liver. Haller mentionsf one that made its Avay to the hand. Silvy speaks of a case in Avhich a quantity of swalloAved pins escaped through the muscles, the bladder, and A'agina; there is another record in which the pins escaped many years afterAvard from the thigh.s The Philosophical Transactions contain a record of the escape of a pin from the skin of the arm after it had entered by the mouth. Gooch, Ruysch, Purmann, and Hoffman speak of needle- Avanderings. Stephenson h gives an account of a pin which Avas finally voided by the bladder after forty-two years' sojourn in a lady's body. On November 15, 1802, the celebrated Dr. Lettsom spoke of an old lady who sat on a needle Avhile riding in a hackney coach ; it passed from the injured leg to the other one, Avhence it AAas extracted. Deckers tells of a gentleman AA'ho Avas wounded in the right hvpochondrium, the ball being taken thirty years after- Avard from the knee. Borellus 841 gives an account of a thorn entering the digit and passing out of the body by the anus. a 440, 1853. b 476, 1863, ii., 524. c 123, July, 1872. d 47^ 1887, i., 230. e 476. 1 *52. t 39s, j., 586. 8 398. i., 371. h Detroit Med. Jour., 1887, i., -95. MANUFACTURE OF CRIPPLED BEGGARS. 737 Strange as it may seem, a prick of a pin not entering a vital center or organ has been the indirect cause of death. Augenius Avrites of a tailor Avho died in consequence of a prick of a needle betAveen the nail and flesh of the end of the thumb. Amatus Lusitanus 119 mentions a similar instance in an old woman, although, from the symptoms given, the direct cause was probably tetanus. In modern times Cunninghame,a Boring,b and Hobartc mention instances in which death has followed the prick of a pin ; in Boring's case the death occurred on the fifth day. Manufacture of Crippled Beggars.—Knowing the sympathy of the Avorld in general for a cripple, in some countries low in the moral scale, vol- untary mutilation is sometimes practised by those who prefer begging to toil- ing. In the same manner artificial monstrosities have been manufactured solely for gain's sake. We quite often read of these instances in lay-journals, but it is seldom that a case comes under the immediate observation of a thor- oughly scientific mind. There is, hoAvever, on record d a remarkable instance accredited to Jamieson of Shanghai av1io presented to the Royal College of Surgeons a pair of feet Avith the folloAving history : Some months previously a Chinese beggar had excited much pity and made a good business by shoAving the mutilated stumps of his legs, and the feet that had belonged to them slung about his neck. While one day scrambling out of the way of a constable av1io had forbidden this gruesome spectacle, he avus knocked down by a car- riage in the streets of Shanghai, and was taken to the hospital, Avhere he was questioned about the accident which deprived him of his feet. After selling the medical attendant his feet he admitted that he had purposely per- formed the amputations himself, starting about a year previously. He had • fastened cords about his ankles, drawing them as tightly as he could bear them, and increasing the pressure every tAvo or three days. For a fortnight his pain was extreme, but when the bones Avere bared his pains ceased. At the end of a month and a half he was able to entirely remove his feet by partly snapping and partly cutting the dry bone. Such cases appear to be quite common in China, and by investigation many parallels could elsewhere be found. The Chinese custom of foot-binding is a curious instance of self- mutilation. In a paper quoted in the Philadelphia Medical Times, January 31, 1880, a most minute account of the modus operandi, the duration, and the suffering attendant on this process are given. Strapping of the foot by means of tight bandages requires a period of two or three years' continuance before the desired effect is produced. There is a varying degree of pain, which is most severe during the first year and gradually diminishes after the binding of all the joints is completed. During the binding the girl at night lies across the bed, putting her legs on the edge of the bed- stead in such a manner as to make pressure under the knees, thus be- a 381, 1829, ii., 21. b 176, 1872. 218. c 313, 1856, 473. d224, 1882, i.,397. 47 738 MISCELLANEOUS SURGICAL ANOMALIES. numbing the parts below and avoiding the major degree of pain. In this position, SAA'inging their legs backAvard and forward, the poor Chinese girls pass many a Aveary night. During this period the feet are unbound once a month only. The operation is begun by placing the end of a long, narrow- bandage on the inside of the instep and carrying it over the four smaller toes, securing them under the foot. After several turns the bandage is reversed so as to compress the foot longitudinally. The young girl is then left for a month, and Avhen the bandage is removed the foot is often found gangrenous and ulcerated, one or tAvo toes not infrequently being lost. If the foot is thus bound for two years it becomes A'irtually dead and painless. By this time the calf disappears from lack of exercise, the bones are attenuated, and all the parts are dry and shrivelled. In after-life the leg frequently regains its muscles and adipose tissue, but the foot always remains small. The binding process is said to exert a markedly depressing influence upon the emotional character of the subject, which lasts through life, and is very characteristic. To show Iioav minute some of the feet of the Chinese Avomen are, Figure I. of the accompanying plate (Plate 8), taken from a paper by Kenthughes on the " Feet of Chinese Ladies "a is from a photograph of a shoe that measured only 3J inches anteroposteriorly. The foot which it was intended to fill must have been smaller still, for the bandage would take up a certain amount of space. Figure II. is a reproduction of a photograph of a foot measuring 5| inches anteroposteriorly, the wrinkled appearance of the skin being due to prolonged immersion in spirit. This photograph shoAvs well the characteristics of the Chinese foot—the prominent and vertically placed . heel, which is raised generally about an inch from the leA'el of the great toe ; the sharp artificial cavus, produced by the altered position of the os calcis, and the doAViiAvard deflection of the foot in front of the mediotarsal joint; the straight and doAvmvard pointing great toe, and the infolding of the smaller toes underneath the great toe. In Figure III. we have a photograph of the skeleton of a Chinese lady's foot about five inches in anteroposterior diameter. The mesial axis of the os calcis is almost directly vertical, Avith a slight for- Avard inclination, forming a right angle Avith the bones in front of the medio- tarsal joint. The upper three-quarters of the anterior articular surface of the calcis is not in contact with the cuboid, the latter being depressed obliquely forward and downward, the lower portion of the posterior facet on the cuboid articulating Avith a neAV surface on the under portion of the bone. The general shape of the bone closely resembles that of a normal one—a marked contrast to its Avasted condition and tapering ex- tremity in paralytic calcaneus. Extension and flexion at the ankle are only limited by the shortness of the ligaments; there is no opposition from the conformation of the bones. The astragalus is almost of normal shape ; the trochlea is slightly prolonged anteriorly, especially on the inner side, from a Intercolonial Journal of Medicine and Surgery, Melbourne, 1894. PLATE 8. C^r***^ Fie. I.-Full Size. Chinese foot-binding (Kenthughes). A PROFESSIONAL LEG-BREAKER. 741 contact with the tibial articular surface. The cartilage on the exposed posterior portion of the trochlea seems healthy. The head of the astragalus is very prominent on the outer side, the scaphoid being depressed downward and inward away from it. The anterior articular surface is prolonged in the direction of the displaced scaphoid. The scaphoid, in addition to its dis- placement, is much compressed on the plantar surface, being little more than one-half the width of the dorsal surface. The cuboid is displaced obliquely doAviiAvard and forward, so that the upper part of the posterior articular sur- face is not in contact with the calcis. A professional leg-breaker is described in the Weekly Medical Review of St. Louis, April, 1890. This person's name was E. L. Landers, and he was accredited with earning his living by breaking or pretending to break his leg in order to collect damages for the supposed injury. Moreover, this in- dividual had but one leg, and was compelled to use crutches. At the time of report he had succeeded in obtaining damages in Wichita, Kansas, for a supposed fracture. The Review quotes a newspaper account of this operation as folloAvs :— " According to the Wichita Dispatch he represented himself as a telegraph operator who was to have charge of the postal telegraph office in that city as soon as the line reached there. He remained about toAvn for a month until he found an inviting piece of defective sidewalk, suitable for his purpose, Avhen he stuck his crutch through the hole and fell screaming to the ground, de- claring that he had broken his leg. He Avas carried to a hospital, and after a week's time, during which he negotiated a compromise Avith the city authori- ties and collected $ 1000 damages, a confederate, claiming to be his nephew, appeared and took the Avounded man away on a stretcher, saying that he Avas going to St. Louis. Before the train was fairly out of Wichita, Landers Avas laughing and boasting over his successful scheme to beat the toAvn. The Wichita story is in exact accord with the artistic methods of a one-legged sharper aaIio about 1878 stuck his crutch through a coal-hole here, and, fall- ing heels over head, claimed to have sustained injuries for Avhich he succeeded in collecting something like $1500 from the city. He is described as a fine- looking fellow, well dressed, and wearing a silk hat. He lost one leg in a railroad accident, and having collected a good round sum in damages for it, adopted the profession of leg-breaking in order to earn a livelihood. He probably argued that as he had made more money in that line than in any other he was especially fitted by natural talents to achieve distinction in this direction. But as it Avould be rather aAvkAvard to lose his remaining leg alto- gether he modified the idea and contents himself with collecting the smaller amounts Avhich ordinary fractures of the hip-joint entitle such an expert ' fine worker' to receive. " He first appeared here in 1874 and succeeded, it is alleged, in beating the Life Association of America. After remaining for some time in the hos- 742 MISCELLANEOUS SURGICAL ANOMALIES. pital he Avas removed on a stretcher to an Illinois village, from Avhich point the negotiations for damages Avere conducted by correspondence, until finally a point of agreement Avas reached and an agent of the company Avas sent to pay him the money. This being accomplished the agent returned to the depot to take the train back to St. Louis AA'hen he AA'as surprised to see the supposed sufferer stumping around on his crutches on the depot platform, laughing and jesting over the case Avith AA'hich he had beaten the corporation. " He afterAvard fell off a Wabash train at EdAvardsville and claimed to have sustained serious injuries, but in this case the company's attorneys beat him and proved him to be an impostor. In 1879 he stumbled into the tele- graph office at the Union Depot here, Avhen Henry C. Maboney, the superin- tendent, catching sight of him, put him out, with the curt remark that he didn't Avant him to stick that crutch into a cuspidor and fall doAvn, as it Avas too expensive a performance for the company to stand. He beat the Mis- souri Pacific and several other railroads and municipalities at different times, it is claimed, and manages to get enough at each successful A'cnture to carry him along for a year or eighteen months, by which time the memory of his trick fades out of the public mind, when he again bobs up serenely." Anomalous Suicides.—The literature on suicide affords many instances of self-mutilations and ingenious modes of producing death. In the Dublin Medical Press for 1854 there is an extraordinary case of suicide, in Avhich the patient thrust a red-hot poker into his abdomen and subsequently pulled it out, detaching portions of the omentum and 32 inches of the colon. Another suicide in Great Britain SAvalloAved a red-hot poker.a In commenting on sui- cides, in 1835, Arntzenius speaks of an ambitious Frenchman Avho AA'as desir- ous of leaving the Avorld in a distinguished manner, and Avho attached himself to a rocket of enormous size Avhich he had built for the purpose, and setting fire to it, ended his life. On September 28, 1895, according to the Gaulois and the NeAV York Herald (Paris edition) of that date, there AAas admitted to the Hopital St. Louis a clerk, aged tAventy-fiA'e, Avhom family troubles had rend- ered desperate and Avho had determined to seek death as a relief from his misery. RevieAving the A'arious methods of committing suicide he found none to his taste, and resolved on something neAV. Being familiar AA'ith the con- stituents of explosives, he resolved to convert his body into a bomb, load it Avith explosives, and thus bloAV himself to pieces. He procured some poAV- dered sulphur and potassium chlorate, and placing each in a separate Avafer he SAA'alloAved both Avith the aid of AA'ater. He then lay doAvn on his bed, dressed in his best clothes, expecting that as soon as the two explosive materials came into contact he would burst like a bomb and his troubles would be OA'er. In- stead of the anticipated result the most A'iolent eollicky pains ensued, Avhich finally became so great that he had to summon his neighbors, Avho took him to the hospital, Avhere, after vigorous application Avith the stomach-pump, it a 548, 1856, 103. RELIGIOUS AND CEREMONIAL MUTILATIONS. 743 Avas hoped that his life Avould be saA'ed. Sankey a mentions an epileptic Avho Avas found dead in his bed in the Oxford County Asylum; the man had ac- complished his end by placing a round pebble in each nostril, and thoroughly impacting in his throat a strip of flannel done up in a roll. In his " Insti- tutes of Surgery" Sir Charles Bell remarks that his predecessor at the Mid- dlesex Hospital entered into a conversation aa ith his barber over an attempt at suicide in the neighborhood, during Avhich the surgeon called the " would-be suicide " a fool, explaining to the barber hoAV clumsy his attempts had been, at the same time giving him an extempore lecture on the anatomic construc- tion of the neck, and shoAving him how a successful suicide in this region should be performed. At the close of the conversation the unfortunate barber retired into the back area of his shop, and following minutely the surgeon's directions, cut his throat in such a manner that there avus no hope of saving him. It is supposed that one could commit suicide by completely gilding or varnishing the body, thus eliminating the excretory functions of the skin. There is an old story of an infant who Avas gilded to appear at a Papal cere- mony who died shortly afterAvard from the suppression of the skin-function. The fact is one well established among animals, but after a full series of actual experiments, Tecontjeff of St. Petersburg concludes that in this respect man differs from animals. This authority states that in man no tangible risk is entailed by this process, at least for any length of time required for thera- peutic purposes. "Tarred and feathered" persons rarely die of the coating of tar they receive. For other instances of peculiar forms of suicide reference may be made to numerous volumes on this subject, prominent among which is that by Brierre de Boismont,226 which, though someAvhat old, has ahvays been found trustworthy, and also to the chapters on this subject written by various authors on medical jurisprudence. Religious and Ceremonial Mutilations.—Turning now to the subject of self-mutilation and self-destruction from the peculiar customs or religious beliefs of people, we find pages of information at our disposal. It is not only among the savage or uncivilized tribes that such ideas have prevailed, but from the earliest times they have had their influence upon educated minds. In the East, particularly in India, the doctrines of Buddhism, that the soul should be Avithout fear, that it could not be destroyed, and that the flesh aa;is only its resting-place, the soul several times being reincarnated, brought about great indifference to bodily injuries and death. In the history of the Brahmans there was a sect of philosophers called the Gymnosophists, Avho had the cxtremest indifference to life. To them incarnation Avas a posi- tive fact, and death Avas simply a change of residence. One of these philoso- phers, Calanus, Avas burned in the presence of Alexander ; and, according to Plutarch, three centuries later another Gymnosophist named Jarmenochegra, Avas similarly burned before Augustus. Since this time, according to Brierre a 224, 1883, i., 88. 744 MISCELLANEOUS SURGICAL ANOMALIES. de Boismont,226 the suicides from indifference to life in this mystic country arc counted by the thousands. Penetrating Japan the same sentiment, according to report, made it common in the earlier history of that country to see ships on its coasts, filled with fanatics Avho, by voluntary dismantling, submerged the vessels little by little, the whole multitude sinking into the sea while chanting praises to their idols. The same doctrines produced the same result in China. According to Bruckera it is Avell knoAvn that among the 500 philosophers of the college of Confucius, there avc re many avIio disdained to survive the loss of their books (burned by order of the savage Emperor Chi- Koung-ti), and throwing themselves into the sea, they disappeared under the Avaves. According to Brierre de Boismont, voluntary mutilation or death was A'ery rare among the Chaldeans, the Persians, or the HebreAvs, their pre- cepts being different from those mentioned. The Hebrews in particular had an aversion to self-murder, and during a period in their history of 4000 years there were only eight or ten suicides recorded. Josephus sIioavs what a marked influence on suicides the invasion of the Romans among the He- breAvs had. In Africa, as in India, there Avere Gymnosophists. In Egypt Sesostris, the grandest king of the country, having lost his eyesight in his old age, calmly and deliberately killed himself. About the time of Mark Anthony and Cleopatra, particularly after the battle of Actium, suicide Avas in great favor in Egypt. In fact a great number of persons formed an academy called The Synapothanoumenes, Avho had for their object the idea of dying together. In Western Europe, as shown in the ceremonies of the Druids, we find among the Celts a propensity for suicide and an indifference to self- torture. The Gauls Avere similarly minded, believing in the dogma of im- mortality and eternal repose. They thought little of bodily cares and ills. In Greece and Rome there Avas always an apology for suicide and death in the books of the philosophers. " Nil igitur mors est, ad nos neque pertinet hilum ; quando quid em natura animi mortalis habetur ! " cries Lucretius. With the advent of Christianity, condemning as it did the barbarous customs of self-mutilation and self-murder, these practices seem to disappear gradually ; but stoicism and indifference to pain Avere exhibited in martyrdom. Toward the middle ages, Avhen fanaticism Avas at its height and the mental malady of demoniacal possession was preA'alent, there Avas something of a reversion to the old customs. In the East the Juggernaut procession Avas still in vogue, but this was suppressed by civilized authorities ; outside of a feAV minor customs still prevalent among our own people Ave must to-day look to the savage tribes for the perpetuation of such practices. In an excellent article on the evolution of ceremonial institutionsb Herbert Spencer mentions the Fuegians, Veddahs, Andamanese, Dyaks, Todas, Gonds, Santals, Bodos, and Dhimals, Mishmis, Kamchadales, and Snake a " Hist. Nat. Philos.," T. iv., 11 and 670. b 638, April, 1878. EXHIBITION OF SCARS. 745 Indians, as among people avIio form societies to practise simple mutilations in slight forms. Mutilations in somewhat graver forms, but still in moderation, are practised by the Tasmanians, Tamaese, the people of NeAV Guinea, Karens, Nagas, Ostiaks, Eskimos, Chinooks, Comanches, and ChippeAvas. What might be called mixed or compound mutilations are practised by the New Zea- landers, East Africans, Kondes, Kukas, and Calmucks. Among those prac- tising simple but severe mutilations are the Ncav Caledonians, the Bushmen, and some indigenous Australians. Those tribes having for their customs the practice of compound major mutilations are the Fiji Islanders, Sandwich Islanders, Tahitians, Tongans, Samoans, Javanese, Sumatrans, natives of Malagasy, Hottentots, Damaras, Bechuanas, Kaffirs, the Congo people, the Coast Negroes, Inland Negroes, Dahomeans, Ashantees, Fulahs, Abyssinians, Arabs, and Dakotas. Spencer has evidently made a most extensive and com- prehensive study of this subject, and his paper is a most valuable contribu- tion to the subject. In the preparation of this section we have frequently quoted from it. The practice of self-bleeding has its origin in other mutilations, although the Aztecs shed human blood in the worship of the sun. The Samoi'edes have a custom of drinking the blood of warm animals. Those of the Fijians who were cannibals drank the warm blood of their victims. Among the Amaponda Kaffirs there are horrible accounts of kindred savage cus- toms. Spencer quotes :—" It is usual for the ruling chief on his accession to be Avashed in the blood of a near relative, generally a brother, Avho is put to death for the occasion." During a Samoan marriage-ceremony the friends of the bride "took up stones and beat themselves until their heads were bruised and bleeding." In Australia a novitiate at the ceremony of manhood drank a mouthful of blood from the veins of the warrior Avho Avas to be his sponsor. At the death of their kings the Lacedemonians met in large numbers and tore the flesh from their foreheads with pins and needles. It is said that when Odin Avas near his death he ordered himself to be marked with a spear; and Niort, one of his successors, followed the example of his predecessor. Shakespeare speaks of " such as boast and show their scars." In the olden times it was not uncommon for a noble soldier to make public exhibition of his scars with the greatest pride ; in fact, on the battlefield they invited the reception of superficial disfiguring injuries, and to-day some students of the learned universities of Germany seem prouder of the possession of scars re- ceived in a duel of honor than in aAvards for scholastic attainments. Lichtcnstein tells of priests among the Bechuanas who made long cuts from the thigh to the knee of each warrior who slew an enemy in battle. Among some tribes of the Kaffirs a kindred custom was practised; and among the Damaras, for every wild animal a young man destroyed his father made four incisions on the front of his son's body. Speaking of certain 746 MISAv;d the latter mentions that the calculus he saAV Avas egg-shaped. There is an old chronicle of a stone taken from the Avomb of a Avoman near Trent, Somersetshire, at Easter, 1666, that Aveighed four ounces. The Ephemerides speaks of a calculus coming aAvay with the menstrual fluid. Stones in the heart are mentioned by medical Avriters, and it is saide that tAvo stones as large as almonds were found in the heart of the Earl of Bal- earic's. Morandf speaks of a calculus ejected from the mouth by a Avoman. An old record says g that stones in the brain sometimes are the cause of convulsions. D'Hericourt reports the case of a girl Avho died after six months' suffering, avIiosc pineal gland Avas found petrified, and the incredible size of a chicken's egg. Blasius, Diemerbroeck, and the Ephemerides, speak of stones in the location of the pineal gland. Salivary calculi are Avell knoAvn; they may lodge in any of the buccal ducts. There is a record of the caseh of a man of thirty-seven who suffered great pain and profuse salivation. It Avas found that he had a stone as large as a pigeon's egg under his tongue. Umbilical calculi are sometimes seen, and Dean1 reports such a case. There is a French record J of a case of exstrophy of the umbilicus, attended Avith abnormal concretions. Aetius, Marcellus Donatus, Scaliger, and Schenck mention calculi of the eyelids. There are some extraordinary cases of retention and suppression of urine on record. Actual retention of urine, that is, urinary secretion passed into the bladder, but retention in the latter viscus by inanition, stricture, or other obstruction, naturally cannot continue any great length of time Avithout mechanically rupturing the vesical walls ; but suppression of urine or abso- lute anuria may last an astonishingly extended period. Of the eases of retention of urine, Fereolk mentions that of a man of forty-nine who suffered absolute retention of urine for eight days, caused by the obstruction of a uric acid calculus. Cunyghame1 reports a case of mechanic obstruction of the flow of urine for eleven days. Trapenard speaks of retention of urine for seven days. Among the older Avriters Bartholinus189 mentions ischuria last- ing fourteen days ; Cornarius, fourteen days ; Rhodius, fifteen days ; the Ephe- merides, ten, eleven, and twelve days. Croom m notes a case of retention of a 130, 1861, ii., 129. b Obs. Med. dec, ii. c 323, 1875, ii., 35. d218, 1870, 70. e 629, 1700, 158. * Paris, 1754. g 462, iv. h 462, vol. v. i 176, 1859. j 363, 443. k 653, 1890, 152. 1 318, 1874-75, xx., 317. m 318, 1885, xxxi., 734. RETENTION AND SUPPRESSION OF URINE. 793 urine from laceration of the vagina during first coitus. Foucard a reports a case of retention of urine in a young girl of nineteen, due to accumulation of the menstrual fluid behind an imperforate hymen. The accumulation of urine in cases of ischuria is sometimes quite exces- sive. De Vildeb speaks of 16 pints being drawn off. Mazoni cites a case in which 15 pounds of urine were retained; and Wilson c mentions 16 pounds of urine being drawn off. Frankd reports instances in Avhich both 12 and 30 pounds of urine were evacuated. There is a record at the beginning of this century e in which it is stated that 31 pounds of urine Avere evacuated in a case of ischuria. FolloAving some toxic or thermic disturbance, or in diseased kidneys, sup- pression of urine is quite frequently noticed. The older writers report some remarkable instances : Haller397 mentions a case lasting twenty-two weeks; Domonceau/ six months; and Marcellus Donatus,306 six months. Whitelaw * describes a boy of eight who, after an attack of scarlet fever, did not pass a single drop of urine from December 7th to December 20th, when two ounces issued, after vesication over the kidneys. On January 2d two ounces more were evacuated, and no more Avas passed until the bowel acted regularly. On January 5th a whole pint of urine passed ; after that the kidneys acted normally and the boy recovered. It Avould be no exaggera- tion to state that this case lasted from December 5th to January 5th, for the evacuations during this period were so slight as to be hardly worthy of men- tion. Lemery h reports observation of a monk Avho during eight years vomited periodically instead of urinating in a natural Avay. FiA'e hours before vom- iting he experienced a strong pain in the kidneys. The vomitus was of dark-red color, and had the odor of urine. He ate little, but drank Avine copiously, and stated that the vomiting was salutary to him, as he suffered more when he missed it. Bryce i records a case of anuria of seventeen days' standing. Butler j speaks of an individual with a single kidney who suffered suppression of urine for thirteen days, caused by occlusion of the ureter by an inspissated thrombus. Dubuck observed a case of anuria AA'hich continued for seventeen days before the fatal issue. Fontainel reports a case of suppression of urine for tAventy-five days. Nunneley m shoAved the kidneys of a Avoman Avho did not secrete any urine for a period of tvveh'e days, and during this time she had not exhibited any of the usual symptoms of uremia. Peebles n mentions a case of suspension of the functions of the kidneys more than once for five weeks, the patient exhibiting neither coma, stupor, nof A'omiting. Oke ° a 100, xxx., 103. b 402, T. xlvii., 134. c 524, ii. <* 351, L. vi., 282. e 565, 1810. f 462, T. xi., 117. g 476, 1877, ii., 460. h 302, iv., 225. i South. Clinic, Richmond, 1881, iv., 545. ■ J 476, 1890, i., 79. k 739, 1879, 715. 1 809, 1874, i., 407. ^779, xi., 145. n 318, 1836, xlvi., 158. ° 656, 1849, x., 259. 794 ANOMALOUS TYPES AND INSTANCES OF DISEASE. speaks of total suppression of urine during seven days, with complete re- covery ; and Paxon mentions a case in a child that recovered after fiye days' suppression. Russell8 reports a case of complete obstructive suppression for twenty days folloAved by complete recovery. Scott and Shroff mention recovery after nine days' suppression. The most persistent constipation may exist for weeks, or even months, with fair health. The fact seemed to be a subject of much interest to the older Avriters. De Cabalisb mentions constipation lasting thirty-seven days ; Caldani, sixty-five days ; Lecheverel,0 thirty-four days ; and Pomma d eight months ; Sylvaticus, thirty months ; Baillie,e fifteen Aveeks ; Blanchard,213 six weeks ; Smetius,730 five months ; Trioen,784 three months ; Devilliers,1' tAvo years ; and Gignony/ seven years. Riverius687 mentions death following constipation of one month, and says that the intestines were completely filled. Moosmanh mentions death from the same cause in sixty days. Frank speaks of constipation from intestinal obstructions lasting for three weeks, and Manget mentions a similar case lasting three months. Early in the century Revolat reported in Marseilles an observation of an eminently nervous subject addicted to frequent abuse as regards diet, Avho had not had the slightest evacuation from the boAvel for six months. A cure was effected in this case by tonics, temperance, regulation of the diet, etc. In Tome xv. of the Commentaries of Leipzig there is an account of a man Avho always had his stercoral evacuations on Wednesdays, and who suffered no evil consequences from this abnormality. This state of affairs had existed from childhood, and, as the evacuations Avere abundant and connected, no morbific change or malformation seemed present. The other excretions were slightly in excess of the ordinary amount. There are many cases of constipation on record lasting longer than this, but none with the same peri- odicity and Avithout change in the excrement. Tommassini * records the his- tory of a man of thirty, living an ordinary life, Avho became each year more constipated. Between the ages of tAventy and twenty-four the evacuations Avere gradually reduced to one in eight or ten days, and at the age of twenty- six, to one every twenty-two days. His leanness increased in proportion to his constipation, and at thirty his appetite Avas so good that he ate as much as tAvo men. His thirst Avas intense, but he secreted urine natural in quantity and quality. Nothing seemed to benefit him, and purgatives only augmented his trouble. His feces came in small, hard balls. His tongue Avas alAvavs in good condition, the abdomen not enlarged, the pulse and temperature normal. Emily Plumley was born on June 11, 1850, Avith an imperforate anus, and lived one hundred and two days Avithout an evacuation. During the Avhole a 548, 1879, i., 474. b Phenom. Medica. c 463, July, 1S10. p. 74. d Ibid. e Trans. Soc. for Improvement of Surg, and Med. Knowl., ii., No. 14. f 462, T. iv., 256. 8 462, T. x., 410. b 524, 1797. i Journal de Med. de Parme., 1808. PERSISTENT CONSTIPATION 795 period there was little nausea and occasional regurgitation of the mother's milk, due to over-feeding.a Crippsb mentions a man of forty-two Avith stricture of the rectum, avIio suffered complete intestinal obstruction for tAvo months, during which time he vomited only once or twice. His appetite Avas good, but he avoided solid food. He recovered after the performance of proc- totomy. Fleckc reports the case of a Dutchman who, during the last two years, by some peculiar innervation of the intestine, had only five or six boAvel movements a year. In the intervals the patient passed small quantities of hard feces once in eight or ten days, but the amount Avas so small that they constituted no more than the feces of one meal. Tavo or three days before the principal evacuation began the patient became ill and felt uncomfortable in the back ; after sharp attacks of colic he would pass hard and large quantities of offensive feces. He would then feel better for two or three hours, Avhen there Avould be a repetition of the symptoms, and so on until he had four or five motions that day. The following day he would have a slight diarrhea and then the bowels Avould return to the former condition. The principal fecal accumulations Avere in the ascending and transA'erse colon and not only could be felt but seen through the abdominal wall. The patient Avas well nour- ished and had tried every remedy Avithout success. Finally he Avent to Marienbad where he drank freely of the waters and took the baths until the boAvel movements occurred once in two or three days. There is a record4 of a man who stated that for tAvo years he had not passed his stool by the anus, but that at six o'clock each evening he voided feces by the mouth. His statement was corroborated by observation. At times the evacuation took place without effort, but Avas occasionally attended Avith slight pain in the esophagus and slight commlsions. SeA'eral hours before the evacuation the abdomen was hard and distended, which appearance vanished in the evening. In this case there was a history of an injury in the upper iliac region. The first accurate ideas in reference to elephantiasis arabum are given by Rhazes, Haly-Abas, and Avicenna, and it is possibly on this account that the disease received the name elephantiasis arabum. The disease Avas after- Avard noticed by Forestus, Mercurialis, Kaempfer, Ludoff, and others. In 1719 Prosper Alpinus Avrote of it in Egypt, and the medical officers of the French army that invaded Kgypt became familiar Avith it; since then the disease has been aacII knoAvn. Alard relates as a case of elephantiasis that of a lady of Berlin, mentioned in the Ephemerides of 1694, who had an abdominal tumor the loAver part of Avhich reached to the knees. In this case the tumor Avas situated in the skin and no vestige of disease avus found in the abdominal cavity and no sensible alteration had taken place in the veins. Delpech quotes a similar case of ele- a 656,1851, 123. b 476, 1886, ii., 444. c 821, quoted 224, 1879, i., 594. <* 822,1891. 796 ANOMALOUS TYPES AND INSTANCES OF DISEASE phantiasis in the Avails of the abdomen in a young Avoman of twenty-four, born at Toulouse. Lymphedema, or elephantiasis arabum, is a condition in Avhich, in the sub- stance of a limb or a part, there is diffused dilatation of the lymphatics, with lymphostasis. Such a condition results when there is obstruction of so large a number of the ducts coiiA'erging to the root of the extremity or part that but little relief through collateral trunks is possible. The affected part becomes SAvollen and hardened, and sometimes attains an enormous size. It is neither reducible by position nor pressure. There is a corresponding dilatation and multiplication of the blood-A'essels Avith the connective-tissue hypertrophy. The muscles Avaste, the skin becomes coarse and hypertrophied. The SAvollen Fig. 272.—Lymphedema of the left leg five years after its onset (Keen and White). Fig. 273.—Lymphedema in its later stage (Keen and AVhite). limb presents immense lobulated masses, heaped up at different parts, separated from one another by deep sulci, Avhich are especially marked at the flexures of the joints. Although elephantiasis is met Avith in all climates, it is more common in the tropics, and its occurrence has been repeatedly demonstrated in these localities to be dependent on the presence in the lymphatics of the filaria sanguinis hominis. The accompanying illustration (Fig. 272)^ sIioavs the condition of the limb of a girl of twenty-one, the subject of lymphedema, five years after the inception of the disease. The changes in the limb Avere as yet ELEPHANTIASIS ARABUM. 797 Fig. 274—Elephantiasis of enormous develop- ment (" Barbadoes leg " ) (after Smith). moderate. The photograph from Avhich the cut Avas made was taken in 1875. A t the present time (seventeen years later) the case presents the typical condition of the Avorst form of elephantiasis. Repeated attacks of lymphangitis have occurred during this period, each producing an aggravation of the previous condition. The leg beloAv the knee has become enor- mously deformed by the production of the elephantoid masses ; the outer side of the thigh remains healthy, but the skin of the inner side has developed so as to form a very large and pendant lobulated mass. A similar condition has begun to develop in the other leg, Avhich is noAV about in the condition of the first, as sIioavii in the fig- ure. Figure 273 represents this disease in its most aggravated form, a condition rarely observed in this country. As an example of the change in the weight of a person after the in- ception of this disease, we cite a case reported by Griffiths.81 The patient was a Avoman of fifty-tAVO Avho, fiA'e years previous, Aveighed 148 pounds. The elephantoid change was below the Avaist, yet at the time of report the Avoman Aveighed 387 pounds. There Avas little thicken- ing of the skin. The cir- cumference of the calf Avas 28 inches ; of the thigh, 38 inches; and of the abdo- men, 80 inches ; Avhile that of the arm Avas only 15 inches. The condition common- ly knoAvn as " Barbadoes leg" (Fig. 274) is a form of elephantiasis deriving its name from its relative frequency in Barbadoes. a Kansas City Med. Index, Dec., 1894. Fig. 275.—Elephantoid change of both feet. 798 ANOMALOUS TYPES AND INSTANIES OF DISEASE. Figure 275 represents a well-known exhibitionist Avho, from all appear- ances, is suffering from an elephantoid hypertrophy of the loAver extremities, due to a lymphedema. Quite a number of similar exhibitionists have been shown in recent years, the most celebrated of Avhom Avas Fanny Mills, one of whose feet alone Avas extensiA'ely involved, and was perhaps the largest foot ever seen. Elephantiasis seldom attacks the upper extremities. Of the older cases Rayer reports four collected by Alard. In one case the hard and per- manent swelling of the arm occurred after the application of a blister; in an- other the arm increased so that it Aveighed more than 200 Genoese pounds, 10 of which consisted of serum. The SAvellings of the arm and forearm resembled a distended bladder. The arteries, veins, and nerves had not undergone any alteration, but the lymphatics avc re very much dilated and loaded Avith lymph. The third case was from Fab- ricius Hildanus, and the fourth from Hendy. Figure 276 repre- sents a remarkable elephantoid change in the hand of an elderly German Avoman. Unfortunately there is no medical description of the case on record, but the photograph is deemed Avorthy of reproduction. Terry a describes a French mulatto girl of eleven whose left hand Avas enormously increased in Aveight and consistency, the Fig. 276.-Elephantoid change of the hand. chief enlargement being in the middle finger, which was 6| inches long, and 5J inches about the nail, and 8| around the base of the finger. The index finger was tAvo inches thick and four inches long, tAvisted and draAvn, Avhile the other fingers were dAvarfed. The elephantiasis in this case slowly and gradually increased in size until the hand weighed 3 J pounds. The skin of the affected finger, contrary to the general appearance of a part affected Avith elephantiasis, Avas of normal color, smooth, shiny, showed no sensibility, and the muscles had undergone fatty degeneration. It Avas suc- cessfully amputated in August, 1894. The accompanying illustration (Fig. 277) shows a dorsal A'ieAv of the affected hand. Magalhaes of Rio Janeirob reports a very interesting case of elephanti- asis of the scalp, representing dermatolysis, in which the fold of hypertro- phied skin fell over the face like the hide of an elephant (Fig. 278), someAvhat similar in appearance to the " elephant-man." Figure 279 represents a some- a 593, July, 1895. b 124, 1893. ELEPHANTIASIS OF THE SCALP AND FACE. 799 Fig. 277.—Elephantiasis of the middle finger (Terry). Fig. 278.—Elephantiasis of the scalp (Magalhaes). 800 ANOMALOUS TYPES AND INSTANCES OF DISEASE. -—B^pi : Fig. 279.—Hypertrophic tumor of the scalp and face. Avhat similar hypertrophic condition of the scalp and face reported in the Pho- tographic RevieAV of Medicine and Surgery, 1870. Elephantiasis of the face sometimes only attacks it on one side. Such a case Avas reported by Alard, in Avliich the elephantiasis seems to have been com- plicated Avith eczema of the ear. AVillier, also quoted by Alard, describes a remark- able case of elephantiasis of the face. After a debauch this patient experienced violent pain in the left cheek beloAv the zygomatic! arch ; this soon extended under the chin, and the submaxillary glands enlarged and became painful ; the face sAvelled and became erythematous, and the patient experienced nausea and slight chills. At the end of six months there Avas another attack, after Avhich the patient perceived that the face continued puffed. This attack Avas folloAved by seA'eral others, the face groAving larger and larger. In similar cases tumefaction assumes enormous proportions, and Schenck a speaks of a man whose head exceeded that of an ox in size, the loAver part of the face being entirely covered with the nose, which had to be raised to enable its unhappy OAvner to breathe. Rayer cites tAvo instances in which elephan- tiasis of the breast enlarged these organs to such a degree that they hung to the knees. Salmuthb speaks of a Avoman Avhose breasts increased to such a size that they hung doAvn to her knees. At the same time she had in both axillae glandular tumors as large as the head of a fetus. Borellus841 also quotes the case of a woman Avhose breasts became so large that it was necessary to support them by straps, Avhich passed over the shoulders and neck. Elephantiasis is occasionally seen in the genital regions of the female (Fig. 280), but more often in the scrotum of the male, in which location it produces enormous tumors, Avhich sometimes reach to the ground and become so heavy as to prevent locomotion. This condition is curious in the fact that a 718. L. i., 12. b 706, cent, ii., obs. ix. Fig. 280.—Elephantiasis of the labia (Scanzoni). ELEPHANTIASIS OF THE SCROTUM 801 these immense tumors have been successfully removed, the testicles and penis, which had long since ceased to be distinguished, saved, and their function restored. Alibert mentions a patient AA'ho was operated upon by Clot-Bey, whose scrotum when removed Aveighed 110 pounds ; the man had two children after the disease had continued for thirteen years, but before it had obtained its monstrous development—a proof that the functions of the testicles had not been affected by the disease. There are several old accounts of scrotal tumors Avhich have evidently been elephantoid in conformation. In the Ephemerides in 1692 there AA'as mentioned a tumor of the scrotum Aveighing 200 pounds. In the West Indies it was reported that rats have been known to feed on these enormous tumors, Avhile the deserted subjects lay in a most helpless condition. Larrey mentioned a case of elephantiasis of the scrotum in which the tumor Aveighed over 200 pounds. Sir Astley Cooper removed a tumor of 56 pounds Aveight from a Chinese laborer. It extended from beneath the umbilicus to the anterior border of the anus; it had begun in the prepuce ten years previously.3, Clot- Bey b removed an elephantoid tumor of the scrotum weighing 80 pounds, per- forming castration at the same time. Alleynec reports a case of elephantiasis, in which he successfully removed a tumor of the integuments of the scrotum and penis weighing 134 pounds. Bicetd mentions a curious instance of elephantiasis of the penis and scrotum which had existed for five years. The subject Avas in great mental misery and alarm at his unsightly condition. The parts of generation Avere completely buried in the huge mass. An operation AA'as performed in AA'hich all of the diseased structures that had totally unmanned him Avere removed, the true organs of generation escaping inviolate. Thebaude mentions a tumor of the scrotum, the result of elephantiasis, Avhich Aveighed 63 J pounds. The Aveight Avas ascertained by placing the tumor on the scales, and directing the patient to squat over them Avithout resting any weight of the body on the scales. This man could readily feel his penis, although his surgeons could not do so. The bladder Avas under perfect control, the urine floAving over a channel on the exterior of the scrotum, extending 18 inches from the meatus. Despite his infirmity this patient had perfect sexual desire, and occasional erections and emissions. A very interesting operation Avas performed Avith a good recovery. Partridgef reports an enormous scrotal tumor AA'hich was removed from a Hindoo of fifty-five, Avith subsequent recovery of the subject. The tumor Aveighed 111\ pounds. The ingenious technic of this operation is Avell Avorth perusal by those interested. Goodman e successfully removed an ele- phantiasis of the scrotum from a native Fiji of forty-five. The tumor weighed 42 pounds, Avithout taking into consideration the weight of the fluid a 476, 1831, ii., 86. b 363, 1*34. c 523, 1852. d 434, 1837, ii., 251. e 597, May. 1867. f 548, 1880, L, 660. 8 476, 1876, ii., 889. 51 802 ANOMALOUS TYPES AND INSTANCES OF DISEASE. which escaped in abundance during the operation and also after the operation, but before it Avas weighed. Van Buren and Kcyes mention a tumor of the scrotum of this nature Aveighing 165 pounds. Quoted by Russell, Hendy describes the case of a negro avIio had successive attacks of glandular SAvelling of the scrotum, until finally the scrotum Avas two feet long and six feet in circumference. It is mentioned that mortification of the part caused this patient's ultimate death. Figure 281 is taken from a photograph loaned to the authors by Dr. James Thorington. The patient was a native of Fiji, and was successfully operated on, Avith preservation of the testes. The tumor, on removal, weighed 120 pounds. W. R. Browne, Surgeon-General, reports from the Madras General Hos- pital an operation on a patient of thirty-five with elephantoid scrotum of six years' duration. The propor- tions of the scrotum were as folloAvs : Horizontally the circumference Avas six feet 6^ inches, and vertically the circumference was six feet ten inches. The penis was Avholly hidden, and the urine passed from an opening Fig. 281. -Elephantiasis of the scrotum in a native of Fiji. two feet 5J inches from the pubis. The man had complete control of his bladder, but was unable to Avalk. The operation for removal occupied one hour and twenty minutes, and the tumor removed weighed 124| pounds. Little blood was lost on ac- count of an elastic cord tied about the neck of the tumor, and secured by straps to a leather waist-belt. Re- covery was prompt. Cody a speaks of the successful removal of a scrotal tumor weighing 56 pounds. Fenger b describes a case of the foregoing nature in a German of tAventy- three, a resident of Chicago. The groAvth had commenced eight years pre- viously, and had progressively increased. There was no pain or active inflammation, and although the patient had to have especially constructed trousers he neA'er ceased his occupation as a driver. The scrotum Avas rep- resented by a hairless tumor weighing 22 pounds, and hanging one inch beloAv the knees. No testicles or penis could be made out. Fenger removed the tumor, and the man Avas greatly improved in health. There Avas still swelling of the inguinal glands on both sides, but otherwise the operation a 476, 1882. b 124, Oct., 1891. ACROMEGALY. 803 was very successful. The man's mental condition also greatly improved. Fenger also calls especial attention to the importance of preserving the penis and testes in the operation, as although these parts may apparently be obliter- ated their functions are undisturbed. The statistics of this major operation show a surprisingly small mor- tality. Fayrer operated on 28 patients with 22 recoveries and six deaths, one from shock and five from pyemia. The same surgeon collected 193 cases, and found the general mortality to be 18 per cent. According to Ashhurst, Turner, who practised as a medical missionary in the Samoan Islands, claims to have operated 136 times with only two deaths. McLeod, Fayrer's suc- cessor in India, reported 129 cases AA'ith 23 deaths. Early in this century Rayer described a case of elephantiasis in a boy of seventeen who, after several attacks of erysipelas, showed marked diminution of the elephantoid change ; the fact shows the antagonism of the streptococcus erysipelatis to hypertrophic and malignant processes. Acromegaly is a term introduced by Marie, and signifies large extremi- ties. It is characterized by an abnormally large development of the extremi- ties and of the features of the face,—the bony as well as the soft parts. In a well-marked case the hands and feet are greatly enlarged, but not otherwise deformed, and the normal functions are not disturbed. The hypertrophy in- volves all the tissues, giving a curious spade-like appearance to the hands. The feet are similarly enlarged, although the big toe may be relatively much larger. The nails also become broad and large. The face increases in volume and becomes elongated, in consequence of the hypertrophy of the superior and inferior maxillary bones. The latter often projects beyond the upper teeth. The teeth become separated, and the soft parts increase in size. The nose is large and broad, and the skin of the eyelids and ears is enormously hypertrophied. The tongue is greatly hypertrophied. The disease is of long duration, and late in the history the bones of the spine and thorax may acquire great deformity. As Ave know little of the influences and sources governing nutrition, the pathology and etiology of acromegaly are obscure. Marie re- gards the disease as a systemic dystrophy analogous to myxedema, due to a morbid condition of the pituitary body, just as myxedema is due to disease of the thyroid. In several of the cases reported the squint and optic atrophy and the amblyopia haA'e pointed to the pituitary body as the seat of a new groAvth of hypertrophy. Pershing11 shows a case of this nature (Fig. 282). The en- largement of the face and extremities was characteristic, and the cerebral and ocular symptoms pointed to the pituitary body as the seat of the lesion. Unverricht, Thomas, and Ransom843 report cases in AA'hich the ocular lesions, indicative of pituitary trouble, Avere quite prominent. Of 22 cases collected by Tamburinib 19 shoAved some change in the pituitary body, and in the remaining three cases either the diagnosis Avas uncertain or the disease Avas » Inter. Med. Mag., June, 1894. b Centralbl. f. Nerv. u. Pscych., Dec., 1894. 804 ANOMALOUS TYPES AND INSTANCES OF DISEASE of verv short duration. Linsmayer a reported a case in which there was a softened adenoma in the pituitary body, and the thymus was absent. Hersmanb reports an interesting case of progressive enlargement of the Fig. 282. Mrs. A. B., aged twenty years, showing normal Same patient, aged forty-two years, affected appearance of the patient. (Pershing.) with acromegaly. hands in a clergyman of fifty. Since youth he had suffered with pains in the joints. About three years before the time of report he noticed enlargement Fi°\ 283.—Progressive enlargements of the hands, anterior and posterior views (Hersman). of the phalangeal joint of the third finger of the right hand. A short time later the Avhole hand became gradually involved and the skin assumed a darker a S38, 1894, No. 14. b inter. Med. Mag., Oct., 1894. CRETINISM. 805 hue. Sensation and temperature remained normal in both hands ; acromegaly Avas excluded on account of the absence of similar changes elsewhere. Hers- man remarks that the change was probably due to increase in o-rowth of the fibrous elements of the subcutaneous lesions about the tendons, caused by rheu- matic poison. Figure 283 sIioavs the palmar and dorsal surfaces of both hands. Chiromegaly is a term that has been applied by Charcot and Brissaud to the pseudoacromegaly that sometimes occurs in syringomyelia. Most of the cases that have been reported as a combination of these tAvo diseases are noAV thought to be only a syringomyelia. X recent case is reported by Marie.789 In this connection it is interesting to notice a case of what might be called acute symptomatic transitory pseudoacromegaly, reported bA' Po- tovski : a In an insane woman, and Avithout ascertainable cause, there ap- peared an enlargement of the ankles, Avrists, and shoulders, and later of the muscles, Avith superficial trophic disturbances that gradually disappeared. The author excludes syphilis, tuberculosis, rheumatism, gout, hemophilia, etc., and considers it to haA'e been a trophic affection of cerebral origin. Cases of pneumonic osteoarthropathy simulating acromegaly have been reported by Kornband Murray.0 Megalocephaly, or as it Avas called by Yirchow, leontiasis ossea, is due to a hypertrophic process in the bones of the cranium. The cases studied by Yirchow Avere diffuse hyperostoses of the cranium. Starr d describes Avhathe supposes to be a case of this disease, and proposes the title megalocephaly as pre- ferable to VirchoAv's term, because the soft parts are also included in the hyper- trophic process. A Avoman of fifty-tAvo, married but having no children, and of negative family history, six years before the time of report showed the first symptoms of the affection, Avhich began Avith formication in the finger-tips. This gradually extended to the shoulders, and AA'as attended Avith some uncertainty of tactile sense and clumsiness of mo\rement, but actual anesthesia had never been demonstrated. This numbness had not invaded the trunk or lower ex- tremities, although there avus slight uncertainty in the gait. There had been a sloAvly progressing enlargement of the head, face, and neck, affecting the bone, skin, and subcutaneous tissues, the first to the greatest degree. The circum- ference of the neck avus 16 inches ; the horizontal circumference of the head Avas 24 inches ; from ear to ear, over the vertex, 15 inches ; and from the root of the nose to the occipital protuberance, 16 inches. The cervical vertebrae were involved, and the AA'oman had lost five inches in height. It may be mentioned here that Brissaud and Meige noticed the same loss in height, only more pro- nounced, in a case of gigantism, the loss being more than 15 inches. In Starr's case the tongue Avas normal and there Avas no SAvelling of the thyroid. Cretinism is an endemic disease among mountainous people who drink largely of lime Avater, and is characterized by a condition of physical, physio- logic, and mental degeneracy and nondevelopment, and possibly goiter. The a Quoted 843, 613. b 224, Dec. 2, 1893. o 224, Feb. 9, 1S95. d 124, Dec., 1894. 806 ANOMALOUS TYPES AND INSTANCES OF DISEASE. subjects of this disease seldom reach five feet in height, and usually not more than four. The Avord cretin is derived from the Latin ereatura. They are found all over the Avorld. In SAvitzerland it is estimated that in some cantons there is one cretin to every 25 inhabitants. In Styria, the Tyrol, and along the Rhine cretins are quite common, and not long since cases existed in Derby- shire. These creatures have been allowed to marry and generate, and thus ex- tend their species. In " Le Medicin de Campagne," Balzac has given a vivid picture of the aAve and respect in which they Ave re held and the Avay in Avhich they were allowed to propagate. Speaking of the endemic cretins, Beaupr6 says : " I see a head of unusual form and size, a squat and bloated figure, a stupid look, bleared, hollow, and heavy eyes, thick, projecting eyelids, and a flat nose. His face is of a leaden hue, his skin dirty, flabby, covered with tetters, and his thick tongue hangs doAvn over his moist, livid lips ; his mouth, always open and full of saliva, shoAvs teeth going to decay. His chest is nar- row, his back curved, his breath asthmatic, his limbs short, misshapen, with- out power. The knees are thick and inclined inward, the feet flat. The large head droops listlessly on the breast; the abdomen is like a bag." The cretin is generally deaf and dumb, or only able to give a hoarse cry. He is indifferent to heat and cold, and even to the most revolting odors. The general opinion has always been that the sexual desire and genital organs are fully developed. A quotation under our observation credits Colonel Sykes Avith the follow- ing statistics of cretinism, Avhich show hoAV in some locations it may be a decided factor of population. In December, 1845, in a population of 2,558,349 souls (the locality not mentioned), there were 18,462 people with simple goiter. Of the cretins Avithout goiter there Avere 2089. Of cretins with goiter there were 3909 ; and cretins in which goiter was not stated 962, making a total of 6960. Of these 2185 had mere animal instincts; 3531 possessed very small intellectual faculties ; 196 were almost without any ; 1048 not classified. Of this number 2483 were born of healthy and sane fathers; 2285 from healthy mothers ; 961 from goitrous fathers ; 1267 from goitrous mothers ; 49 from cretin fathers; 41 from cretin mothers; 106 from cretin fathers with goiter ; 66 from cretin mothers with goiter ; 438 fathers and 405 mothers were not specified. Sporadic cretinism, or congenital myxedema, is characterized by a con- genital absence of the thyroid, diminutiveness of size, thickness of neck, short- ness of arms and legs, prominence of the abdomen, large size of the face, thickness of the lips, large and protruding tongue, and imbecility or idiocy (Fig. 284). It is popularly believed that coitus during intoxication is the cause of this condition. Osiera was able to collect 11 or 12 cases in this country. The diagnosis is all-important, as the treatment by the thyroid extract produces the most noteworthy results. There are several remarkable a 124, Nov., 1893. MYXEDEMA. 807 recoveries on record, but possibly the most Avonderful is the case of J. P. West of Bellaire, Ohio,a the portraits of which are reproduced in Plate 11. At seventeen months the child presented the typical appearance of a spo- radic cretin. The astonishing results of six months' treatment Avith thyroid extract are shown in the second figure. After a year's treatment the child presents the appearance of a healthy and well-nourished little girl. Myxedema proper is a constitutional condition due to the loss of the func- tion of the thyroid gland. The disease Avas first described by Sir William Gull as a cretinoid change, and later by William Ord of London, who suggested the name. It is characterized clinically by a mxyedematous condition of the sub- cutaneous tissues and mental failure, and anatomically by atrophy of the thyroid gland. The symptoms of myxedema, as given by Ord, are marked increase in the general bulk of the body, a firm, inelastic swelling of the skin, which does not pit on pressure; dryness and roughness Avhich tend, Avith swelling, to obliterate the lines of expression in the face; im- perfect nutrition of the hair ; local tume- faction of the skin and subcutaneous tissues, particularly in the supraclavic- ular region. The physiognomy is re- markably altered ; the features are coarse and broad, the lips thick, the nostrils broad and thick, and the mouth enlarged. There is a striking sloAvness of thought and of movement; the memory fails, and conditions leading to incipient dementia intervene. The functions of the thoracic and abdominal organs seem to be normal, and death is generally due to some intercurrent disease, possibly tuberculosis. A condition akin to myxedema occurs after operative removal of the thy- roid gland. In a most interesting lecture Brissaud b shows the intimate relation between myxedema, endemic cretinism, sporadic cretinism, or myxedematous idiocy, and infantilism. He considers that they are all dependent upon an inherited or acquired deficiency or disease of the thyroid gland, and he presents cases illustrating each affection. Figure 285 shows a case of myxedema, one of myxedema in a case of arrested development—a transition case betAveen myx- a 165, May, 1894. b Lecons sur les Mai. Nerv., Paris, 1895, 606. Fig. 284.—Sporadic cretinism. 808 ANOMALOUS TYPES AND INSTANCES OF DISEASE. edema of the adult and sporadic cretinism—and a typical case of sporadic cretinism. Cagots arc an outcast race or clan of dAA'arfs in the region of the Pyr- enees, and formerly in Brittany, Avhose existence has been a scientific problem since the sixteenth century, at Avhich period they Avere known as Cagots, Gahets, Gafets, Agotaes, in France; Agotes or Gafos, in Spain; and (aeons, in Lower Brittany. Cagot meant the dog of a Goth ; they avc re of supposed Gothic origin by some, and of Tartar origin by others. These people Avere formerly supposed to have been the descendants of lepers, or to haA'e been the victims of leprosy themselves. From the descriptions there is a decided Fig. 285.—Cases of myxedema and sporadic cretinism (Brissaud). difference betAveen the Cagots and the cretins. In a recent issue of Cosmos a Avriter describes Cagots as folloAvs :— "They inhabit the valley of the Ribas in the northwestern part of the Spanish province now called Gerona. They never exceed 51| inches in height, and have short, ill-formed legs, great bellies, small eyes, flat noses, and pale, unwholesome complexions. They are usually stupid, often to the verge of idiocy, and much subject to goiter and scrofulous affections. The chief toAvn of the Ribas Valley is Ribas, a place of 1500 inhabitants, about 800 feet above sea-level. The mountains rise about the town to a height of from 6000 to 8000 feet, and command an amazingly beautiful panorama of mountain, plain, and river, AA'ith Spanish cities visible upon the one side and French upon the other. The region is rich, both agri- Case <>f infantile myxedema (AA'est) : the picture in the center represents the ease after six months" thyroid-treatment : the picture on the ri«-lit alter on > year's treatment. PERSISTENT HICCOUGH. 811 culturally and minerally, and is famous for its medicinal springs. In this paradise dwell the dAA'arfs, perhaps as degraded a race of men and AA'omen as may be found in any civilized community. They are almost Avithout educa- tion, and inhabit Avretched huts Avhen they have any shelter. The most intelligent are employed as shepherds, and in summer they live for months at an elevation of more than 6000 feet Avithout shelter. Here they see no human creature save some of their own kind, often idiots, Avho are sent up every fifteen or twenty days with a supply of food. " It is said that formal marriage is almost unknoAvn among them. The Avomen in some instances are employed in the village of Ribas as nurses for children, and as such are found tender and faithful. Before communication throughout the region Avas as easy as it is now, it was thought lucky to have one of these dAA'arfs in a family, and the dAvarfs were hired out and even sold to be used in beggary in neighboring cities. There are somewhat similar dAvarfs in other valleys of the Pyrenees, but the number is decreasing, and those of the Ribas Valley are reduced to a feAV individuals." Hiccough is a symptom due to intermittent, sudden contraction of the diaphragm. Obstinate cases are most peculiar, and sometimes exhaust the physician's skill. Synies divides these cases into four groups :— (1) Inflammatory, seen particularly in inflammatory diseases of the viscera or abdominal membranes, and in severe cases of typhoid fever. (2) Irritative, as in direct stimulus of the diaphragm in swallowing some very hot substance; local disease of the esophagus near the diaphragm, and in many conditions of gastric and intestinal disorder, more particularly those associated Avith flatus. (3) Specific or idiopathic, in Avhich there are no evident causes present; it is sometimes seen in cases of nephritis and diabetes. (4) Neurotic, in Avhich the primary cause is in the nervous system,—hys- teria, epilepsy, shock, or cerebral tumors. The obstinacy of continued hiccough has long been discussed. Osier calls to mind that in Plato's " Symposium" the physician, Eryximachus, rec- ommended to Aristophanes, avIio had hiccough from eating too much, either to hold his breath or to gargle Avith a little Avater; but if it still continued, " tickle your nose Avith something and sneeze, and if you sneeze once or twice even the most A'iolent hiccough is sure to go." The attack must have been a severe one, as it is stated subsequently that the hiccough did not disappear until Aristophanes had excited the sneezing. Among the older medical Avriters AVeber speaks of singultus lasting for five days; Tulpius,842 for twelve days ; Eller and Schenck,a for three months ; Taranget,b for eight months ; and Bartholinus,190 for four years. At the present day it is not uncommon to read in the neAVspapers accounts of prolonged hiccoughing. These cases are not mythical, and are paral- a 718, L. iii., obs. 49. b 462, lxxxvi., 363. 812 ANOMALOUS TYPES AND INSTANCES OF DISEASE. leled by a number of instances in reliable medical literature. The eau-e is not always discernible, and cases sometimes resist all treatment. Holston* reports a case of chronic singultus of seven years' standing. It had followed an attack of Avhooping-cough, and Avas finally cured apparently by the administration of strychnin. CoAvan b speaks of a shoemaker of twen- ty-two AA'ho experienced an attack of constant singultus for a week, and then intermittent attacks for six years. CoAvan also mentions instances of pro- longed hiccough related by Heberden, Good, Hoffman, and Wartmouth. Barrett0 is accredited AA'ith reporting a case of persistent hiccough in a man of thirty-five. RoAvland d speaks of a man of thirty-five avIio hiccoughed for tAAelve years. The paroxysms Ave re almost constant, and occurred once or tAvice a minute during the hours Avhen the man Avas not sleeping. There Avas no noise Avith the cough. There is another case related in the same journal of a man Avho died on the fourth day of an attack of singultus, probably due to abscess of the diaphragm, Avhich no remedy Avould relieA'e. Moore ° records a case of a child, injured Avhen young, avIio hiccoughed until about tAventy years of age (the age at the time of report). Foot f mentions a lad of fifteen avIio, except AA'hen asleep, hiccoughed incessantly for twenty-tAvo Aveeks, and avIio suffered tAvo similar, but less severe, attacks in the summer of 1879, and again in 1XSO. The disease Avas supposed to be due to the habit of pressing the chest against the desk when at school. Dexter g reports a ease of long-continued singultus in an Irish girl of eighteen, ascribed to habitual masturbation. There AAas no intermission in the paroxysm, AA'hich increased in force until general convulsions ensued. The patient said that the paroxysm could be stopped by firm pressure on the upper part of the external genital organs. Dexter applied firm pressure on her clitoris, and the convulsions subsided, and the patient fell asleep. They could be excited by firm pressure on the loAver vertebra?. Corson h speaks of a man of fifty-seven Avho, after exposure to cold, suffered exhausting hiccough for nine days ; and also records the case of an Irish servant AA'ho suffered hic- cough for four months; the cause Avas ascribed to fright. Stevenson1 cites a fatal instance of hiccough in a stone-mason of forty-four avIio suffered continu- ously from May 14th to AI ay 28th. The only remedy that seemed to have any effect in this case AA'as castor-oil in strong purgative doses. Willard•> speaks of a man of thirty-four who began to hiccough after an attack of pneumonia, and continued for eighty-six hours. The treatment con- sisted of the application of belladonna and cantharides plasters, bismuth, and lime-Avater, camphor, and salts of Avhite hellebore inhaled through the nose in finest poAvder. Tavo other cases are mentioned by the same author. Cap- perk describes the case of a young man avIio Avas seized with loud and dis- a West. Lancet, Cincin., 1849. b 476, 1841-42, ii., 398. c 703, xlvii., 377. dlbid. e ibid. t 310, issi. g 218, xxxii., 195. b 594, is.yr. ii., 264. i 476, 1883. i., 1043. J 616, 1871-72, v., 507. t 535, 1*01. vi., 17. ANOMALOUS SNEEZING. 813 tressing hiccough that never ceased for a minute during eighty hours. Tavo ounces of laudanum avc re administered in the three days Avithout any decided effect, producing only slight languor. Ranney a reports the ease of an unmarried Avoman of forty-four AA'ho suf- fered from paroxysms of hiccough that persisted for four years. A peculiar- ity of this attack Avas that it invariably folloAved moA'enients of the upper ex- tremities. Tenderness and hyperesthesia over the spinous processes of the 1th, 5th, and (5th cervical vertebra? led to the application of the thermo- cautery, Avhich, in conjunction AA'ith the administration of ergot and bromids, AA'as attended AA'ith marked benefit, though not by complete cure. BarloAVb mentions a man Avith a rheumatic affection of the shoulder avIio hiccoughed AA'hen he moved his joints. BarloAV also recites a case of hiccough Avhich Avas caused by pressure on the cicatrix of a Avound in the left hand. Beilby c reports a peculiar case in a girl of seventeen avIio suffered an anomalous affection of the respiratory muscle, producing a sound like a cough, but shriller, almost resembling a IioavI. It Avas repeated every five or six seconds during the Avhole of the Avaking moments, and subsided during sleep. Under rest and free purgation the patient recovered, but the paroxysms con- tinued during prolonged intervals, and in the last six years they only lasted from tAventy-four to forty-eight hours. Parker d reports four rebellious cases of singultus successfully treated by dry cups applied to the abdomen. In each case it avus necessary to repeat the operation after tAvo hours, but recovery avus then rapid. Tatevosoff re- ports a brilliant cure in a patient Avith chronic chest trouble, by the use of common snuff, enough being given several times to induce lively sneezing. (IrisAvold e records a successful treatment of one case in a man of fifty, occur- ring after a debauch, by the administration of glonoin, -^ of a grain every three hours. Heidenhainf records a very severe and prolonged case caused, as shoAvn later at the operation and postmortem examination, by carcinoma of the pancreas. The spasms Avere greatly relieved by cocain administered by the mouth, as much as 15 grains being given in tAvelve hours. Laborde and Lepine g report the case of a young girl who Avas relieved of an obstinate case of hiccough lasting four days by traction on her tongue. After the tongue had been held out of the mouth for a feAV minutes the hiccoughs ceased. Laborde referred to tAvo cases of a similar character reported by Viand. Anomalous Sneezing.—In the olden times sneezing Avas considered a good omen, and Avas regarded as a sacred sign by nearly all of the ancient peoples. This feeling of reverence was already ancient in the days of Homer. Aristotle inquired into the nature and origin of the superstition, some- Avhat profanely wondering why sneezing had been deified rather than cough- ing. The Greeks traced the origin of the sacred regard for sneezing to the a 533, 1884, xliv., 695. b 476, 1840-41, i., 295. c 318, 1835. d 632, Oct., 1894. e 45o' Oct, 27. 1*94. f 199, June 11, 1884. 8 Quoted 533, March 28. 1896. 354. 814 ANOMALOUS TYPES AND INSTANCES OF DISEASE. days of Prometheus, aaIio blessed his man of clay Avhen he sneezed. Ac- cording to Seguin the rabbinical account says that only through Jacob's struggle Avith the angel did sneezing cease to be an act fatal to man. Not only in Greece and Rome Avas sneezing revered, but also by races in Asia and Africa, and even by the Mexicans of remote times. Xenophon speaks of the reverence as to sneezing, in the court of the King of Persia. In Mesopota- mia and some of the African towns the populace rejoiced AA'hen the monarch sneezed. In the present day we frequently hear " God bless you " addressed to persons Avho have just sneezed, a perpetuation of a custom quite universal in the time of Gregory the Great, in Avhose time, at a certain season, the air was filled with an unAA'holesome vapor or malaria Avhich so affected the peo- ple that those who sneezed were at once stricken with death-agonies. 1 n this strait the pontiff is said to have devised a form of prayer to be uttered Avhen the paroxysm Avas seen to be coming on, and Avhich, it Avas hoped, would avert the stroke of the death-angel. There are some curious cases of anomalous sneezing on record, some of Avhich are possibly due to affections akin to our present " hay fever," while others are due to causes beyond our comprehension. The Ephemerides records a paroxysm of continual sneezing lasting thirty days. Bonet,216 Lancisi,475 l^abricius Hildanus,334 and other older observers speak of sneezing to death. Morgagni576 mentions death from congestion of the vasa cerebri caused by sneezing. The Ephemerides records an instance of prolonged sneezing which was distinctly hereditary. Ellison a makes an inquiry for treatment of a case of sneezing in a Avhite child of ten. The sneezing started without apparent cause and Avould con- tinue 20 or 30 times, or until the child Avas exhausted, and then stop for a half or one minute, only to relapse again. Beilbyb speaks of a boy of thirteen avIio suffered constant sneezing (from one to six times a minute) for one month. Only during sleep was there any relief. The patient recovered under treatment consisting of active leeching, purgation, and blisters applied behind the ear, together Avith the application of olive oil to the nostrils. Leec reports a remarkable case of yawning followed by sneezing in a girl of fifteen who, just before, had a tooth removed without difficulty. Half an hour afterward yaAvning began and continued for five weeks continuously. There Avas no pain, no illness, and she seemed amused at her condition. There Avas no derangement of the sexual or other organs and no account of an hysteric spasm. Potassium bromid and belladonna were administered for a feAV days Avith negatiA'e results, Avhen the attacks of yaAvning suddenly turned to sneez- ing. One paroxysm followed another Avith scarcely an interval for speech. She AA'as chloroformed once and the sneezing ceased, but Avas more violent on recovery therefrom. Ammonium bromid in half-drachm doses, Avith rest in bed for psychologic reasons, checked the sneezing. Woakesd presented a a Memphis Jour. Med. Sc, 1889, i., 100. b 318, 1835. c 536, 1888, i., 28. d476, 1880, i., 253. HEMOPHILIA. 815 paper on Avhat he designated " ear-sneezing," due to the caking of cerumen in one ear. Irritation of the auricular branch of the vagus Avas produced, Avhence an impression Avas propagated to the lungs through the pulmonary branches of the vagus. Yawning was caused through implication of the third division of the 5 th nerve, sneezing folloAving from reflex implication of the spinal nerves of respiration, the lungs being full of air at the time of yaAvn- ing. Woakes also speaks of " ear-giddiness " and offers a neAV associate symp- tom—superficial congestion of the hands and forearm. A case of anomalous sneezing immediately prior to sexual intercourse is mentioned on page 511. Hemophilia is an hereditary, constitutional fault, characterized by a ten- dency to uncontrollable bleeding, either spontaneous or from slight Avounds. It is sometimes associated with a form of arthritis (Osier). This hemorrhagic diathesis has been knoAvn for many years; and the fact that there were some persons Avho showed a peculiar tendency to bleed after wounds of a trifling nature is recorded in some of the earliest medical literature. Only recently, however, through the Avritings of Buel, Otto, Hay, Coates, and others, has the hereditary nature of the malady and its curious mode of transmission through the female line been knoAvn. As a rule the mother of a hemophile is not a "bleeder" herself, but is the daughter of one. The daughters of a hemo- phile, though healthy and free from any tendency themselves, are almost cer- tain to transmit the disposition to the male offspring. The condition gener- ally appears after some slight injury in the first tAvo years of life; but must be distinguished from the hemorrhagic affections of the neAV-born, Avhich Avill be discussed later. The social condition of the family does not alter the pre- disposition ; the old Duke of Albany AA'as a "bleeder" ;a and bleeder fami- lies are numerous, healthy looking, and haA'e fine, soft skins. The duration of this tendency, and its perpetuation in a family, is remark- able. The Appleton-SAvain family of Reading, Mass., has shoAvn examples for tAvo centuries. Osier has been advised of instances already occurring in the seventh generation. Kolsterb has investigated hemophilia in women, and reports a case of bleeding in the daughter of a hemophilic Avoman. He also analyzes 50 genealogic trees of hemophilic families, and remarks that Xasse's laAV of transmission does not hold true. In 14 cases the transmission Avas direct from the father to the child, and in 11 cases it Avas direct from the mother to the infant. The hemorrhagic symptoms of bleeders may be divided into external bleedings, either spontaneous or traumatic ; interstitial bleedings, petechise, and ecchymoscs ; and the joint-affections. The external bleedings are seldom spon- taneous, and generally folloAV cuts, bruises, scratches, and often result seriously. A minor operation on a hemophile may end in death; so slight an operation as draAving a tooth has been folloAved by the most disastrous consequences. a 476, 1852, i., 360. b Fiuska Liikar. Handlingar, March, 1895. 816 ANOMALOUS TYPES AND INSTANCES OF DISEASE. Armstrong,* Blagden,b and Roberts,0 have seen fatal hemorrhage after the extraction of teeth. MacCormac observed five bleeders at St. Thomas Hos- pital, London, and remarks that one of these persons bled tAvelve days after a tooth-extraction. Buchanan and Clay cite similar instances. Cousinsd mentions an individual of hemorrhagic diathesis avIio succumbed to extensive extravasation of blood at the base of the brain, folioAving a slight fall during an epileptic convulsion. Dunlape reports a case of hemorrhagic diathesis, folloAving suppression of the eatamenia, attended by vicarious hemorrhage from the gums, Avhich terminated fatally. Erichsen f cites an instance of extravasation of blood into the calf of the leg of an individual of hemophilic tendencies. A cavity Avas opened, AA'hich extended from above the knee to the heel; the clots Avere removed, and cautery applied to check the bleeding. There Avas extension of the blood-cavity to the thigh, Avith edema and incipient gangrene, necessitating amputation of the thigh, Avith a fatal termination. Mackenzieg reports an instance of hemophilic purpura of the retina, folloAved by death. Harkin gives an account of vicarious bleeding from the under lip in a Avoman of thirty-eight. The hemorrhage occurred at every meal and lasted ten minutes. There is no evidence that the Avoman Avas of hemophilic descent. Of ;>-*>4 cases of bleeding in hemophilia collected by Grand id ier, 169 Avere from the nose, 43 from the mouth, 15 from the stomach, 86 from the boAvels, 16 from the urethra, 17 from the lungs, and a feAV from the skin of the head, eyelids, scrotum, navel, tongue, finger-tips, auIa'u, and external ear. Osier remarks that Professor Agnew knew of a ease of a bleeder Avho had ah\'ays bled from cuts and bruises above the neck, never from those beloAv. The joint-affections closely resemble acute rheumatism. Bleeders do not nec- essarily die of their early bleedings, some living to old age. OliA'er Appleton, the first reported American bleeder, died at an advanced age, OAving to hem- orrhage from a bed-sore and from the urethra. Fortunately the functions of menstruation and parturition are not seriously interfered Avith in hemophilia. Menstruation is neA'er so excessive as to be fatal. Grandidier states that of 152 boy subjects 81 died before the termination of the seventh year. Hemo- philia is rarely fatal in the first year. Of the hemorrhagic diseases of the new-born three are worthy of note. In syphilis haemorrhagica neonatorum the child may be born healthy, or just after birth there may appear extensive cutaneous extravasations Avith bleeding from the mucous surfaces and from the naA'el ; the child may become deeply jaundiced. Postmortem examination shoAvs extensive extravasations into the internal viscera, and also organic syphilitic lesions. Winckel's disease, or epidemic hemoglobinuria, is a A'ery fatal affection, a Trans. Belfast Clin, and Path. Soc, 1854. b 550. 1820. c 476, 1841-42, i., 752. d 548, 1869, ii., 277. e 594, 1850, iv., 314. f 476, 1856, i., 511. g 548, 1877, i., 25*. TETANUS NEONATORUM. 817 sometimes epidemic in lying-in institutions ; it develops about the fourth day after birth. The principal symptom is hematogenous icterus Avith cyanosis,— the urine contains blood and blood-coloring matter. Some cases have .shoAvn in a marked degree acute fatty degeneration of the internal organs —Buhl's disease. Apart from the common visceral hemorrhages, the results of injuries at birth, bleeding from one or more of the surfaces is a not uncommon event in the neAV-born, particularly in hospital-practice. According to Osier ToAvn- scnd reports 45 cases in 6700 deliveries, the hemorrhage being both general and from the navel alone. Bleeding also occurs from the bowels, stomach, and mouth, generally beginning in the first week, but in rare instances it is delayed to the second or third. Out of 50 cases collected by ToAvnsend 31 died and 19 recoA'ered. The nature of the disease is unknown, and post- mortem examination reveals no pathologic changes, although the general and not local nature of the affection, its self-limited character, the presence of fever, and the greater prevalence of the disease in hospitals, suggest an infec- tious origin (ToAvnsend). Kenta speaks of a neAV-born infant dying of spontaneous hemorrhage from about the hips. Infantile scurvy, or Barlow's disease, has lately attracted marked attention, and is interesting for the numerous extravasations and spontaneous hemorrhages which are associated Avith it. A most interesting collection of specimens taken from the victims of Barlow's disease were shown in London in 1895.619 In an article on the successful preventive treatment of tetanus neo- natorum, or the "scourge of St. Kilda," of the ncAv-born, Turnerb says the first mention of trismus nascentium or tetanus neonatorum avus made by Rev. Kenneth Macaulay in 1764, after a visit to the island of St. Kilda in 1758. This gentleman states that the infants of this island give up nursing on the fourth or fifth day after birth ; on the seventh day their gums are so clinched together that it is impossible to get anything doAvn their throats ; soon after this they are seized with convulsive fits and die on the eighth day. So gen- eral was this trouble on the island of St. Kilda that the mothers never thought of making any preparation for the coming baby, and it was wrapped in a dirty piece of blanket till the ninth or tenth day, Avhen, if the child survived, the affection of the mother asserted itself. This lax method of caring for the infant, the neglect to dress the cord, and the unsanitary condition of the dwel- lings, make it extremely probable that the infection was through the umbili- cal cord. All cases in which treatment was properly carried out by compe- tent nurses have survived. This treatment consisted in dressing the cord with iodoform powder and antiseptic avooI, the breast-feeding of the baby from the first, and the administration of one-grain doses of potassium bromid at short intervals. The infant death-rate on the island of St. Kilda has, conse- a 476, 1868, ii., 487. b 381, March, 1895. 52 818 ANOMALOUS TYPES AND INSTANCES OF DISEASE. quently, been much reduced. The author suggests the use of a new iodin- preparation called loretin fot dressing the cord. The poAvder is free from odor and is nonpoisonous. Human Parasites.—Worms in the human body are of interest on account of the immense length some species attain, the anomalous symptoms AA'hich they cause, or because of their anomalous location and issue. According to modern Avriters the famous Viennese collection of helminths contains chains of taenia saginata 24 feet long. The older reports, according to Avhich the taenia solium (/. e., generally the taenia saginata) grew to such lengths as 10, 50, 60, and even as much as 800 yards, are generally regarded as erroneous. The observers have apparently taken the total of all the fragments of the worm or worms evacuated at any time and added them, thus obtaining results so colossal that it Avould be impossible for such an immense mass to be con- tained in any human intestine. The name solium has no relation to the Latin solus, or solium. It is quite possible for a number of tapeworms to exist simultaneously in the human body. Palma mentions the fact of four tapeAvorms existing in one person; and Mongealbhas made observations of a number of cases in AA'hich several teniae existed simultaneously in the stomach. Davidc speaks of the expulsion of five teniae by the ingestion of a quantity of sweet wine. Cobbold d reports the case of four simultaneous tapeworms ; and Aguiel e describes the case of a man of tAventy-four Avho expelled a mass weighing a kilogram, 34.5 meters long, consisting of several different Avorms. Garfinkel812 mentions a case which has been extensively quoted/ of a peasant Avho voided 238 feet of tape- worms, 12 heads being found. Laveran g reports a case in AA'hich 23 teniae were expelled in the same day. Greenhow h mentions the occurrence of tAvo taeniae mediocanellata. The size of a tapeAvorm in a small child is sometimes quite sur- prising. Even the new-born have exhibited signs of teniae, and Hauss- mann* has discussed this subject. Armorj speaks of a fully-matured tapeAvorm being expelled from a child five days old. Kennedy k reports cases in Avhich tapeAvorms have been expelled from infants fiAre, and five and one- half months old. Heisberg1 gives an account of a tapeAvorm eight feet in length Avhich came from a child of two. Tvviggs m describes a case in AA'hich a tapeAvorm 36 feet long was expelled from a child of four ; and Fabre n men- tions the expulsion of eight teniae from a child. Occasionally the tapeAvorm is expelled from the mouth. Such cases are mentioned by Hitch ° and Mar- tel.p White q speaks of a tapeworm Avhich Avas discharged from the stomach a 476, 1885, ii., 991. b i62, 1840, 310. c 368, 1843, xi., 41. d 476, 1885, ii., 566. e 728, 1883. f 476, 1885, ii., 1221. g Arch, de nied. et pharm. mil., Paris, 1885, v., 173. b 476, 1863, ii., 699. i 224, 1872, ii., 466. j 597, 1871, xiv., 518. k " Proceedings of the Pathological Society of Dublin," 1885-87. 1 538, Nov. 24, 1878. m 744, 1847, iii., 413. n 368, 1887. v., 447. o 224, 1882, ii., 789. P 363, 1886, 101. q 149, 1798. ii., 292. HUMAN PARASITES. 819 after the use of an emetic. Lile a mentions the removal of a tapeworm Avhich had been in the bowel twenty-four years. The peculiar effects of a tapeAvorm are exaggerated appetite and thirst, nausea, headaches, vertigo, ocular symptoms, cardiac palpitation, and Mur- sinna b has even observed a case of trismus, or lockjaw, due to taenia solium. Fereolc speaks of a case of vertigo, accompanied Avith epileptic convulsions, Avhich was caused by teniae. On the administration of kousso three heads were expelled simultaneously. There is a record of an instance of cardiac pulsation rising to 240 per minute, Avhich ceased upon the expulsion of a large tapeworm.4 It is quite possible for the presence of a tapeworm to indirectly produce death. Garroway e describes a case in AA'hich death Avas apparently imminent from the presence of a tapeworm. Kiself has recorded a fatal case of anemia, in a child of six, dependent on teniae. The number of ascarides or round-worms in one subject is sometimes enormous. Victor s speaks of 129 round-worms being discharged from a child in the short space of five days. Pole h mentions the expulsion of 441 lumbricoid Avorms in thirty-four days, and Fauconneau-Dufresne} has re- ported a most remarkable case in which 5000 ascarides were discharged in less than three years, mostly by vomiting. The patient made an ultimate recovery. There are many instances in which the lumbricoid worms have pierced the intestinal tract and made their way to other viscera, sometimes leading to an anomalous exit. There are several cases on record in Avhich the lumbricoid worms have been found in the bladder. Par6 speaks of a case of this kind during a long illness ; and there is mention J of a man who voided a Avorm half a yard long from his bladder after suppression of urine. The Ephe- merides contains a curious case in which a stone was formed in the bladder, having for its nucleus a Avorm. Fontanelle presented to the Royal Academy of Medicine of Paris several yards of tapeworm passed from the urethra of a man of fifty-three. The following is a quotation from the British Medical Journal :k "I have at present a patient passing in his urine a Avorm-like body, not unlike a tapeworm as far as the segments and general appearance are con- cerned, the length of each segment being about % inch, the breadth rather less; sometimes 1J segments are joined together. The AA'orm is serrated on the one side, each segment having lj cusps. The urine pale, faintly acid at first, within the last week became almost neutral. There Avas considerable vesical irritation for the first Aveek, AA'ith abundant mucus in the urine; spe- cific gravity was 1010 ; there were no albumin nor tube-casts nor uric acid a 545, 1890, 42. b Lond. Med. Rev. and Mag., 1799-1800, ii., 290. c 237, 1876, 172. d 224, June, 1867. e 224, 1868, ii., 221. f Trudi. obsch. dietsk vrach, St. Petersburg, 1869, ii., 67. 8 435, 1885, 319. b Med. Chron., Bait., 1882-83, i., 184. >' 789, 1880, 186. j 629, 1700, 135. k 224, 1895, ii., 512. 820 ANOMALOUS TYPES AND INSTANCES OF DISEASE. in the urinary sediments. Later there avc re pus-cells and abundant pus. Tenderness existed behind the prostate and along the course of left ureter. Temperature of patient oscillated from 97.5° to 103.2° F. There Avas no history at any time of recto-vesical fistula. Can anyone suggest the name, etc., of this helminth ? " Other cases of worms in the bladder are mentioned in Chapter XIII. Mitra a speaks of the passage of round-Avorms through the umbilicus of an adult ; and there is a case mentionedb in Avhich round-Avorms about seven inches long were voided from the navel of a young child. Borgeois c speaks of a lumbricoid worm found in the biliary passages, and another in the air passages. Turnbulld has recorded tAvo cases of perforation of the tympanic mem- brane from lumbricoides. Dagan e speaks of the issue of a lumbricoid from the external auditory meatus. Laughtonf reports an instance of lumbricoid in the nose. Rake? speaks of asphyxia from a round-Avorm. Morland'1 men- tions the ejection of numerous lumbricoid Avorms from the mouth. Worms have been found in the heart; and it is quite possible that in cases of trichinosis, specimens of the trichinae may be discovered anvAvhcre in the line of cardiac or lymphatic circulation. Quoted by Fournier,302 La- peyronnie has seen Avorms in the pericardial sac, and also in the ventricle. There is an old record of a person dying of intestinal Avorms, one of Avhich was found in the left A'entricle.1 A Castro and Vidal speak of Avorms in the aorta. RakeJ reports a case of sudden death from round-worm; and BroAvnk has noted a similar instance. The echinococcus is a tiny cestode Avhich is the factor in the production of the Avell-knoAvn hydatid cysts Avhich may be found in any part of the body. Delafield and Prudden report the only instance of multilocular echinococcus seen in this country. Their patient was a German avIio had been in this coun- try five years. There are only about 100 of these cases on record, most of them being in Bavaria and S\vitzerland. The filaria sanguinis hominis is a small yvorm of the nematode species, the adult form of which lives in the lymphatics, and either the adult or the prematurely discharged ova (Manson) block the lymph-channels, producing the conditions of hematochyluria, elephantiasis, and lymph-scrotum. The Dra- cun cuius medinensis or Guinea-worm is a Avidely-spread parasite in parts of Africa and the West Indies. According to Osier several cases have occurred in the United States. Jarvis reports a case in a post-chaplain avIio had liA'ed at Fortress Monroe, Va., for thirty years. Van Harlingen's patient, a man of forty-seven, had never lived out of Philadelphia, so that the AA'orm must be included among the parasites infesting this country. a 436, 1891, ii., 381. b Lond. Med. Jour., 1786, vii., 372. c 789, 1856, x., 279. d 545,1881, 32. e Jour, de med. et chir. prat., Paris, 1883, 258. f 547, 1870-71, i., 181. g 224, 1887, i., 1274. h 218, 1867, 409. i 469, 1772. j 703, 1890, 26. k 776, 1824. i., 663. "EATEN OF WORMS." 821 In February, 1896, Henry of Philadelphia showed microscopic slides containing blood which Avas infested with numbers of living and active filaria embryos. The blood Avas taken from a colored woman at the Woman's Hospital, Avho developed hematochyluria after labor. Henrv believed that the Avoman had contracted the disease during her residence in the Southern States. Curran a gives quite an exhaustive article on the disease called in olden times "eaten of worms,"—a most loathsome malady. Herod the Great, the Emperor Galerius, and Philip II. of Spain perished from it. In speak- ing of the Emperor Galerius, Dean Milman, in his "History of Latin Chris- tianity," b says, " a deep and fetid ulcer preyed on the loAver parts of his body and ate them away into a mass of living corruption." Gibbon, in his "De- cline and Fall," c also says that " his (Galerius's) death avus caused by a very painful and lingering disorder. His body, swelled by an intemperate course of life to an unwieldy corpulence, Avas covered Avith ulcers and devoured by im- mense SAvarms of those insects avIio have given their names to this most loathsome disease." It is also said that the African Vandal King, the Arian Huneric, died of the disease. Antiochus, surnamed the " Madman," d Avas also afflicted AA'ith it; and Josephus makes mention of it as afflicting the body of Herod the Great. The so-called " King Pym " died of this " morbus pedicularis," but as prejudice and passion militated against him during his life and after his death, this fact is probably more rumor than verity. A case is spoken of bv Curran, Avhich Avas seen by an army-surgeon in a very aged Avoman in the remote parts of Ireland, and another in a female in a dissecting-room in Dublin. The tissues avc re permeated Avith lice Avhich emerged through rents and fissures in the body. Instances of the larvae of the estrus or the bot-fly in the skin are not uncommon. In this country Allene removed such larA'ae from the skin of the neck, head, and arm of a boy of tAvelve. Bethune, Delavigne, Howship, Jacobs, Jannuzzi, and others, report similar cases. These flesh-flies are called crcophilae, and the condition they produce is called myiosis. Accord- ing to Osier, in parts of Central America, the eggs of a bot-fly, called the dermatobia, are not infrequently deposited in the skin, and produce a savcII- ing A'erv like the ordinary boil. Matas has described a case in Avhich the estrus larA'ae Avere found in the gluteal region. Finlayson of GlasgoAv has recently reported an interesting case in a physician avIio, after protracted con- stipation and pain in the back and sides, passed large numbers of the larA'ae of the floAver-fly, anthomyia canicularis, and there are other instances of mviosis interna from sAA'alloAving the larA'ae of the common house-fly. There are forms of nasal disorder caused by larvae, Avhich some motive surgeons in India regard as a chronic and malignant ulceration of the mucous a 536, 1SS6. ii., 142. >> Vol. i.. 227. c Vol. ii., 122. d Maccabes. ch. ix., verses 1, 5, 9, and 10. e 218, lxxxvii., 306. 822 ANOMALOUS TYPES AND INS TAN ( ES OF DISEASE. membranes of the nose and adjacent sinuses in the debilitated and the scrofu- lous. Worms lodging in the cribriform plate of the ethmoid feed on the soft tissues of that region. Eventually their ravages destroy the olfactory nerves, with subsequent loss of the sense of smell, and they finally eat away the bridge of the nose. The head of the victim droops, and he complains of crawling of AA'orms in the interior of the nose. The eyelids swell so that the patient cannot see, and a deformity arises Avhich exceeds that produced by syphilis. Lyonsa says that it is one of the most loathsome diseases that comes under the observation of medical men. He describes the disease as " essentially a scrofulous inflammation of the Schneiderian membrane, . . . Avhich finally attacks the bones." Flies deposit their ova in the nasal discharges, and from their infection maggots eventually arise. In Sanskrit peenash sig- nifies disease of the nose, and is the Indian term for the disease caused by the deposition of larvae in the nose. It is supposed, to be more common in South America than in India. a Indian Annals of Medicine, Oct., 1885. CHAPTER XVI. ANOMALOUS SKIN-DISEASES. Ichthyosis is a disease of the skin characterized by a morbid develop- ment of the papillae and thickening of the epidermic lamellae ; according as the skin is affected over a larger or smaller area, or only the epithelial lining of the follicles, it is known as ichthyosis diffusa, or ichthyosis follicularis. The hardened masses of epithelium develop in excess, the epidermal layer loses in integrity, and the surface becomes scaled like that of a fish. Ichthyosis may be congenital, and over sixty years ago Stcinhausena described a fetal monster in the anatomic collection in Berlin, the whole surface of whose body Avas covered Avith a thick layer of epidermis, the skin being so thick as to form a covering like a coat-of-mail. According to Rayer the celebrated " porcupine-man " avIio exhibited himself in England in 1710 Avas an example of a rare form of ichthyosis. This man's body, except the face, the palms of the hands, and the soles of the feet, Avas covered Avith small excrescences in the form of prickles. These appendages Avere of a reddish-broAvn color, and so hard and elastic that they rustled and made a noise Avhen the hand Avas passed over their surfaces. They appeared tAvo months after birth and fell off'every Avinter, to reappear each summer. In other respects the man Avas in A'ery good health. He had six children, all of Avhom Avere covered Avith excrescences like himself. The hands of one of these children has been represented by Edwards in his " Gleanings of Natural History." A picture of the hand of the father is sIioavii in the fifty-ninth A'olume of the Philosophical Transactions. PettigreAVb mentions a man Avith Avarty elongations encasing his whole body. At the parts where friction occurred the points of the elongations Avere Avorn off. This man Avas called " the biped armadillo." His great grand- father AA'as found by a Avhaler in a Avild state in Davis's Straits, and for four gene- rations the male members of the family had been so encased. The females had normal skins. All the members of the Avell-knoAvn family of Lambert had the body covered AA'ith spines. Tavo members, brothers, aged tAventy-tAvo and four- teen, Avere examined by Geoffroy-Saint-Hilaire. This thickening of the epi- dermis and hair Avas the effect of some morbid predisposition Avhich Avas transmitted from father to son, the daughters not being affected. Five gene- rations could be reckoned Avhich had been affected in the manner described. a 368, 1831. T. ii., 10. b 476, 1832, ii., 146. 823 824 A NOMAL OIW SKIN-DISEA SEs. The "porcupine-man" seen by Baker contracted small-pox, and his skin AA-as temporarily freed from the squamae, but these reappeared shortly after- Avard. There are several older records of prickly men or porcupine-men. Ascaniusa mentions a porcupine-man, as do Buffon and Schrcber. Auten- reith speaks of a porcupine-man avIio avus covered Avith innumerable ver- rucae. Martinb described a remarkable variety of ichthyosis in Avhich the Fig. 286.—An alligator-boy. skin was covered Avith strong hairs like the bristles of a boar. When numer- ous and thick the scales sometimes assumed a greenish-black hue. An example of this condition Avas the individual who exhibited under the name of the " alligator-boy." Figure 286 represents an " alligator-boy " exhibited by C. T. Taylor. The skin affected in this case resembled in color and consistency that of a young alligator. It was remarked that his olfactory sense Avas intact. a 462, T. iv., 216. b 550, ix., part i., 53. "HARLEQUIN FETUS." 825 The harlequin fetus, of which there are specimens in Guy's Hospital, London Hospital, and the Royal College of Surgeons Museum, is the result of ichthyosis congenita. According to Crocker either after the removal of the vernix caseosa, Avhich may be thick, or as the skin dries it is noticeably red, smooth, shiny, and in the more severe cases covered with actual plates. In the harlequin fetus the Avhole surface of the body is thickly covered Avith fatty epidermic plates, about -A^ inch in thickness, Avhich are broken up by horizontal and vertical fissures, and arranged transversely to the sur- face of the body like a loosely-built stone Avail. After birth these fissures may extend doAvn into the corium, and on movement produce much pain. The skin is so stiff and contracted that the eyes cannot be completely opened or shut, the lips are too stiff to permit of sucking, and are often inverted ; the nose and ears are atrophied, the toes are contracted and cramped, and, if not born dead, the child soon dies from starvation and loss of heat. When the dis- ease is less severe the child may survive some time. Crocker had a patient, a male child one month old, avIio survived three months. Hallopeau and Elliot also report similar cases. Contagious follicular keratosis is an extremely rare affection in Avhich there are peculiar, spine-like outgroAvths, consisting in exudations of the mouths of the sebaceous glands. Leloir and Vidal shorten the name to acne cornee. Erasmus AVilson speaks of it as ichthyosis sebacea cornea. H. G. Brooke describes a ease in a girl of six. The first sign had been an eruption of little black spots on the nape of the neck. These spots gradually developed into papules, and the Avhole skin took on a dirty yellow color. Soon after- Avard the same appearances occurred on both shoulders, and, in the same order, spread gradually doAvn the outer sides of the arms—first black specks, then papules, and lastly pigmentation. The black specks soon began to pro- ject, and comedo-like plugs and small, spine-like groAvths Avere produced. Both the spines and plugs Avere very hard and firmly-rooted. They resisted firm pressure with the forceps, and Avhen placed on sheets of paper rattled like scraps of metal. X direct history of contagion Avas traced from this case to others. Mibellia describes an uncommon form of keratodermia (porokeratosis). The patient Avas a man of twenty-one, and exhibited the folloAving changes in his skin : On the left side of the neck, beyond a feAV centimeters beloAv the lobe of the ear, there Avere about ten small Avarty patches, irregularly scat- tered, velloAvish-broAvn in color, irregular in outline, and varying in size from a lentil to a half-franc piece, or rather more. Similar patches avc re seen on other portions of the face. Patches of varying size and form, sharply limited bv a kind of small, peripheral "dike," sinuous but uninterrupted, of a color varying from red to Avhitish-red, dirty white, and to a hue but little different a "International Atlas of Rare Skin-Diseases." 826 ANOMALOUS SKIN-DISEASES. from that of the healthy skin. Similar patches were seen on the right hand, and again on the back of the right hand was a wide space, prolonged upward in the form of a broad band on the posterior surface of the forearm to just below the olecranon, where the skin Avas a little smoother and thinner than the surrounding skin, and altogether bare of hairs. The disease was noticed at the age of tAvo, and gradually progressed. The patient ahvays enjoyed the most perfect health, but had contracted syphilis three years before. A brother of the patient, aged twenty-four, for sixteen years has had the same skin- affection as this patient, on the back of the hand, and the sister and father had noticed similar lesions. Diffuse symmetric scleroderma, or hide-bound disease, is quite rare, and presents itself in two phases : that of infiltration (more properly called hypertrophy) and atrophy, caused by shrinkage. The whole body may be involved, and each joint may be fixed as the skin OA'er it becomes rigid. The muscles may be implicated independently of the skin, or simultaneously, and they give the resemblance of rigor mortis. The Avhole skin is so hard as to suggest the idea of a frozen corpse, Avithout the coldness, the temperature being only slightly subnormal. The skin can neither be pitted nor pinched. As Crocker has Avell put it, Avhen the face is affected it is gorgonized, so to speak, both to the eye and to the touch. The mouth cannot be opened ; the lids usually escape, but if involved they are half closed, and in either case immovable. The effect of the disease on the chest-Avails is to seriously inter- fere Avith the respiration and to flatten and almost obliterate the breasts ; as to the limbs, from the shortening of the distended skin the joints are fixed in a more or less rigid position. The mucous membranes may be affected, and the secretion of both sAveat and sebum is diminished in proportion to the degree of the affection, and may be quite absent. The atrophic type of scleroderma is preceded by an edema, and from pressure-atrophy of the fat and muscles the skin of the face is strained over the bones; the lips are shortened, the gums shrink from the teeth and lead to caries, and the nostrils are compressed. The strained skin and the emotionless features (relieved only by telangiectatic striae) give the countenance a ghastly, corpse-like aspect. The etiology and pathology of this disease are quite obscure. Hap- pily the prognosis is good, as there is a tendency to spontaneous recovery, although the convalescence may be extended. Although regarded by many as a disease distinct from scleroderma, mor- phea is best described as a circumscribed scleroderma, and presents itself in tAvo clinical aspects : patches and bands, the patches being the more common. Scleroderma neonatorum is an induration of the skin, congenital and occurring soon after birth, and is invariably fatal. A disease somewhat analogous is edema neonatorum, AA'hich is a subcutaneous edema Avith indura- tion affecting the neAV-born. If complete it is invariably fatal, but in a feAV cases in which the process has been incomplete recovery has occurred. THE "ELEPHANT-MAN 827 Gerard a reports recovery from a case of sclerema neonatorum in an infant five Aveeks old, which seemed in perfect health but for this skin-affection. The back presented a remarkable induration AA'hich involved the entire dorsal aspect, including the deltoid regions, the upper arms, the buttocks, and the thighs, doAvn to and involving the popliteal spaces. The edges of the indu- rated skin Avere sharply defined, irregular, and map-like. The affected skin was stretched, but not shiny, and exhibited a pink mottling; it could not be pinched betAveen the fingers ; pressure produced no pitting, but rendered the surface pale for a time. The induration upon the buttocks had been noticed immediately after birth, and the region was at first of a deep pink color. During the first nine days the trouble had extended to the thighs, but only shortly before the examination had it attacked the arms. Inunctions of cod- liver oil Avere at first used, but with little improvement. Blue ointment Avas substituted, and improvement commenced. As the induration cleared up, outlying patches of the affected skin were left surrounded by normal integu- ment. No pitting could be produced even after the tension of the skin had decreased during recovery. The lowest rectal temperature Avas 98° F. In a little more than four months the skin became normal. The treatment Avith mercurial ointment avus stopped some time before recovery. Possibly the most interesting of the examples of skin-anomaly was the " elephant-man " of London (Figs. 287 and 288). His real name Avas Merrick. He Avas born at Leicester, and gave an elaborate account of shock experienced by his mother shortly before his birth, when she Avas knocked doAvn by an elephant at a circus ; to this circumstance he attributed his un- fortunate condition. He derived his name from a proboscis-like projection of his nose and lips, together Avith a peculiar deformity of the forehead. He AA'as victimized by shoAvmen during his early life, and for a time Avas shown in Whiteehapel Road, AA'here his exhibition Avas stopped by the police. He Avas afterAvard shoAvn in Belgium, and Avas there plundered of all his savings. The gruesome spectacle he presented ostracized him from the pleasures of friendship and society, and sometimes interfered with his travels. On one occasion a steamboat captain refused to take him as a passenger. Treves ex- hibited him tAvice before the Pathological Society of London.b His affection Avas not elephantiasis, but a complication of congenital hypertrophy of certain bones and pachydermatocele and papilloma of the skin. From his youth he suffered from a disease of the left hip-joint. The papillary masses devel- oped on the skin of the back, buttock, and occiput. In the right pectoral and posterior aspect of the right axillary region, and over the buttocks, the affected skin hung in heavy pendulous flaps. His left arm Avas free from disease. His head grew so heavy that at length he had great difficulty in holding it up. He slept in a sitting or crouching position, Avith his hands clasped over his legs, and his head on his knees. If he lay down flat, the a 476, May 4, 1895. b 224, 1890, i., 916. 828 ANOMALOUS SKIN-DISEASES. heavy head showed a tendency to fall back and produce a sense of suffocation. For a long time he AA'as an inmate of the London Hospital, Avhere special quarters Avere provided for him, and it Avas there that he Avas found dead, Fig. 288.—The "Elephant-man" (Treves). April 11, 1890 ; while in bed his ponderous head had fallen backAvard and dislocated his neck. Ainhum may be defined as a pathologic process, the ultimate result of Avhich is a spontaneous amputation of the little toe. It is confined almost 36 AINHUM. 829 exclusively to negroes, chiefly males, and of African descent. In Brazil it is called "ainham" or "quigila." "Ainham " literally means to saAv, and is doubtless a colloquial name derived from a supposed sIoav, sawing process. The Hindoo name for it is " sukha pakla," meaning dry suppuration. In 1866 da Silva Lima of Bahia, at the Misericordia Hospital, gave the first reports of this curious disease, and. for quite a period it Avas supposed to be confined to Brazilian territory. Since then, hoAvever, it has been reported from nearly every quarter of the globe. Relative to its geographic distribu- tion, Pylea states that da Silva Lima and Seixas of Bahia ha\Te reported numerous cases in Brazil, as have Figueredo, Pereira, Pirovano, Alpin, and Guimares. Toppin reports it in Pernambuco. Mr. Milton reports a case from Cairo, and Dr. CresAvell at Suez, both in slaves. E. A. G. Doyle reports several cases at the Fernando Hospital, Trinidad. Digby reports its prev- alence on the Avest coast of Africa, particularly among a race of negroes called Krumens. Messum reports it in the South African Republic, and speaks of its prevalence among the Kaffirs. Evles reports it on the Gold Coast. It has also been seen in Algiers and Madagascar. Through the able efforts of Her Majesty's surgeons in India the presence of ainhum has been shoAvn in India, and considerable investigation made as to its etiology, path- ologic histology, etc. Wise at Dacca, Smyth and Crombie at Calcutta, Hen- derson at Bombay, and Warden, Sen, Cnnvford, and Cooper in other portions of Southern India have all rendered assistance in the investigation of ainhum. In China a case has been seen, and British surgeons speak of it as occurring in Ceylon. Von Winckler presents an admirable report of 20 cases at GeorgetoAvn, British Guiana. Dr. Potoppidan sends a report of a case in a negress on St. Thomas Island. The disease has several times been observed in Polynesia. Dr. Hornaday reports a case in a negress from Xorth Carolina, and, curious to relate, Honvitz of Philadelphia and Shepherd of Canada found cases in negroes both of North Carolina antecedents. Dr. James Evans reports a case in a negro seventy-four years of age, at Darlington, S. C. Dr. R. H. Days of Baton Rouge, La., had a case in a negress, and Dr. J. L. Deslates, also of Louisiana, reports four cases in St. James Parish. Pyle has seen a case in a negress aged fifty years, at the Emergency Hospital in Washington. So prevalent is the disease in India that Crawford found a case in every 2500 surgical cases at the Indian hospitals. The absence of pain or incon- venience in many instances doubtless keeps the number of cases reported feAV, and again Ave must take into consideration the fact that the class of persons afflicted Avith ainhum are seldom brought in contact Avith medical men. The disease usually affects the oth phalanx at the interphalangeal joint. Cases of the 4th and other phalanges have been reported. Cooper speaks of a 533, Jan. 26, 1895. 830 ANOMALOUS SKIN-DISEASES. a young Brahman avIio lost his left great toe by this process. ( Yonibie speaks of a simultaneous amputation of both fourth toes. Potoppidan reports a simi- lar case in a negress on St. Thomas Island. Sen reports a case in a super- numerary digit in a child, Avhose father, a Hindoo, lost a toe by ainhum. Eyles reports a case in a negro in whom the second finger avus affected. Mirault, at Anglers, speaks of a casein Avhich two fingers Avere lost in fifteen days, a fact Avhich makes his diagnosis dubious. Beranger-Ferraud has seen all the toes amputated, and there is a wax model by Baretta, Paris, in the Army Medical Museum at Washington, in Avhich all the toes of the right foot have been amputated, and the process is fast making progress at the middle third of the leg. Ainhum is much more common in males than in females ; it is, in fact, distinctly rare in the latter. Of von Winckler's 20 cases all were males. Fig. 289. Ainhum (dorsal surface). Plantar surface (Ohmann-Dumesnil). It may occur at any age, but is most common between thirty and thirty-five. It has been reported in utero by Guyot, and was seen to extend up to the thigh, a statement that is most likely fallacious. However, there are well- authenticated cases in infants, and again in persons over seventy years of age. In some feAV cases the metatarsophalangeal joint is affected ; but no case has been seen at the base of the ungual phalanx. The duration of the dis- ease is betAveen two and four years, but Dr. Evans's case had been in pro- gress fifty years. It rarely runs its full course before a year. Ainhum begins as a small furrow or crack, such as soldiers often experi- ence, at the digito-plantar fold, seen first on the inner side. This process of furrowing never advances in soldiers, and has been given a name more ex- pressive than elegant. In ainhum the toe will swell in a feAV days, and a pain, burning or shooting in nature, may be experienced in the foot and leg affected. Pain, however, is not constant. There may be an erythematous AINHUM. 831 eruption accompanying the swelling. The furrow increases laterally and in depth, and meets on the dorsal aspect of the toe, giving the toe the appearance of being constricted by a piece of fine cord. As the furrow deepens the dis- tal end of the toe becomes ovoid, and soon an appearance as of a marble at- tached to the toe by a fibrous pedicle presents itself. By this time the SAvell- ing, if any, has subsided. The distal end of the toe bends under the foot, and becomes twisted when walking, and causes inconvenience, and, unfortu- nately, says Eyles, it is in this last stage only that the Fanti presents himself. There is in the majority of cases a small ulcer in or near the digito-plantar fold, Avhich causes most of the pain, particularly when pressed upon. This ulcer does not occur early, and is not constant. The case under Pyle's observa- tion shoAved no ulceration, and Avas absolutely painless, the negress applying for diagnosis rather than treatment. The furroAV deepens until spontaneous am- putation takes place, which rarely occurs, the patient generally hastening the process by his OAvn operation, or by seeking surgical treatment. A dry scab forms at the furroAV, and Avhen picked and repicked constantly re-forms, be- ing composed of horny desquamation or necrosis. The histology of ainhum shoAvs it to be a direct ingrowth of epithelium, Avith a corresponding depression of surface due to a rapid hyperplasia that pushes doAvn and strangles the papillae, thus cutting off the blood supply from the epithelial cells, causing them to undergo a horny change. The disease is not usually symmetric, as formerly stated, nor is it simul- taneous in different toes. There are no associated constitutional symptoms, no tendency to similar morbid changes in other parts, and no infiltration else- where. There is little or no edema with ainhum. In ainhum there is, first, simple hypertrophy, then active hyperplasia. The papillae degenerate when deprived of blood supply, and become horny. MeaiiAvhile the pressure thus exerted on the nervi vasorum sets up A-aseular changes which bring about epithelial changes in more distant areas, the process advancing anteriorly, that is, in the direction of the arteries. This makes the cause, according to Eyles, an inflammatory and trophic phenomenon due mainly to changes following pressure on the vasomotor nerves. Etiology.—The theories of the causation of ainhum are quite numerous. The first cause is the admirable location for a furroAV in the digito-plantar fold, and the excellent situation of the furrow for the entrance of sand or other particles to make the irritation constant, thus causing chronic inflamma- tory changes, Avhich are folloAved subsequently by the changes peculiar to ainhum. The cause has been ascribed to the practice of wearing rings on the toes ; but von Winckler says that in his locality (British Guinea) this practice is confined to the coolie Avomen, and in not one of his 20 cases had a ring been previously Avorn on the toe ; in fact all of the patients were males. Digby says, hoAvever, that the Krumens, among Avhom the disease is common, have long Avorn brass or copper rings on the fifth toe. Again the 832 ANOMAL O US SKIN DISEASES. natives of India, avIio are among those most frequently afflicted, have no such custom. Injury, such as stone-bruise, has been attributed as the initial cause, and Avell-authenticated eases have been reported in AA'hich traumatism is distinctly remembered ; but Smyth, Weber, and several other observers deny that habits, accidents, or Avork, are a feature in causation. Von During reports a curious case AA'hich he calls sclerodactylia annu- laris ainhumoides. The patient Avas a boy about twelve years old, born in Erzeroum, brought for treatment for scabies, and not for the affection about to be described. A very defective history led to the belief that a similar affection had not been observed in the family. AVhen he avus six years old it began on the terminal phalanges of the middle fingers. A myxomatous SAvelling attacked the phalanges and effected a complete absorption of the ter- minal phalanx. It did not advance as far as gangrene or exfoliation of bone. At the time of report the Avhole ten fingers Avere iiiA'oh'ed ; the bones seemed to be thickened, the soft parts being indurated or sclerosed. In the right index finger a completely sclerosed ring passed around the middle phalanx. The nails on the absorbed phalanges had become small and considerably thickened plates. No analogous changes Avere found elseAvherc, and sensation Avas perfectly normal in the affected parts. There were no signs Avhatever of a multiple neuritis nor of a leprous condition. There is a rare and curious condition knoAvn as lt deciduous skin " or keratolysis, in Avhich the OAvners possess a skin, Avhich, like that of a ser- pent, is periodically cast off, that of the limbs coming off like the finger of a glove. Preston a of Canterbury, XeAV Zealand, mentions the case of a Avoman avIio had thus shed her skin every few weeks from the age of seven or even earlier. The Avoman avus sixty-seven years of age ; the skin in every part of the body came aAvay in casts and cuticles Avhich separated entire and sometimes in one unbroken piece like a glove or stocking. Before each paroxysm she had an associate symptom of malaise. Even the skin of the nose and ears came off complete. None of the patient's large family shoAved this idiosyncrasy, and she said that she had been told by a medical man that it had been due to catching cold after an attack of small-pox. Frank b men- tions a case in Avhich there Avas periodic and complete shedding of the cuticle and nails of the hands and feet, Avhich avus repeated for thirty-three consecu- tive years on July 24th of each year, and between the hours of 3 p. m. and 9 P. m. The patient remembered shedding for the first time while a child at play. The paroxysms ahvays commenced abruptly, constitutional febrile symptoms were first experienced, and the skin became dry and hot. The acute symptoms subsided in three or four hours and Avere entirely gone in tAvelve hours, Avith the exception of the redness of the skin, which did not disappear for thirty-six hours more. The patient had been delirious during this a 476, Oct. 22, 1881. bi24, July, 1891. SKIN-SHEDDING. 833 period. The cuticle began to shed some time between the third and twelfth day, in large sheets, as pictured in the accompanying illustrations (Figs. 290 and 291). The nails were shed in about four weeks after the acute stage. Crocker had an instance of this nature in a man Avith tylosis palmaa, in Avhich the skin Avas cast off every autumn, but the process lasted two months. Lang observed a case in Avhich the fingers alone were affected. There is a case of general and habitual desquamation of the skin in the Ephemerides of 1686 ; and NeAvella records a case which recovered under the use of Cheltenham Avater for several seasons. Lathamb describes a man of fifty who Avas first seized about ten years previously Avith a singular kind of fever, and this returned many times afterAvard, even tAvice in the course of the same year, attended Avith the same symptoms and circumstances, and appearing to be brought on by obstructed perspiration, in consequence of catching cold. Besides the common febrile symptoms, upon the invasion of the disease his skin universally itched, more especially at the joints, and the itching avus folloAved by many little red spots, with a small degree of SAvelling. Soon after this his fingers became stiff, hard, and painful at the ends, and at the roots of the nails. In about tAventy-four hours the cuticle began to sepa- rate from the cutis, and in ten or tAvelve days this separation Avas general from head to foot, during Avhich time he completely turned the cuticle off from the Avrists to the fingers' ends like a glove, and in like manner on the legs to the toes, after Avhich his nails shot gradually from their roots, at first with exquisite pain, Avhich abated as the separation of the cuticle adA'anced, and the old nails Avere generally thrown off by neAV ones in about six months. The cuticle rose in the palms and soles like blisters, having, hoAvever, no fluid beneath, and when it came off it left the underlying cutis exposed for a few days. Sometimes, upon catching cold, before quite free from feverish symp- toms, a second separation of the cuticle from the cutis occurred, but it appeared so thin as to be like scurf, demonstrating the quick reneAval of the parts. There is a similar case in the Philosophical Transactionsc in a miller of thirty-five avIio AA'as exposed to great heat and clouds of dust. On the first cold a fever attacked him, and once or tAvice a year, chiefly in the autumn, this again occurred, attended with a loosening and detachment of the cuticle. The disorder began Avith violent fever, attended Avith pains in the head, back, limbs, retching, A'omiting, dry skin, furred tongue, urgent thirst, con- stipation, and high-colored urine. Usually the whole surface of the body then became yellow. It afterAvard became florid like a rash, and then great uneasiness avus felt for several days, Avith general numbness and tingling; the urine then began to deposit a thick sediment. About the third Aveek from the first attack the cuticle appeared elevated in many places, and in eight or ten days afterward became so loose as to admit of its easy removal in large flakes. The cuticle of the hands, from the Avrists to the fingers' ends, came off a 490, iii., 576. b 629, lx., 451. c 629, lix., 281. 53 834 A NOMALOUS SKIN-DISEASES Fig. 290.—Skin-shedding Fig. 291.—Casts of a case of skin-shedding (Frank). DERMATITIS EXFOLIATIVA NEONATORUM. 835 like a glove. The patient Avas never disposed to SAveat, and Avhen it was at- tempted to force perspiration he grew worse ; nor was he much at ease until his urine deposited a sediment, after Avhich he felt little inconvenience but from the rigidity of the skin. The nails Avere not detached as in the previous case. It is quite natural that such cases as this should attract the attention of the laity, and often find report in newspapers. The folloAving is a lay-report of a " snake-boy " in ShepardstoAvn, Ya. :— "Jim Twyman, a colored boy living Avith his foster-parents ten miles from this place, is a Avonder. He is popularly knoAvn as the " snake-boy." Mentally he is as bright as any child of his age, and he is popular with his playmates, but his physical peculiarities are probably unparalleled. His entire skin, except the face and hands, is covered Avith the scales and markings of a snake. These exceptions are kept so by the constant use of Castile soap, but on the balance of his body the scales groAv abundantly. The child sheds his skin every year. It causes him no pain or illness. From the limbs it can be pulled in perfect shape, but off the body it comes in pieces. His feet and hands arc always cold and clammy. He is an inordinate eater, sometimes spending an hour at a meal, eating voraciously all the time, if per- mitted to do so. After these gorgings he sometimes sleeps tAvo days. There is a strange suggestion of a snake in his face, and he can manipulate his tongue, accompanied by hideous hisses, as viciously as a serpent." Under the name of dermatitis exfoliativa neonatorum, Ritter has described an eruption Avhich he observed in the foundling asylum at Prague, Avhere nearly 300 cases occurred in ten years. According to Crocker it begins in the second or third week of life, and occasionally as late as the fifth Aveek, Avith diffuse and universal scaling, Avhich may be branny or in laminae like pityriasis rubra, and either dry or AA'ith suffusion beneath the epidermis. Sometimes it presents flaccid bullae like pemphigus foliaceus, and then there are crusts as Avell as scales, Avith rhagades on the mouth, anus, etc. ; there is a total absence of fcAer or other general symptoms. About 50 per cent, die of marasmus and loss of heat, Avith or Avithout diarrhea. In those avIio recover the surface gradually becomes pale and the desquamation ceases. Opinions differ regarding it, some considering it of septic origin, while others believe it to be nothing but pemphigus foliaceus. Kaposi regards it as an aggravation of the physiologic exfoliation of the neAV-born. Elliott of Noav Yorka reports tAvo cases Avith a revieAV of the subject, but none haA'e been reported in England. Oases on the Continent have been described by Billard, von Baer, Caspary, those already mentioned, and others. The name epidemic exfoliative dermatitis has been given to an epi- demic skin-disease Avhich made its appearance in 1891 in England ; 425 cases Avere collected in six institutions, besides sporadic cases in private houses. a 124, Jan., 1888. 836 ANOMALOUS SKIN-DISEASES. In 1895, in London,619 some photographs and sketches Avere exhibited that were taken from seA'eral of the 163 eases which occurred in the Paddington Infirmary and Workhouse, under the care of Dr. SaA'ill, from avIiosc negatives they Avere prepared. They Avere arranged in order to illustrate the suceessivc stages of the disorder. The eruption starts usually Avith discrete papules, often in stellate groups, and generally arranged symmetrically Avhen on the limbs. These become fused into crimson, slightly raised maculae, which in severe cases become further fused into red thickened patches, in Avhich the papules can still be felt and sometimes seen. Vesicles form, and exudation occurs in only about one-third of the cases. Desquamation of the epidermis is the invariable feature of all cases, and it usually commences betAveen the fourth and eighth days. In severe cases successive layers of the epidermis are shed, in larger or smaller scales, throughout the Avhole course of the malady. One-half of the epidermis shed from the hand of a patient is ex- hibited in this collection. Of sphaceloderma, or gangrene of the skin, probably the most inter- esting is Raynaud's disease of symmetric gangrene, a vascular disorder, which is seen in three grades of intensity : there is local syncope, producing the condition known as dead-fingers or dead-toes, and analogous to that pro- duced by intense cold ; and local asphyxia, which usually follows local syn- cope, or may develop independently. Chilblains are the mildest manifestation of this condition. The fingers, toes, and ears, are the parts usually affected. In the most extreme degree the parts are swollen, stiff, and livid, and the capillary circulation is almost stagnant; this is local or symmetric gangrene, the mildest form of AA'hich folloAvs asphyxia. Small areas of necrosis appear on the pads of the fingers and of the toes ; also at the edges of the ears and tip of the nose. Occasional symmetric patches appear on the limbs and trunk, and in extensive cases terminate in gangrene. Raynaud suggested that the local syncope Avas produced by contraction of the vessels; the asphyxia is probably caused by a dilatation of the capillaries and venules, Avith persistence of the spasm of the arterioles. According to Osier two forms of congestion occur, which may be seen in adjacent fingers, one of which may be swollen, intensely red, and extremely hot; the other savoIIcu, cyanotic, and in- tensely cold. Sometimes all four extremities are involved, as in Southey's case,a in a girl of tAvo and a half in Avhom the process began on the calves, after a slight feverish attack, and then numerous patches rapidly becoming gangrenous appeared on the backs of the legs, thighs, buttocks, and upper arms, Averse Avhere there was pressure; the child died thirtv-tAvo hours after the onset. The whole phenomenon may be unilateral, as in Smith's case, quoted by Crocker,— in a girl of three years in Avhom the left hand avus cold and livid, Avhile on the right there Avas lividity, progressing to gangrene of the fingers and of the thumb up to the first knuckles, where complete separation occurred. a 779, xxxiv., 286. NEUROSES OF THE SKIN. 837 A considerable number of cases of apparently spontaneous gangrene of the skin have been recorded in medical literature as occurring generally in hysteric young Avomen. Crocker remarks that they are generally classified as erythema gangraenosum, and are ahvays to be regarded with grave suspicion of being self-induced. Ehrla records an interesting case of this nature with an accompanying illustration. The patient was a girl of eigh- teen whose face, left breast, anus, legs, and feet became affected every autumn since her sixth year, after an attack of measles. At first the skin became red, then water-blisters formed, the size of a grain of corn, and in three days reaching the size of a hazel-nut; these burst and healed, leaving no scars. The menses appeared at the fifteenth year, lasted eight days, AA'ith great loss of blood, but there Avas no subsequent menstruation, and no vicarious hemor- rhage. Afterward the right half of the face became red for three or four weeks, with a disturbance of the sensibility of this part, including the right half of the mucosa of the mouth and the conjunctiva of the right eye. At the seventeenth year the patient began to have a left-sided headache and increased SAveating of the right half of the body. In 1892 the periodically-appearing skin-affection became Averse. Instead of healing, the broken vessels became blackish and healed slowly, leaving ulcers, granulations, and scars, and the gangrenous tendency of the skin increased. Disturbance of the sight shortly intervened, associated with aphonia. The sensibility of the Avhole body, with the exception of the face, was greatly impaired, and there was true gangrene of the corium. A younger sister of the patient Avas similarly affected with symptoms of hysteria, hemianesthesia, etc. Neuroses of the skin consist in augmentation of sensibility or hyper- esthesia and diminution of sensibility or anesthesia. There are some curi- ous old eases of loss of sensation. Ferdinandusb mentions a case of a young man of tAventy-four avIio, after having been seized with insensibility of the whole body Avith the exception of the head, Avas cured by purgatives and other remedies. Bartholinus cites the case of a young man Avho lost the senses of taste and feeling; and also the case of a young girl avIio could permit the skin of her forehead to be pricked and the skin of her neck to be burned without experiencing any pain. In his " Surgery " Lamothe mentions a case of insensibility of the hands and feet in consequence of a horse-kick in the head Avithout the infliction of any external wound. In the " Memoires de l'Academie des Sciences" for the year 1743, Ave read an account of a soldier who, after having accidentally lost all sensation in his left arm, continued to go through the Avhole of the manual exercise Avith the same facility as ever. It avus also knoAvn that La Coudamine avus able to use his hands for many years after they had lost their sensation. Rayer gives a case of paralysis of the skin of the left side of the trunk Avithout any affection of the muscles, in a man of forty-three of apoplectic constitution. The paralysis extended from a 838, May 3, 1894. b Venetiis, 1612, Historia, 46. 838 ANOMALOUS SKIN-DISEASES. the left mammary region to the haunch, and from the vertebrae to the linea alba. Throughout this Avhole extent the skin Avas insensible and could be pinched or even punctured Avithout the patient being aware that he was even touched. The parts did not present any perceptible alteration in texture or in color. The patient Avas free from fever and made no complaint except a slight headache. Haver quotes another case in a man of sixty who had been bitten three years previously by a dog that Avas not Fig. 292.—Neuroma cutis dolorosum (Duhring). mad. He was greatly frightened by the accident and every time he saw a dog he trembled violently, and on one occasion he suffered a convulsive attack for one and a half hours. The convulsions increased in number and frequency, he lost his memory, and exhibited other signs of incipient dementia. He was admitted to the hospital with tAvo small wounds upon the head, one above the left eyebroAv and the other on the scalp, occasioned by a fall on his entrance into the hospital. For several davs a great degree of insensibility of the skin of the Avhole body Avas observed Avithout any YA WS 839 implication of the poAver of voluntary motion. He Avas entirely cured in eighteen days. Duhring a reports a very rare form of disease of the skin, Avhich may be designated neuroma cutis dolorosum, or painful neuroma of the skin (Fig. 292). The patient Avas a boiler-maker of seventy who had no family history bearing on the disease. Ten years previously a feAV cutaneous tubercles the size and shape of a split-pea Avere noticed on the left shoulder, attended with decided itching but not Avith pain. The latter symptom did not come on until three years later. In the course of a year or tAvo the lesions increased in number, so that in four years the shoulder and arm Avere thickly studded with them. During the next five years no particular changes occurred either in lesions or in the degree of pain. The region affected simply looked like a solid sheet of variously-sized, closely-packed, confluent tubercles, hard and dense. The tubercles Avere at all times painful to the touch, and even the contact of air was sufficient to cause great suffering. During the paroxysms, Avhich occurred usually at several short intervals every day, the skin changed color frequently and rapidly, passing through various reddish and violet tints, at times be- coming purplish. As a paroxysm came on the man Avas in the habit of gently pressing and holding the arm closely to his body. At one time he endured the attack in a standing posture, Avalking the floor, but usually he seated himself very near a hot stove, in a doubled-up, cramped position, utterly unmindful of all sur- roundings, until the worst pain had ceased. Frequently he avus unable to con- trol himself, calling out piteously and vehemently and beseeching that his life be terminated by any means. In desperation he often lay and Avrithed on the floor in agony. The intense suffering lasted, as a rule, for about a half hour, but he Avas never Avithout pain of the neuralgic type. He Avas freer of pain in summer than in Avinter. Exsection of the brachial plexus Avas performed, but gave only temporary relief. The man died in his eighty-fourth year of senile debility. According to Osier the tubercula dolorosa or true fascicular neuroma is not ahvavs made up of nerve-fibers, but, as shoAvn by Hoggan, may be an adenomatous groAvth of the sAveat-glands. Yaws may be defined as an endemic, specific, and contagious disease, characterized by raspberry-like nodules Avith or Avithout constitutional dis- turbance. Its synonym, frambesia, is from the French, framboise, a rasp- berry. YaAvs is derived from a Carib Avord, the meaning of AA'hich is doubt- ful. It is a disease confined chiefly to tropical climates, and is found on the west coast of Africa for about ten degrees on each side of the equator, and also on the east coast in the central regions, but rarely in the north. It is also found in Madagascar, Mozambique, Ceylon, Hindoostan, and nearly all the tropical islands of the AA'orld. Crocker belieA'es it probable that the a124, Oct., 1881. 840 ANOMA L 0 US SKIN-DISEA SES button-scurvy of Ireland, iioav extinct, but described by various Avriters of 1823 to 1857 as a contagious disease Avhich Avas prevalent in the south and in the interior of the island, Avas closely allied to yaAvs, if not identical with it. The first mention of the yaAvs disease is by Oviedo, in 1535, avIio met Avith it in San Domingo. Although Sauvages at the end of the last century Avas the first to give an accurate description of this disease, many physicians had observed it before. Frambesia or yaAvs Avas observed in Brazil as early as 1643,a and in America later by Lebat in 1722. In the last century Winterbottom and Hume describe yaAvs in Africa, Hume calling it the African distemper. In 1769 in an essay on the u Natural History of Guiana," Bancroft mentions yaAvs ; and Thomsonb speaks of it in Jamaica. Hillary in 1759 describes yaws in Barbadoes; and Bajou in Domingo and Cayenne in 1777, Dazille having already observed it in San Domingo in 1742.c Crocker takes his account of yaAvs from Xuma Rat of the LeeAvard Islands, avIio divides the case into four stages : incubation, primary, sec- ondary, and tertiary. The incubation stage is taken from the date of infec- tion to the first appearance of the local lesion at the sight of inoculation. It varies from three to ten weeks. The symptoms are vague, possibly palpita- tion, A'ertigo, edema of the limbs and eyelids. The primary stage begins Avith the initial lesion, Avhich consists of a papule which may be found most any- where on the body. This papule ulcerates. The secondary stage commences about a fortnight after the papule has healed. There is intermittent fever, headache, backache, and shooting pains in the limbs and intercostal spaces, like those of dengue, Avith nocturnal exacerbations. An eruption of minute red spots appears first on the face, and gradually extends so that the Avhole body is coA'ered at the end of three days. By the seventh day the apex of the papule is of a pale yelloAV color, and the black skin has the appearance of being dotted OA'er AA'ith yellow Avax. The papule then deA'elops into nodules of cylindric shape, with a dome-shaped, thick, yellow crust. It is only with the crust off that there is any resemblance to a raspberry. During the month folloAving the raspberry appearance the skin is covered Avith scabs AA'hich, falling off, leaA'e a pale macula; in dark races the macula becomes darker than normal, but in pale races it becomes paler than the natural skin, and in neither case is it scarcely ever obliterated. Intense itching is almost ahvays present, and anemia is also a constant symptom. The disease is essentially contagious and occurs at all ages and among all sexes, to a lesser degree in Avhites and hybrids, and is never congenital. It seems to have a tendency to undergo spontaneous recovery. Furunculus orientalis, or its synonyms, Oriental boil, Aleppo boil, Delhi boil, Biskra button, etc., is a local disease occurring chiefly on the face a De medicina Brsesilium, 1643. b318, xv., 321. cObs. sur les maladies des negres, Paris, 1742. PIGMENTARY ANOMALIES. 841 and other uncovered spots, endemic in limited districts in hot climates, char- acterized by the formation of a papule, a nodule, and a scab, and beneath the last a sharply punched-out ulcer. Its different names indicate the districts in which it is common, nearly ahvays in tropical or subtropical climates. It differs from yaAvs in the absence of febrile symptoms, in its unity, its occurrence often on the feet and the backs of the hands, its duration, and the deep scar Avhich it leaves. A fatal issue is rare, but disfiguring and disabling cicatrices may be left unless great care is employed. Pigmentary Processes.—Friction, pressure, or scratching, if long con- tinued, may produce extensive and permanent pigmentation. This is seen in its highest degree in itching diseases like prurigo and pityriasis. Grcen- Iioav a has published instances of this kind under the name of "vagabond's disease," a disease simulating morbus addisonii, and particularly found in tramps and vagrants. In aged people this condition is the pityriasis nigra of Willan. According to Crocker in two cases reported by Thibierge, the oral mucous membrane Avas also stained. Carrington and Crocker both record cases of permanent pigmentation folloAving exposure to great cold.b Gautier is accredited Avith recording in 1890 the case of a boy of six in Avhom pig- mented patches from sepia to almost black began to form at the age of two, and Avere distributed all OA'er the body. Precocious maturity of the genital organs preceded and accompanied the pigmentation, but the hair Avas illy developed. Chloasma uterinum presents some interesting anomalies. SAvaync re- cords a singular variety in a Avoman in Avhom, during the last three months of three successive pregnancies, the face, arms, hands, and legs Avere spotted like a leopard, and remained so until after her confinement. Crocker speaks of a lady of thirty Avhose skin during each pregnancy became at first bronze, as if it had been exposed to a tropical sun, and then in spots almost black. Kaposi kneAV a woman Avith a pigmented mole tAvo inches square on the side of the neck, Avhich became quite black at each pregnancy, and AA'hich Avas the first recog- nizable sign of her condition. It is quite possible that the black disease of the Garo Hills in Assam0 is due to extreme and acute development of a pernicious form of malaria. In chronic malaria the skin may be yelloAvish, from a chestnut-broAvn to a black color, after long exposure to the influence of the fever. Various fungi, such as tinea versicolor and the Mexican " Caraati," may produce discoloration on the skin. Acanthosis Nigricans may be defined as a general pigmentation with papillary mole-like growths. In the " International Atlas of Rare Skin Dis- eases" there are two cases pictured, one by Politzer in a Avoman of sixty-two, and the other by Janovsky in a man of forty-two. The regions affected AA'ere mostly of a dirty-brown color, but in patches of a bluish-gray. The disease began suddenly in the Avoman, but gradually in the man. Crocker has a 7(57, ix. b 7({7) xiv. c 224, Nov. 29, 1884. 842 ANOMALOUS SKIN-DISEASES. reported a case someAvhat similar to these two, under the head of general bronzing without constitutional symptoms, in a SAvedish sailor of twenty-tAvo, Avith rapid onset of pigmentation.3 Xeroderma pigmentosum, first described by Kaposi in 1870, is a very rare disease, but OAving to its striking peculiarities is easily recognized. Crocker saAV the first three cases in England, and describes one as a type. The patient avus a girl of tAvelve, whose general health and nutrition avc re good. The disease began when she was betAveen tAvelve and eighteen months old, without any premonitory symptom. The disease occupied the parts habitually uncovered in childhood. The whole of these areas Avas more or less densely speckled Avith pigmented, freckle-like spots, Aarying in tint from a light, raAV umber to a deep sepia, and in size from a pin's head to a bean, and of a roundish and irregular shape. Interspersed among the pigment- spots, but not so numerous, Avere white atrophic spots, AA'hich in some parts coalesced, forming Avhite, shining, cicatrix-like areas. The skin upon this Avas finely Avrinkled, and either smooth or shiny, or covered Avith thin, Avhite scales. On these white areas bright red spots were conspicuous, due to telangiectasis, and there Avere also some stellate vascular spots and striae inter- spersed among the pigment. Small Avarts were seen springing up from some of the pigment-spots. These Avails ulcerated and gave rise to numerous superficial ulcerations, covered Avith yelloAV crusts, irregularly scattered over the face, mostly on the right side. The pus coming from these ulcers was apparentlv inocuous. The patient complained neither of itching nor of pain. Archambaultb has collected 60 cases, and gives a good resume to date. Amiscis reports tAvo cases of brothers, in one of whom the disease began at eight months, and in the other at a year, and concludes that it is not a lesion due to external stimuli or known parasitic elements, but must be regarded as a specific, congenital dystrophy of the skin, of unknoAvn pathogenesis. Hoav- ever, observations have shoAvn that it may occur at forty-three years (Riehl), and sixty-four years (Kaposi). Crocker believes that the disease is an atrophic degeneration of the skin, dependent on a primary neurosis, to Avhich there is a congenital predisposition. Nigrities is a name given by the older Avriters to certain black blotches occurring on the skin of a Avhite person—in other words, it is a synonym of melasma. According to Rayer it is not uncommon to see the scrotum and the skin of the penis of adults almost black, so as to form a marked contrast Avith the pubes and the upper part of the thighs. Haller c met with a Avoman in whom the skin of the pubic region Avas as black as that of a negress. During nursing the nipples assume a deep black color Avhich disappears after Aveaning. Le Cat speaks of a Avoman of thirty years, whose forehead assumed a dusky hue of the color of iron rust Avhen she Avas pregnant about the seventh month. By degrees the Avhole face became black except the eyes and the edges of the a 767, xiv., 152. b "These de Bordeaux," 1890. c 400, v., 18. ANOMALOUS DISCOLORATION OF THE SKIN 843 lips, Avhich retained their natural color. On some days this hue Avas deeper than on others ; the Avoman being naturally of a very fair complexion had the appearance of an alabaster figure Avith a black marble head. Her hair, Avhich Avas naturally exceedingly dark, appeared coarser and blacker. She did not suffer from headache, and her appetite was good. After becoming black, the face Avas very tender to the touch. The black color disappeared two days after her accouchement, and following a profuse perspiration by which the sheets Avere stained black. Her child was of a natural color. In the folloAving pregnancy, and even in the third, the same phenomenon reappeared in the course of the seventh month; in the eighth month it disappeared, but in the ninth month this Avoman became the subject of convulsions, of Avhich she had one each day. The existence of accidental nigrities rests on well-established facts which are distinctly different from the pigmentation of purpura, icterus, or that produced by metallic salts. Chomela quotes the case of a very apathic old soldier, whose skin, Avithout any appreciable cause, became as broAvn as that of a negro in some parts, and a yelloAvish-broAvn in others. Rustin b has published the case of a woman of seventy avIio became as black as a negress in a single night. GoodAvin302 relates the case of an old maiden lady Avhose complexion up to the age of twenty-one Avas of ordinary Avhiteness, but then became as black as that of an African. Wells and Rayer have also published accounts of cases of accidental nigrities. One of the latter cases Avas a sailor of sixty-three who suffered from general nigrities, and the other Avas in a woman of thirty, appearing after weaning and amenorrhea. Mitchell Bruce has described an anomalous discoloration of the skin and mucous membranes resembling that produced by silver or cyanosis. The patient, a harness-maker of forty-seven, was affected generally over the body, but particularly in the face, hands, and feet. The conjunctival, nasal, and aural mucosa Avere all iiiA'olved. The skin felt Avarm, and pressure did not influence the discoloration. The pains complained of Avere of an inter- mittent, burning, shooting character, chiefly in the epigastric and left lumbar regions. The general health aajis good, and motion and sensation were nor- mal. Nothing abnormal Avas discovered in connection AA'ith the abdominal and thoracic examinations. The pains and discoloration had commenced two years before his admission, since which time the skin had been deepening in tint. He remained under observation for three months Avithout obvious change in his symptoms. There was nothing in the patient's occupation to account for the discoloration. A year and a half previously he had taken medicine for his pains, but its nature could not be discovered. He had had syphilis. Galtier mentions congenital and bronze spots of the skin. A man born in Switzerland the latter part of the last century, calling himself Joseph Galart, attracted the attention of the curious by exhibiting himself under the a Bull, de la Fac. de Med. de Paris, 1814, No. 6. b ibid., 1817, Nos. 9 and 10. 844 ANOMALO US SKINDISEASES. name of the "Living Angel." He presented the folloAving appearance: The skin of the Avhole posterior part of the trunk, from the nape of the neck to the loins, Avas of a bronze color. This color extended over the shoulders and the sides of the neck, and this part AA'as covered with hairs of great fine- ness and groAving A'ery thick ; the skin of the rest of the body Avas of the usual Avhiteness. Those parts Avere the darkest Avhich AA'ere the most covered Avith hair; on the back there Avas a space of an inch in diameter, Avhich had preserved its Avhiteness, and Avhere the hairs Avere fewer in number, darker at their bases, and surrounded by a A'ery small black circle ; the hair Avas thin- ner at the sides of the neck ; there avc re a great many individual hairs sur- rounded by circles of coloring matter; but there were also many AA'hich pre- sented nothing of this colored areola. In some places the general dark color of the skin blended with the areola surrounding the roots of the hair, so that one uniform black surface resulted. In many places the dark color changed into black. The irides were broAvn. The man Avas of A'ery unstable charac- ter, extremely undecided in all his undertakings, and had a lively but silly expression of countenance. A distinct smell, as of mice, Avith a mixture of a garlicky odor, Avas emitted from those parts Avhere the excessh'e secretion of the coloring matter took place. In those places the heat Avas also greater than natural. Rayer recites the case of a young man whom he saw, Avhose eyelids and adjacent parts of the cheeks Avere of a bluish tint, similar to that Avhich is produced on the skin by the explosion of gunpoAvder. Billarda has published an extraordinary case of blue discoloration of the skin in a young laundress of sixteen. Her neck, face, and upper part of the chest shoAved a beautiful blue tint, principally spreading over the fore- head, the alae, and the mouth. When these parts Ave re rubbed with a Avhite toAvel the blue parts of the skin were detached on the toAvel, coloring it, and leaving the skin Avhite. The girl's lips Avere red, the pulse avus regular and natural, and her strength and appetite like that of a person in health. The only morbid symptom Avas a dry cough, but without mucous rattle or anv defi- ciency of the sound of the chest or alteration of the natural beat of the heart. The eatamenia had never failed. She had been engaged as a laundress for the past tAvo years. From the time she began this occupation she perceived a blueness around her eyes, Avhich disappeared hoAvever on going into the air. The phenomenon reappeared more particularly Avhen irons were heated by a bright charcoal fire, or Avhen she Avorked in a hot and confined place. The blueness spread, and her breast and abdomen became shaded with an azure blue, Avhich appeared deeper or paler as the circulation was accelerated or retarded. When the patient's face should have blushed, the face became blue instead of red. The changes exhibited Avere like the sudden transition of shades presented by the chameleon. The posterior part of the trunk, the axillae, the sclerotic coats of the eyes, the nails, and the skin of the head remained in a 162, T. xxvi., 453. LEUKODERMA. 845 their natural state and preserved their natural color. The linen of the patient Avas stained blue. Chemical analysis seemed to throAv no light on this ease, and the patient improved on alkaline treatment. She vomited blood AA'hich contained sufficient of the blue matter to stain the sides of the vessel. She also stated that in hemorrhage from the nose she had seen blue drops among the drops of blood. One cannot but suspect indigo as a factor in the causation of this anomalous coloration. Artificial discolorations of the skin are generally produced by tattoo- ing, by silver nitrate, mercury, bismuth, or some other metallic salt. Melasma has been designated as an accidental and temporary blackish discoloration of the skin. There are several varieties : that called Addison's disease, that due to uterine disease, etc. In this affection the skin assumes a dark and even black hue. Leukoderma is a pathologic process, the result of Avhich is a deficiency in the normal pigmentation of the skin, and possibly its appendages. Its synonyms are leukopathia, vitiligo, achroma, leukasmus, and chloasma album. In India the disease is called sufaid-korh, meaning white leprosy. It has numerous colloquial appellations, such as chumba or phoolyree (Hindoo), buras (Urdu), cabbore (Singalese), kuttam (Taneil), dhabul (Bengal). It differs from albinism in being an acquired deficiency of pigment, not universal and not affecting the eye. Albinism is congenital, and the hair and eyes are affected as Avell as the skin. The disease is of universal distribution, but is naturally more noticeable in the dark-skinned races. It is much more common in this country among the negroes than is generally supposed. The " leopard-boy of Africa," so extensively advertised by dime museums over the country, was a Avell-defined case of leukoderma in a young mulatto, a fitting parallel for the case of ichthyosis styled the " alligator-boy." Figure 293 represents a family of three children, all the subjects of leuko- derma. Leukoderma is more common among females. It is rarely seen in children, being particularly a disease of middle age. Bissell reports a case in an Indian ninety years of age, subsequent to an attack of rheumatism thirty years previous. It is of varying duration, nearly every case giving a different length of time. It may be associated Avith most any disease, and is directly attributable to none. In a number of cases collected rheumatism has been a marked feature. It has been noticed folloAving typhoid fever and pregnancy. In Avhite persons there are spots or blotches of pale, lustreless appearance, either irregular or symmetric, scattered over the body. In the negro and other dark-skinned races a mottled appearance is seen. If the process goes to completion, the Avhole surface changes to white. The hair, though rarely affected, may present a mottled appearance. There seems to be no constitu- tional disturbances, no radical change in the skin, no pain—in fact, no dis- 846 ANOMAL 0 US SKIN-DISEASES. turbance worthy of note. The eye is not affected; but in a negro the sclerotic generally appears muddy. It appears first in small spots, either on the lips, nose, eyelids, soles, palms, or forehead, and increases peripherally—the several spots fusing together. The skin is peculiarly thin and easily irritated. Exposure to the sun readily blisters it, and after the slightest abrasion it bleeds freely. Sev- eral cases have been reported in Avhich the specific gravity of the urine Avas extremely high, due to an excess of urea. Wood calls attention to the AvaA'e- Fig. 293.—" The leopard family." like course of leukoderma, receding on one side, increasing on the other. The fading is gradual, and the margins may be abrupt or diffuse. The mucous membranes are rosy. The functions of the sAveat-glands are unim- paired. The theory of the absence of pigment causing a loss of the olfactory sense, spoken of by Wallace, is not borne out by several observations of Wood and others. AVilson says : " Leukasma is a neurosis, the result of AA'eakened innervation of the skin, the cause being commonly referable to the organs of assimilation or reproduction." It is not a dermatitis, as a dermatitis usually CANITIES UNGUIUM. 847 causes deposition of pigment. The rays of the sun bronze the skin ; mustard, cantharides, and many like irritants cause a dermatitis, which is accompanied by a deposition of pigment. Leukoderma is as common in housemaids as in field-laborers, and is in no Avay attributable to exposure of sun or wind. True leukodermic patches sIioav no vascular changes, no infiltration, but a partial obliteration of the rete mucosum. It has been ascribed to syphilis ; but syphilitic leukoderma is generally the result of cicatrices following syphilitic ulceration. Many observers have noticed that negroes become several degrees lighter after syphilization; but no definite relation between syphilis and leukoderma has yet been demonstrated in this race. Postmortem examinations of leuko- dermic persons show no change in the suprarenal capsule, a supposed organ of pigmentation. Climate has no influence. It is seen in the Indians of the Isthmus of Darien, the Hottentots, and the Icelanders. Why the cells of the rete muco- sum should have the function in some races of manufacturing or attracting pigment in excess of those of other races, is in itself a mystery. By his ex- periments on the pigment-cells of a frog Lister has established the relation existing between these elements and innervation, AA'hich formerly had been supposititious. Doubtless a solution of the central control of pigmentation would confirm the best theory of the cause of leukoderma—i. e., faulty innervation of the skin. At present, whether the fault is in the cell proper, the conducting media, or the central center, we are unable to say. It is certainly not due to any vascular disturbances, as the skin shows no vascular changes. White spots on the nails are quite common, especially on young people. The mechanic cause is the presence of air betAveen the lamellae of the affected parts, but their origin is unknoAvn. According to Crocker in some cases they can be shoAvn to be a part of trophic changes. BielschoAvsky a records the case of a man Avith peripheral neuritis, in Avhom Avhite spots appeared at the loAver part of the finger-nails, greAV rapidly, and in three Aveeks coalesced into a band across each nail a millimeter wide. The toes Avere not affected. Shoemaker mentions a patient Avho suffered from relapsing fever and bore an additional band for each relapse. Crocker quotes a case reported by Mori- son of Baltimore, in Avhich transverse bars of white, alternating Avith the nor- mal color, appeared Avithout ascertainable cause on the finger-nails of a young lady and remained unchanged. Giovannini describes a case of canities unguium in a patient of twenty- nine, folloAving an attack of typhoid fever. On examining the hands of this patient the nails showed in their entire extent a Avhite, opaque, almost ivory color. An abnormal quantity of air found in the interior of the nails explains in this particular case their impaired appearance. It is certain that the nails, a 224, Jan. 17, 1891. 848 ANOMALO US SKIN-DISEASES in order to have admitted such a large quantity of air into their interior must have altered in their intimate structure ; and Giovannini suggests that they were subject to an abnormal process of keratinization. Unna describes a simi- lar case, which, hoAvever, he calls leukonychia. Plica polonica, or, as it Avas knoAvn in CracoAV—iccichsekopf, is a disease peculiar to Poland, or to those of Polish antecedents, characterized by the agglutination, tangling, and anomalous development of the hair, or by an alteration of the nails, AA'hich become spongy and blackish. In older days the disease Avas avcII knoAvn and occupied a prominent place in books on skin- diseases. Hercules de Saxonia and Thomas Minadous, in 1610, speak of plica as a disease already long knoAvn. The greater number of Avriters fix the date of its appearance in Poland at about the year 1285, under the reign of Lezek- le-Noir. Lafontaine* stated that in the provinces of Cracow and Sandomir ' plica formerly attacked the peasantry, beggars, and JeAvs in the proportion of 1| in 20 ; and the nobility and burghers in the proportion of tAvo in 30 or 40. In WarsaAv and surrounding districts the disease attacked the first classes in the proportion of one to ten, and in the second classes one to 30. In Lithu- ania the same proportions Avere observed as in WarsaAv ; but the disease has gradually grown rarer and rarer to the present day, although occasional cases are seen even in the United States. Plica has ahvays been more frequent on the banks of the Vistula and Borysthenes, in damp and marshy situations, than in other parts of Poland. The custom formerly prevailing in Poland of shaving the heads of children, neglect of cleanliness, the heat of the head-dress, and the exposure of the skin to cold seem to favor the production of this disease. Plica began after an attack of acute fever, with pains like those of acute rheumatism in the head and extremities, and possibly vertigo, tinnitus aurium, ophthalmia, or coryza. Sometimes a kind of redness was observed on the thighs, and there Avas an alteration of the nails, which became black and rough; and again, there was clammy sweat. When the scalp Avas affected the head was sore to the touch and excessively itchy. A clammy and agglu- tinating sAveat then occurred over the cranium, the hair became unctuous, stuck together, and appeared distended Avith an adhesive matter of reddish-brown color, believed by many observers to be sanguineous. The hair was so acutely sensitive that the slightest touch occasioned severe pain at the roots. A viscid matter of a very offensive smell, like that of spoiled vinegar, or according to Rayer like that of mice or garlic, exuded from the whole surface of each affected hair. This matter glued the hairs together, at first from their exit at the skin, and then along the entire length ; it appeared to be secreted from the whole surface of the scalp and afterward dried into an incrustation. If there was no exudation the disease was called plica sicca. The hair was matted and stuck together in a variety of ways, so as to resemble ropes (plica mul- a Traite dela Plique Polonaise, etc., Paris, 1808. PLICA POLONICA. 849 tiformis). Sometimes these masses united together and formed one single thick club like the tail of a horse (plica caudiformis). Again, and particu- larly in females, the hair Avould become matted and glued together into one uniform intricate mass of various magnitudes. The hair of the whole body Avas likely to be attacked Avith this disease. Kalschmidt of Jena pos- sessed the pubes of a Avoman dead of plica, the hair of which Avas of such length that it must have easily gone around the body. There Avas formerly a superstition that it Avas dangerous to cut the hair until the discharge diminished. Lafontaine, Schlegel, and Hartman all assure us that the sec- tion of the affected masses before this time has been known to be followed by amaurosis, convulsions, apoplexy, epilepsy, and even death. Alarmed or taught by such occurrences, the common people often went about all their lives with the plica gradually dropping off. Formerly there was much the- orizing and discussion regarding the etiology and pathology of plica, but since this mysterious affection has been proved to be nothing more than the product of neglect, and the matting due to the inflammatory exudation, excited by in- numerable pediculi, agglutinating the hair together, the term is now scarcely mentioned in dermatologic works. Crocker speaks of a rare form which he entitles neuropathic plica, and cites two cases, one reported by Le Page a whose specimen is in the Royal College of Surgeons Museum ; and the other was in a Hindoo described by Pestonji.b Both occurred in young women, and in both it came on after washing the hair in Avarm Avater, one in a few minutes, and the other in a few hours. The hair Avas draAvn up into a hard tangled lump, impossible to unravel, limited to the right side in Le Page's patient, Avho had very long hair, and in Pestonji's case to the back of the head, Avhere on each side was an elongated mass, very hard and firm, like a rope and about the size of the fist. There Avas no reason to believe that it was ascribable to imposture ; the Hindoo Avoman cut the lumps off herself and threAv them aAvay. Le Page found the most contracted hairs flattened. Stell- Avagon c reports a case of plica in a Avoman. It occupied a dollar-sized area above the nape of the neck, and in twelve years reached the length of 12 feet. There Avas no history of its manner of onset. Tinea nodosa is a name given by Morris and Cheadle to a case of nodu- lar groAvth on the beard and Avhiskers of a young man. In a case noticed by Crocker this disease affected the left side of the mustache of a medical man, who complained that the hair, if twisted up, stuck together. When disintegrated the secretion in this case seemed to be composed of fungous spores. Epithelium fragments, probably portions of the internal root-sheath, sometimes adhere to the shaft of the hair as it groAVs up, and look like con- cretions. Crocker states that he is informed by White of Boston that this disease1 is common in America in association AA'ith alopecia furfuracea, and is erroneously thought to be the cause of the loss of hair, hence the popular name, " hair-eaters." 54 a 224, Jan. 26, 1884. b 476, Sept. 3, 1885. c 124, Dec, 1892. 850 ANOMAL O US SKIN-DISEASES. Thomson describes a case of mycosis fungoides a in a young girl of the age of fourteen, whom he saAV in Brussels toAvard the end of October, 1S93. She AA'as the third of a family of 13 children of Avhom only fh*e survived. Of the children born subsequently to the patient, the first avc re either pre- mature or died a few days after their births. The seventh Avas under treatment for interstitial keratitis and tuberculous ulceration of the lips and throat. The disease in the patient made its appearance about seven months previously, as a small raised spot in the middle of the back just above the buttocks. Many of the patches coalesced. At the time of report the lumbar region was the seat of the disease, the affection here presenting a most peculiar appearance, looking as if an enormous butterfly had alighted on the patient's back, Avith its dark blue wings covered with silvery scales, Avidely expanded. The patient Avas not anemic and appeared to be in the best of health. None of the glands avc re affected. According to Thomson there is little doubt that this disease is caused by non- pyogenic bacteria gaining access to the sweat-glands. The irritation produced by their presence gives rise to prolifera- tion of the connective-tissue corpuscles. Jamieson reports a case of mycosis in a native of Aberdeenshire aged thirty- eight. There Avas no history of any pre- vious illness. The disease began three years preA'ious to his application for treatment, as a red, itching, small spot on the cheek. Two years later lumps presented themselves, at first upon his shoulders. The first thing to strike an observer was the offensive odor about the patient. In the hospital wards it made all the occupants sick. The various stages of the disease were marked upon the different parts of the body. On the chest and abdomen it resembled an eczema ; on the shoulders there Avere broAvn, pinkish-red areas. On the scalp the hair was scanty, the eye-broAvs denuded, and the eyelashes absent. The forehead was leonine in aspect. From between the various nodosities a continual discharge exuded, the nodosi- ties being markedly irregular over the limbs. The backs of the hands, the dorsums of the feet, the wrists and ankles, had closely approximating growths upon them, while under the thick epidermis of the palms of the hands Avere blisters. Itching was intense. The patient became emaciated and died thir- teen days after his admission into the hospital. A histologic examination showed the sarcomatous nature of the various groAvths. The disease differed a "Interuat. Atlas Pare Skin Diseases." Fig. 294.—Mycosis fungoides (Jamieson, Edin Med. Jour., March, 1893). Plate 12. o_&&J **X*5-:.' ™ - s r$ :p£c % - .:- ■ack again, and so on for many times. Hammond relates the history of a case in an intelligent man avIio in undressing for bed Avould spend an hour or two determining Avhether he should first take off his coat or his shoes. In the morning he Avould sit for an hour Avith his stockings in his hands, unable to determine Avhich he should put on first, Syphilophobia is morbid fear of syphilis. Lyssophobia is a fear of hydrophobia Avhich sometimes assumes all the symptoms of the major dis- ease, and even produces death. Gelineau, Colin, Berillon, and others have studied cases. In Berillon's case the patient Avas an artist, a woman of brunet complexion, avIio for six years had been tormented AA'ith the fear of becoming mad, and in Avhom the symptoms became so intense as to constitute a " Les frontieres de la folie," p. 82. 880 ANOMALOUS NERVOUS AND MENTAL DISEASES. pseudohydrophobia. At their subsidence she Avas the victim of numerous hallucinations Avhich almost drove her to the point of suicide. Spermatophobia has been noticed among the ignorant, caused or in- creased by inspection of sensational literature, treatises on the subject of spermatorrhea, etc. Ferre mentions a woman of thirty-six, of intense religious scruples, who Avas married at eighteen, and lost her husband six years afterAvard. She had a proposition of marriage which she refused, and was prostrated by the humid touch of the proposer avIio had kissed her hand, imagining that the humidity was due to semen. She was several times over- come by contact with men in public conveyances, her fear of contamination being so great. Zoophobia, or dread of certain animals, has been mentioned under another chapter under the head of idiosyncrasies. Pantophobia is a general state of fear of everything and everybody. Phobophobia, the fear of being afraid, is another coinage of the wordmakers. The minor 'phobias, such as pyrophobia, or fear of fire; stasophobia, or inability to arise and Avalk, the victims spending all their time in bed ; toxicophobia or fear of poison, etc., Avill be left to the reader's inspection in special Avorks on this subject. Demonomania is a form of madness in which a person imagines himself possessed of the devil. Ancient records of this disease are frequent, and in this century Lapointe a reports the history of demonomania in father, mother, three sons, and tAvo daughters, the Avhole family, with the exception of one son, avIio AA'as a soldier, being attacked. They imagined themselves poisoned by a sor- ceress, saAV devils, and had all sorts of hallucinations, Avhich necessitated the confinement of the whole family in an asylum for over a month. They con- tinued free from the hallucinations for two years, when first the mother, and then gradually all the other members of the family, again became afflicted Avith demonomania and Avere again sent to the asylum, Avhen, after a residence therein of five months, they Avere all sufficiently cured to return home. Particular aversions may be temporary only, that is, due to an existing condition of the organism, Avhich, though morbid, is of a transitory character. Such, for instance, are those due to dentition, the commencement or cessation of the menstrual function, pregnancy, etc. These cases are frequently of a serious character, and may lead to derangement of the mind. Millington re- lates the history of a lady who, at the beginning of her first pregnancy, ac- quired an overpowering aversion to a half-breed Indian woman avIio Avas em- ployed in the house as a servant. Whenever this Avoman came near her she was at once seized with violent trembling; this ended in a few minutes with vomiting and great mental and physical prostration lasting several hours. Her husband would have sent the Avoman aAvay, but Mrs. X insisted on her remaining, as she Avas a good servant, in order that she might o\'ercome what she regarded as an unreasonable prejudice. The effort was, hoAvever, too a 144, Nov., 1846. CIRCULAR OR PERIODIC INSANITY. 881 great, for upon one occasion when the woman entered Mrs. X's apartment rather unexpectedly, the latter became greatly excited, and, jumping from an open aa indoAv in her fright, broke her arm, and otherwise injured herself so severely that she was confined to her bed for several weeks. During this period, and for some time afterAvard, she Avas almost constantly subject to hallucinations, in Avhich the Indian woman played a prominent part. Even after her recovery the mere thought of the woman Avould sometimes bring on a paroxysm of trembling, and it was not till after her confinement that the antipathy disappeared. Circular or periodic insanity is a rare psychosis. According to DreAvry reports of very few cases have appeared in the medical journals. " Some systematic Avriters," says Drewry, " regard it as a mere subdivision of peri- odic insanity (Spitzka). A distinguished alienist and author of Scotland hoAvever has given us an admirable lecture on the subject. He says : * I have had under my care altogether about 40 cases of typical folie circu- tairc.1 In the asylum at Morningside there Avere, says Dr. Clouston, in 800 patients 16 cases of this peculiar form of mental disease. Dr. Spitzka, who was the first American to describe it, found in 2300 cases of pauper in- sane four per cent, to be periodic, and its sub-group, circular, insanity. Dr. Stearns states that less than one-fourth of one per cent, of cases in the Hart- ford (Conn.) Retreat classed as mania and melancholia have proved to be folie circulaire. Upon examination of the annual reports of the superinten- dents of hospitals for the insane in this country, in only a feAV are references made to this as a distinct form of insanity. In the New York State hospitals there is a regular uniform classification of mental diseases in which ' circu- lar (alternating) insanity' occupies a place. In the report of the Buffalo Hospital for 1892, in statistical table No. 4, ' shoAving forms of insanity in those admitted, etc., since 1888,' out of 1428 cases, only one AAas 'alter- nating (circular) insanity.' In the St. Lawrence Hospital only one case in 992 Avas credited to this special class. In the institution in Philadelphia, of Avhich Dr. Chapin is the superintendent, 10,379 patients haA'e been treated, only three of whom were diagnosed cases of manie circulaire. Of the 900 cases of insanity in the State Hospital at Danville, Pa., less than four per cent. Avere put in this special class. There are in the Central (Ya.) State Hospital (Avhich is exclusively for the colored insane) 775 patients, three of Avhom are genuine cases of circular insanity, but they are included in ' peri- odic insanity.' This same custom evidently prevails in many of the other hospitals for the insane." DreAvrya reports three cases of circular insanity, one of Avhich was as folloAvs :— " William F., a negro, thirty-six years old, of fair education, steady, sober habits, Avas seized Avith gloomy depression a few Aveeks prior to his a 466, April, 1895. 56 882 ANOMALOUS NERVOUS AND MENTAL DISEASES. admission to this hospital, in September, 1886. This condition came on after a period of fever. He Avas a stranger in the vicinity and scarcely any informa- tion could be obtained regarding his antecedents. When admitted he Avas in a state of melancholic hypochondriasis ; he Avas the very picture of abject mis- ery. Many imaginary ills troubled his peace of mind. He spoke of commit- ting suicide, but evidently for the purpose of attracting attention and sympathy. On one occasion he said he intended to kill himself, but when the means to do so were placed at his command, he said he would do the deed at another time. The most trivial physical disturbances Avere exaggerated into very serious diseases. From this state of morbid depression he slowly emerged, greAv brighter, more energetic, neater in personal appearance, etc. During this period of slow transition or partial sanity he Avas taken out on the farm where he proved to be a careful and industrious laborer. He escaped, and when brought back to the hospital a few weeks subsequently he was in a con- dition of great excitement and hilarity. His expression was animated, and he AA'as, as it Avere, overflowing Avith superabundance of spirit, very loquacious, and incessantly moA'ing. He bore an air of great importance and self-satis- faction ; said he felt perfectly well and happy, but abused the officers for keeping him ' confined unjustly in a lunatic asylum.' It was his habit almost daily, if not interfered with, to deliver a long harangue to his fellow- patients, during which he would become very excited and noisy. He shoAved evidences of having a remarkable memory, particularly regarding names and dates. (Unusual memory is frequently observed in this type of insanity, says Stearns.) He was sometimes disposed to be somewhat destructive to furni- ture, etc., AAas neat in person, but Avould frequently dress rather 'gorgeously,' Avearing feathers and the like in his hat, etc. He was not often noisy and sleepless at night, and then only for a short time. His physical health was good. This ' mental intoxication,' as it Avere, lasted nearly a year. After this long exacerbation of excitement there AAas a short remission and then depression again set in, Avhich lasted about fifteen months. At this time this patient is in the depressed stage or period of the third circle. So, thus the cycles have continuously repeated their Aveary rounds, and in all probability they Avill keep this up ' until the final capitation in the battle of life has taken place.' " Katatonia, according to Gray, is a cerebral disease of cyclic symptoms, ranging in succession from primary melancholia to mania, confusion, and de- mentia, one or more of these stages being occasionally absent, while convul- sive and epileptoid symptoms accompany the mental changes. It is manifestly impossible to enter into the manifold forms and instances of insanity in this volume, but there is one case, seldom quoted, Avhich may be of interest. It appeared under the title, " A Modern Pygmalion." a It recorded a history of a man named Justin, who died in the Bicetre Insane a 476, 1879, ii., 436. D 0 UBLE CONSCIO USNESS. 883 Asylum. He had been an exhibitor of wax works at Montrouge, and became deeply impressed with the beautiful proportions of the statue of a girl in his collection, and ultimately became intensely enamored with her. He Avould spend hours in contemplation of the inanimate object of his affections, and finally had the illusion that the figure, by movements of features, actually responded to his devotions. Nemesis as usual at last arrived, and the Avife of Justin, irritated by his long neglect, in a fit of jealousy destroyed the wax figure, and this resulted in a murderous attack on his wife by Justin Avho resented the demolition of his love. He was finally secured and lodged in Bicetre, Avhere he lived for five years under the influence of his lost love. An interesting condition, AA'hich has been studied more in France than elsewhere, is double consciousness, dual personality, or, as it is called by the Germans, Doppelwakrnehmungen. In these peculiar cases an indi- vidual at different times seems to lead absolutely different existences. The idea from a moralist's view is inculcated in Stevenson's " Dr. Jekyl and Mr. Hyde." In an article on this subject a Weir Mitchell illustrated his paper by examples, tAvo of which will be quoted. The first was the case of Mary Reynolds Avho, Avhen eighteen years of age, became subject to hysteric at- tacks, and on one occasion she continued blind and deaf for a period of five or six Aveeks. Her hearing returned suddenly, and her sight gradually. About three months afterAvard she Avas disco\'ered in a profound sleep. Her memory had fled, and she Avas apparently a neAV-born individual. When she aAvoke it became apparent that she had totally forgotten her previous exis- tence, her parents, her country, and the house Avhere she lived. She might be compared to an immature child. It Avas necessary to recommence her education. She was taught to Avrite, and Avrote from right to left, as in the Semitic languages. She had only fh'e or six Avords at her command—mere reflexes of articulation AA'hich Avere to her devoid of meaning. The labor of re-education, conducted methodically, lasted from seven to eight Aveeks. Her character had experienced as great a change as her memory; timid to excess in the first state, she became gay, unreserved, boisterous, daring, even to rashness. She strolled through the Avoods and the mountains, attracted by the dangers of the Avild country in which she lived. Then she had a fresh attack of sleep, and returned to her first condition; she recalled all the mem- ories and again assumed a melancholy character, which seemed to be aggra- vated. No conscious memory of the second state existed. A new attack brought back the second state, Avith the phenomenon of consciousness Avhich accompanied it the first time. The patient passed successively a great many times from one of these states to the other. These repeated changes stretched over a period of sixteen years. At the end of that time the varia- tions ceased. The patient Avas then thirty-six years of age; she lived in a mixed state, but more closely resembling the second than the first; her a 768, x. 884 ANOMALOUS NERVOUS AND MENTAL DISEASES. character Avas neither sad nor boisterous, but more reasonable. She died at the age of sixty-five years. The second case Avas that of an itinerant Methodist minister named Bourne, living in Rhode Island, Avho one day left his home and found himself, or rather his second self, in NorristoAvn, Pennsyh'ania. Having a little money, he bought a small stock in trade, and instead.of being a minister of the gospel under the Methodist persuasion, he kept a candy shop under the name of A. J. BroAvn, paid his rent regularly, and acted like other people. At last, in the middle of the night, he aAvoke to his former con- sciousness, and finding himself in a strange place, supposed he had made a mistake and might be taken for a burglar. He Avas found in a state of great alarm by his neighbors, to Avhom he stated that he Avas a minister, and that his home Avas in Rhode Island. His friends were sent for and recognized him, and he returned to his home after an absence of tAvo years of abso- lutely foreign existence. A most careful investigation of the case Avas made on behalf of the London Society for Psychical Research. An exhaustive paper on this subject, Avritten by Richard Hodgson in the proceedings of the Society for Psychical Research, states that Mr. Bourne had in early life shoAvn a tendency to abnormal psychic conditions; but he had never before engaged in trade, and nothing could be remembered which Avould explain Avhy he had assumed the name A. J. BroAvn, under which he did business. He had, howe\'er, been hypnotized Avhen young and made to assume A'arious characters on the stage, and it is possible that the name A. J. BroAvn Avas then suggested to him, the name resting in his memory, to be revived and resumed Avhen he again went into a hypnotic trance. Alfred Binet describes a case somewhat similar to that of Mary Reynolds : " Felida, a seamstress, from 1858 up to the present time (she is still liv- ing) has been under the care of a physician named Azam in Bordeaux. Her normal, or at least her usual, disposition when he first met her Avas one of melancholy and disinclination to talk, conjoined with eagerness for Avork. Nevertheless her actions and her answers to all questions were found to be perfectly rational. Almost every day she passed into a second state. Sud- denly and Avithout the slightest premonition saA'e a A'iolent pain in the tem- ples she Avould fall into a profound slumber-like languor, from which she Avould aAvake in a feAV moments a totally different being. She Avas iioav as gay and cheery as she had formerly been morose. Her imagination Avas over-excited. Instead of being indifferent to everything, she had become alive to excess. In this state she remembered everything that had happened in the other similar states that had preceded it, and also during her normal life. But Avhen at the end of an hour or Iavo the languor reappeared, and she returned to her normal melancholy state, she could not recall anything that had happened in her second, or joyous, stage. One day, just after passing into the second stage, she attended the funeral of an acquaintance. Returning DOUBLE CONSCIOUSNESS. 885 in a cab she felt the period coming on Avhich she calls her crisis (normal state). She dozed several seconds, Avithout attracting the attention of the ladies avIio were in the cab, and awoke in the other state, absolutely at a loss to know why she was in a mourning carriage with people who, according to custom, Avere praising the qualities of a deceased person Avhose name she did not even know. Accustomed to such positions, she Avaited ; by adroit questions she managed to understand the situation, and no one suspected what had hap- pened. Once when in her abnormal condition she discovered that her hus- band had a mistress, and Avas so overcome that she sought to commit suicide. Yet in her normal mind she meets the Avoman Avith perfect equilibrium and forgetfulness of any cause for quarrel. It is only in her abnormal state that the jealousy recurs. As the years went on the second state became her usual condition. That Avhich was at first accidental and abnormal iioav constitutes the regular center of her psychic life. It is rather satisfactory to chronicle that as between the two egos which alternately possess her, the more cheerful has finally reached the ascendant." Jackson a reports the history of the case of a young dry-goods clerk Avho was seized Avith convulsions of a violent nature during Avhich he became uncon- scious. In the course of twenty-four hours his convulsions abated, and about the third day he imagined himself in Ncav York paying court to a lady, and having a rival for her favors; an imaginary quarrel and duel ensued. For a half-hour on each of three days he would start exactly Avhere he had left off on the previous day. His eyes were open and to all appearances he was awake during this peculiar delirium. When asked Avhat he had been doing he would assert that he had been asleep. His language assumed a re- finement above his ordinary discourse. In proportion as his nervous system became composed, and his strength improA'ed, this unnatural manifestation of consciousness disappeared, and he ultimately regained his health. A further example of this psychologic phenomenon Avas furnished quite recently at a meeting of the Clinical Society of London, Avhere a Avell knoAvn physician exhibited a girl of tAvelve, belonging to a family of good standing, who displayed in the most complete and indubitable form this condition of dual existence. X description of the case is as folloAvs :— " Last year, after a severe illness which was diagnosed to be meningitis, she became subject to temporary attacks of unconsciousness, on aAvakcning from Avhich she appeared in an entirely different character. In her normal condition she could read and write and speak fluently, and with comparative correctness. In the altered mental condition folio av ing the attack she loses all memory for ordinary events, though she can recall things that have taken place during previous attacks. So complete is this alteration of memory, that at first she was unable to remember her own name or to identify her- self or her parents. By patient training in the abnormal condition she has a 124, 1869. 886 ANOMALOUS NERVOUS AND MENTAL DISEASES. been enabled to give things their names, though she still preserves a baby- fashion of pronouncing. She sometimes remains in the abnormal condition for days together and the change to her real self takes place suddenly, Avith- out exciting surprise or dismay, and she forth Avith resumes possession of her memory for events of her ordinary life. During the last month or tAvo she ap- pears to have entered on a new phase, for after a mental blank of a fort- night's duration she aAvakened completely oblivious of all that had happened since June, 1895, and she alludes to events that took place just anterior to that date as though they Avere of recent occurrence ; in fact she is living mentally in July, 1895. These cases, though rare, are of course not infre- quently met with, and they have been carefully studied, especially in France, where Avomen appear more prone to neurotic manifestations. The hypothesis that finds most favor is that the tAvo halves of the brain do not Avork in uni- son ; in other words, that there has been some interference with the connec- tions Avhich in the ordinary normal being make of a Avonderful composite organ like the brain one organic whole." Prousta tells a story of a Parisian barrister of thirty-three. His father Avas a heavy drinker, his mother subject to nervous attacks, his younger brother mentally deficient, and the patient himself was very impression- able. It was said that a judge in a court, by fixing his gaze on him, could send him into an abnormal state. On one occasion, while looking into a mirror in a cafe, he suddenly fell into a sleep, and Avas taken to the Charite where he was aAvakened. He suffered occasional loss of memory for considerable lengths of time, and underwent a change of personality during these times. Though wide aAvake in such conditions he could remember nothing of his past life, and Avhen returned to his original state he could remember nothing that occurred during his secondary state, having vir- tually two distinct memories. On September 23, 1888, he quarreled with his stepfather in Paris and became his second self for three weeks. He found himself in a village 100 miles from Paris, remembering nothing about his journey thereto ; but on inquiry he found that he had paid a visit to the priest of the village who thought his conduct odd, and he had previously stayed with an uncle, a bishop, in Avhose house he had broken furniture, torn up let- ters, and had even had sentence passed upon him by a police court for misde- meanor. During these three Aveeks he had spent the equivalent of $100, but he could not recall a single item of expenditure. Davies b cites a remarkable case of sudden loss of memory in a man Avho, Avhile on his way to Australia, AA'as found by the police in an exhausted condition and who Avas confined in the Kent County Insane Asylum. He suffered absolute loss of all memory Avith the exception of the names of two men not close acquaintances, both of Avhom failed to recognize him in his changed condition in confinement. Four months later his memory returned and his identity was established. a Quoted 224, 1890, i., 1143. b 123, 1886. AUTOMATISM. 887 In the Revue Philosophique for 1885 there are the details of a case of a young man Avho seemed able to assume six states of what might be fairly called different personalities. The memories attached to each of these states were very different, though only one was completely exclusive of the others. The hand Avriting varied from complete competence to complete incompetence. His character varied between childish timidity, courteous reserve, and reck- less arrogance ; and to four of his conditions there was a form of hysteric paralysis attached. Mere suggestion would not only induce any one of these varied forms of paralysis, but also the memories, capacities, and characters habitually accompanying it. A young man named Spencer, an inmate of the Philadelphia Hospital, was exhibited before the American Neurological Society in June, 1896, as an example of dual personality. At the time of writing he is and has been in apparently perfect health, Avith no evidence of having been in any other con- dition. His faculties seem perfect, his education manifests itself in his intel- ligent performance of the cleric duties assigned to him at the hospital, yet the thread of continuous recollection which connects the present moment with its predecessors—consciousness and memory—has evidently been snapped at some point of time prior to March 3d and after January 19th, the last date at which he wrote to his parents, and as if in a dream, he is now living another life. The hospital staff generally believe that the man is not " shamming," as many circumstances seem to preclude that theory. His memory is perfect as to everything back to March 3d. The theory of hypnotism was advanced in explanation of this case. The morbid sympathy of twin brothers, illustrated in Dumas's " Cor- sican Brothers," has been discussed by Sedgwick, Elliotson, Trousseau, Lay- cock, Cagentre, and others. Marshall Hall relates Avhat would seem to verify the Corsican myth, the history of twin brothers nine months of age, who always became simultaneously affected Avith restlessness, Avhooping and croAving in breathing three weeks previous to simultaneous convulsions, etc. Rush a describes a case of tAvin brothers dwelling in entirely different places, who had the same impulse at the same time, and who eventually committed suicide synchronously. Baunir b describes a similar development of suicidal tendency in twin brothers. A peculiar case of this kind Avas that of the twin brothers Laustand who were nurses in a hospital at Bordeaux ; they invariably became ill at the same time, and suffered cataract of the lens together.0 Automatism has been noticed as a sequel to cranial injuries, and Huxley quotes a remarkable case reported by Mesnet.d The patient was a young man Avhose parietal bone Avas partially destroyed by a ball. He exhibited signs of hemiplegia on the right side, but these soon disappeared and he became subject to periodic attacks lasting from twenty-four to forty-eight a 368, 1837, 559. b 144, 1863, No. 2. c 221, July, 1844, 169. d 362, July 17, 1874. 888 ANOMALOUS NERVOUS AND MENTAL DISEASES. hours, during which he Avas a mere automaton. In these attacks he Avalked continually, incessantly moving his jaAV, but not uttering a word. lie was insensible to pain, electric shock, or pin-prick. If a pen avus placed in his hand he Avould Avrite a good letter, speaking sensibly about current topics. When a cigarette-paper was placed in his hand he sought his tobacco box, and adroitly rolled a cigarette and lighted it. If the light went out he procured another, but Avould not alloAv another to substitute a match. He alloAved his mustache to be burned Avithout resistance, but would not alloAv a light to be presented to him. If chopped charpie was put in his pocket instead of tobacco he knew no difference. While in his periods of automatism he was in the habit of stealing everything within his grasp. He had been a concert singer, and a peculiar fact Avas that if given white gloves he Avould carefully put them on and commence a pantomime of the actions of a singer, looking over his music, boAving, assuming his position, and then singing. It is particularly in hypnotic subjects that manifestations of automatism are most marked. At the suggestion of battle an imaginary struggle at once begins, or if some person present is suggested as an enemy the fight is con- tinued, the hypnotic taking care not to strike the person in question. Moll conceded that this looked like simulation, but repetition of such experiments forced him to conclude that these Avere real, typical hypnoses, in Avhich, in spite of the sense-delusions, there Avas a dim, dreamy consciousness existing, Avhich influenced the actions of the subject, and which prevented him from striking at a human being, although hitting at an imaginary object. Many may regard this behavior of hypnotics as pure automatism ; and Moll adds that, as Avhen Avalking in the street Avhile reading we automatically avoid knocking passers-by, so the hypnotic avoids hitting another person, although he is dimly or not at all aware of his existence. Gibbs a reports a curious case of lack of integrity of the Avill in a man of fifty-five. When he had once started on a certain labor he seemed to have no power to stop the muscular exercise that the task called forth. If he Avent to the barn to throAv doAvn a forkful of hay, he Avould never stop un- til the hay Avas exhausted or someone came to his rescue. If sent to the Avood-pile for a handful of wood, he Avould continue to bring in Avood until the pile was exhausted or the room Avas full. On all occasions his automatic movements could only be stopped by force. At a meeting in Breslau Meschede b rendered an account of a man av!io suffered from simple misdirection of movement Avithout any mental derange- ment. If from his OAvn desire, or by direction of others, he Avanted to at- tempt any muscular movement, his muscles performed the exact opposite to his inclinations. If he desired to look to the right, his eyes involuntarily moA'ed to the left. In this case the movement was not involuntary, as the a Penins. and Ind. Med. Jour., Detroit, 1859-60, ii., 14. b 465, Oct.. 1876, 474. PRESENTIMENT OF DEATH. 889 muscles were quiet except Avhen called to action by the will, and then they moved to the opposite. Presentiment, or divination of approaching death, appearing to be a hypothetic allegation, has been established as a strong factor in the produc- tion of a fatal issue in many cases in Avhich there Avas every hope for a recovery. In fact several physicians have mentioned with dread the peculiar obstinacy of such presentiment. Hippocrates, Romanus, Moller, Richter, Jordani, and other older writers speak of it. Montgomery a reports a remarkable case of a woman suffering from carcinoma of the uterus. He saAv her on October 6, 1847, Avhen she told him she had a strong presentiment of death on October 28th. She stated that she had been born on that day, her first husband had died on October 28th, and she had married her second husband on that day. On October 27th her pulse began to fail, she fell into a state of extreme pros- tration, and at noon on the 28th she died. In substantiation of the possi- bility of the influence of presentiment Montgomery cites another case in which he was called at an early hour to visit a lady, the mother of several children. He found her apparently much agitated and distressed, and in great nervous excitement over a dream she had had, in which she saw a handsome monument erected by some children to their mother. She had aAvakened and became dreadfully apprehensive, she could not tell as to Avhat. The uneasiness and depression continued, her pulse continued to groAv Aveak, and she died at tAvelve that night without a struggle. AndreAVS b has made several observations on this subject, and concludes that presentiment of death is a dangerous symptom, and one Avhich should never be overlooked. One of his cases was in a man Avith a fractured leg in the Mercy Hospital at Pittsburg. The patient Avas in good health, but one day he became possessed of a cool, quiet, and perfectly clear impression that he Avas about to die. Struck with his conviction, AndreAvs examined his pulse and general condition minutely, and assured the patient there was not the slightest ground for apprehension. But he persisted, and Avas attacked by pneumonia three days later which brought him to the verge of the grave, although he ultimately recovered. In another instance a young man of ruddy complexion and apparent good health, after an operation for varicocele, had a very clear impression that he would die. Careful examination shoAved no reason for apprehension. After five or six days of encouragement and assurance, he appeared to be convinced that his reasoning was foolish, and he gave up the idea of death. About the ninth day the wound presented a healthy, rosy appearance, and as the patient was cheerful he Avas allowed to leave his bed. After a few hours the nurse heard the noise of labored breathing, and on investigation found the patient apparently in a dying condition. He Avas given stimulants and regained consciousness, but again relapsed, and died in a feAV moments. At the necropsy the heart was found healthy, but there were two or three spots of a 308, 1857, n. s., vol. iv., 18. b 526, 1872. 890 ANOMALOUS NERVOUS AND MENTAL DISEASES. extraAasated blood in the brain, and evidences of cerebral congestion. Vos a remarks that he remembers a case he had Avhen dressing for Mr. 11 olden at St. BartholomeAv's Hospital: " A man avIio had been intemperate Avas roll- ing a sod of grass, and got some grit into his left palm. It inflamed; he put on hot coAA-dung poultices by the advice of some country friends. He was admitted with a dreadfully swollen hand. It was opened, but the phlegmonous process spread up to the shoulder, and it Avas opened in many places, and at last, under chloroform, the limb Avas amputated below the joint, The stump sloughed, and pus pointing at the back of the neck, an opening was again made. He became in such a weak state that chloroform could not be administered, and one morning he had such a dread of more incisions that, saying to us all standing round his bed, ' I can bear it no more, I must now die,' he actually did die in a few minutes in our presence. His was the last arm that Mr. Holden ever amputated at St. Bartholomew's." a 224, 1895, ii., 460. CHAPTER XVIII. HISTOEIC EPIDEMICS. A short history of the principal epidemics, including as it does the description of anomalous diseases, many of which are now extinct, and the valuable knowledge which finally led to their extinction, the extraordinary mortalities Avhich these epidemics caused, and many other associate points of interest would seem fitting to close the observations gathered in this volume. As the illustrious Hecker says, in the history of every epidemic, from the earliest times, the spirit of inquiry was always aroused to learn the machinery of such stupendous engines of destruction ; and even in the earliest times there was neither deficiency in courage nor in zeal for investigation. " When the glandular plague first made its appearance as a universal epidemic, whilst the more pusillanimous, haunted by visionary fears, shut themselves up in their closets, some physicians at Constantinople, astonished at the phenomena, opened the boils of the deceased. The like has occurred both in ancient and modern times, not Avithout favorable results for Science; nay, more mature views excited an eager desire to become acquainted Avith similar or still greater visitations among the ancients, but, as later ages have always been fond of referring to Grecian antiquity, the learned of those times, from a partial and meagre predilection, Avere contented AA'ith the descriptions of Thucydides, even Avhere nature had revealed, in infinite diversity, the work- ings of her powers." There cannot but be a natural interest in every medical mind to-day in the feAV descriptions given of the aAvful ravages of the epidemics which, fortun- ately, in our enlightened sanitary era, have entirely disappeared. In the his- tory of such epidemics the name of Hecker stands out so prominently that any remarks on this subject must necessarily, in some measure, find their origin in his Avritings, which include exhaustive histories of the black death, the dancing mania, and the SAveating sickness. FeAV historians have consid- ered Avorthy of more than a passing note an event of such magnitude as the black death, Avhich destroyed millions of the human race in the fourteenth century and was particularly dreadful in England. Hume has given but a single paragraph to it and others have been equally brief. Defoe has given us a journal of the plague, but it is not written in a true scientific spirit; and Cains, in 1552, gave us a primitive treatise on the SAveating sickness. It 891 892 HISTORIC EPIDEMICS. is due to the translation of Heckcr's " Epidemics of the Middle Ages " by Bab- bington, made possible through the good offices of the Sydenham Society, that a major part of the knowledge on this subject of the English-read ing popu- lace has been derh'ed. The Black Death, or, as it has been knoAvn, the Oriental plague, the bubonic plague, or in England, simply the plague, and in Italy, " la Mor- talega " (the great mortality) derived its name from the Orient; its inflam- matory boils, tumors of the glands, and black spots, indicative of putrid decom- position, were such as haA'e been seen in no other febrile disease. All the symp- toms Avere not found in every ease, and in many cases one symptom alone pre- ceded death. Although afflicted Avith all the manifestations of the plague, some patients recovered. According to Hecker the symptoms of cephalic affliction Avere seen ; many patients Avere stupefied and fell into a deep sleep, or became speechless from palsy of the tongue, Avhile others remained sleepless and Avith- out rest. The fauces and tongue Avere black and as if suffused with blood ; no beverage could assuage the burning thirst, so that suffering continued without alleA'iation until death, which many in their despair accelerated AA'ith their OAvn hands. Contagion Avas evident, for attendants caught the disease from their parents and friends, and many houses Avere emptied of their inhabitants. In the fourteenth century this affection caused still deeper sufferings, such as had not been hitherto experienced. The organs of respiration became the seats of a putrid inflammation, blood Avas expectorated, and the breath possessed a pes- tiferous odor. In the West an ardent fever, accompanied by an evacuation of blood, proved fatal in the first three days. It appears that buboes and inflam- matory boils did not at first appear, but the disease in the form of carbun- cular affection of the lungs (anthrax artigen) caused the fatal issue before the other symptoms deA'eloped. Later on in the history of the plague the inflam- matory boils and buboes in the groins and axillae Avere recognized at once as prognosticating a fatal issue. The history of this plague extends almost to prehistoric times. There Avas a pest in Athens in the fifth century before Christ. There was another in the second century, A. D., under the reign of Marcus Aurelius, and again in the third century, under the reign of the Gauls ; following this was the terrible epidemic of the sixth century, which, after having ravaged the terri- tory of the Gauls, extended AvestAvard. In 542 a Greek historian, Proco- pius, born about the year 500, gives a good description of this plague in a Avork, " Pestilentia Gravissima," so called in the Latin translation. Dupouy in " Le Moyen Age Medical," 314 says that it commenced in the village of Peleuse, in Egypt, and folloAved a double course, one branch going to Alex- andria and the other to Palestine. It reached Constantinople in the Spring of 543, and produced the greatest devastation Avherever it appeared. In the course of the succeeding half century this epidemic became pandemic and spread over all the inhabited earth. The epidemic lasted four months in THE BLACK DEATH. 893 Constantinople, from 5000 to 10,000 people dying each day. In his "His- tory of France," from 417 to 591, Gregorius speaks of a malady under the name inguinale Avhich depopulated the Province of Aries. In another passage this illustrious historian of Tours says that the town of Narbonne Avas devastated by a maladie des aines. We have records of epidemics in France from 567 to 590, in which bubonic symptoms were a prominent fea- ture. About the middle of the fourteenth century the bubonic plague made another incursion from the East. In 1333, fifteen years before the plague appeared in Europe, there Avere terrible droughts in China folioAved by enor- mous floods in Avhich thousands of people perished. There are traditions of a plague in Tche in 1334, folloAving a drought, Avhich is said to have car- ried off about 5,000,000 people. During the fifteen years before the appear- ance of the plague in Europe there were peculiar atmospheric phenomena all over the world, besides numerous earthquakes. From the description of the stinking atmosphere of Europe itself at this time it is quite possible that part of the disease came, not from China, but originated in Southern Europe itself. From China the route of caravans ran to the north of the Caspian Sea, through Asia, to Tauris. Here ships Avere ready to take the produce of the East to Constantinople, the capital of commerce, and the medium of communication between Europe, Asia, and Africa. Other caravans Avent from Europe to Asia Minor and touched at the cities south of the Caspian Sea, and lastly there were others from Bagdad through Arabia to Egypt; the maritime communication on the Red Sea to Arabia and Egypt Avas also not inconsiderable. In all these directions contagion found its Avay, though doubtless Constantinople and the harbors of Asia Minor Avere the chief foci of infection, Avhence it radiated to the most distant seaports and islands. As early as 1347 the Mediterranean shores Avere visited by the plague, and in January, 1348, it appeared in the south of France, the north of Italy, and also in Spain. Place after place Avas attacked throughout the year, and after ravishing the whole of France and Germany, the plague appeared in Eng- land, a period of three months elapsing before it reached London. The northern kingdoms were attacked in 1349, but in Russia it did not make its appearance before 1351. As to the mortality of this fearful epidemic Dupouy considers that in the space of four years more than 75,000,000 fell victims, that is, about half of the population of the countries visited. Hecker estimates that from 1347 to 1351, 25,000,000 people died, or one-quarter of the total population of Europe. It was reported to Pope Clement that throughout the East, probably Avith the exception of China, nearly 24,000,000 people had fallen victims to the plague. Thirteen millions are said to have died in China alone. Constantinople lost tAvo-thirds of its population. When the plague Avas at its greatest violence Cairo lost daily from 10,000 to 15,000, as many as modern plagues have carried off during their whole course. India was depopulated. Tartary, Mesopotamia, 894 HISTORIC EPIDEMICS. Syria, Armenia, and Arabia were covered AA'ith dead bodies. In this latter country Arabian historians mention that Maara el nooman, Schisur, and Harem in some unaccountable manner remained free. The shores of the Mediter- ranean were ravaged and ships Avere seen on the high seas Avithout sailors. In "The Decameron" Boccaccio gives a most graphic description of the plague and states that in Florence, in four months, 100,000 perished ; before the calamity it was hardly supposed to contain so many inhabitants. Accord- ing to Hecker, Venice lost 100,000 ; London, 100,000 ; Paris, 50,000 ; Siena, 70,000; Avignon, 60,000; Strasburg, 16,000; Norwich, 51,100. Dupouy says that in one month there were 56,000 victims in Marseilles, and at Montpellier three-quarters of the population and all the physicians were stricken with the epidemic. Johanna of Burgundy, wife of King Philip VI. of Valois ; Johanna II., Queen of NaA'arre, granddaughter of Philippe le Bel; Alphonse XI. of Castile, and other notable persons perished. All the cities of England suf- fered incredible losses. Germany seems to have been particularly spared ; according to a probable calculation, only about 1,250,000 dying. Italy Avas most severely visited, and Avas said to have lost most of its inhabitants. In the north of Europe tAvo of the brothers of Magnus, King of SAveden, died ; and in Westgothland alone 466 priests died. The plague showed no decrease in the northern climates of Iceland and Greenland, and caused great havoc in those countries. The moral effect of such a great pandemic plague can be readily sur- mised. The mental shock sustained by all nations during the preA'alence of the black plague is beyond parallel and description. An aAvful sense of con- trition and repentance seized Christians of every community. They resoh'ed to forsake their A'ices, and to make restitution for past offenses ; hence ex- treme religious fanaticism held full sAvay throughout Europe. The zeal of the penitents stopped at nothing. The so-called Brotherhood of the Cross, otherAvise knoAvn as the Order of Flagellants, which had arisen in the thir- teenth century, but avus suppressed by the mandates and strenuous efforts of the Church, Avas revived during the plague, and numbers of these advocates of self-chastisement roamed through the A'arious countries on their great pil- grimages. Their poAver increased to such an extent that the Church Avas in considerable danger, for these religious enthusiasts gained more credit among the people, and operated more strongly on their minds than the priests from Avhom they so entirely Avitlidrew that they even absolved each other. Their strength grew with such rapidity, and their numbers increased to such an extent daily, that the State and the Church Avere forced to combine for their suppres- sion. Degeneracy, however, soon crept in, crimes were committed, and they went beyond their strength in attempting the performance of miracles. One of the most fearful consequences of this frenzy Avas the persecution of the JeAvs. This alien race Avas given up to the merciless fury and cruelty of the populace. THE GREAT PLAGUE OF LONDON. 895 The persecution of the Jews commenced in September and October, 1348, at Chillon on Lake Geneva, where criminal proceedings were instituted against them on the mythic charge of poisoning the public Avells. These persecuted people were summoned before sanguinary tribunals, beheaded and burned in the most fearful manner. At Strasburg 2000 Jews Avere burned alive in their OAvn burial-ground, where a large scaffold had been erected, their wealth being divided among the people. In Mayence 12,000 Jews were said to have been put to a cruel death. At Eslingen the whole Jewish community burned themselves in their synagogue, and mothers were often seen throwing their children on the pile, to prevent them from being baptized, and then precipitating themselves into the flames. The cruel and avaricious desires of the monarchs against these thrifty and industrious people added fuel to the flames of the popular passion, and even a fanatic zeal arose among the Jews to perish as martyrs to their ancient religion. When we sum up the actual effects as well as the after effects of the black death, we are appalled at the magnitude of such a calamity, the like of which the world had never seen before. In the fifteenth and sixteenth centuries the plague was generally diffused throughout Europe, and in the latter half of the seventeenth century a final Occidental incursion of the plague took place. From 1603 to 1604 over 30,000 people perished in London from the plague, and in 1625 the mortality in that city amounted to 35,417 persons. But the great plague of London did not begin until 1664. In this plague the patient at first became sensible of great weariness and fatigue, had slight chills, nausea, vomiting, vertigo, and pains in the loins. The mental disturbance rapidly increased, and stupor and de- lirium ensued. The face was alternately flushed and pallid, and a sense of constriction was experienced in the region of the heart. Darting pains were felt all over the body, soon followed by the enlargement of the lymphatic glands, or by the formation of carbuncles in various parts of the body. About the third day the tongue became dry and brown, and the gums, tongue, and teeth were covered Avith a dark fur, and the excretions became offensive; paralysis intervened ; ecchymosed patches or stripes due to extra- vasation appeared on the skin; finally the pulse sank, the body grew cold and clammy, delirium or coma seized the victim, and in five or six days, sometimes in tAvo or three, the painful struggle was at an end. It Avas supposed that the disease originated in the Orient and was brought to London from Holland. In his " Journal of the Plague in London " Defoe describes its horrors, and tells of the dead-cart Avhich Avent through the streets gathering the victims. A few extracts from Pepys's " Diary," the evidence of an eye-Avitness and a contemporary, shoAv the ghastly aspects of this terrible visitation. On August 31st he writes : " In the City, this Aveek, died 7496, and of them 6102 died of the plague. But it is found that the true number of the dead this week is nearer 10,000 ; partly from the poor who cannot be 896 HISTORIC EPIDEMICS. taken care of through the greatness of the number, and partly from the Quakers and others that will not have any bell rung for them." According to Adams, John EA'elyn noted in his " Kalendarium " :—" Sept. 7th.— Near 10,000 now died weekly; hoAvever, I went all along the City and suburbs from Kent street to St. James's, a dismal passage, and dangerous to see so many coffins exposed in the streets; the streets thin of people, the shops shut up, and all in silence, no one knoAving Avhose turn might be next." As the cold weather came on the plague diminished in intensity and the people regained their confidence and returned to the city. According to Adams, a in the first Aveek of March, 1666, deaths by the plague had decreased to 42 ; and by the end of the month it was nearly extinct after carrying off about 100,000 A'ictims. In our days we can hardly comprehend the filthy hygi- enic conditions under which the people in the cities lived, and it Avas proba- bly to this fact that the growth and perpetuation of this plague Avas due. As to the bubonic plague recently raging in Camptown, China, Mary Niles b says that it was the same disease as the great London plague, and Avas characterized mainly by glandular enlargement. It had not appeared in the Canton district for forty years or more, though it Avas endemic in Yun- nan. In some places it began in the Avinter; and as early as January she herself found the first case in Canton in an infected house. In no case was direct contagiousness found to exist. The glands enlarged twelve hours after the fever began, and sometimes suppurated in nonfatal cases in a short time. Kitasato has recently announced the discovery of the specific cause of the bubonic plague. Sweating Sickness.—According to Hecker, very shortly after Henry's triumphant march from Bosworth Field, and his entry into the Capital on August 8, 1485, the SAveating sickness began its ravages among the peo- ple of the densely populated city. According to Lord Bacon the disease be- gan about September 21st, and lasted to the end of October, 1485. The physicians could do little or nothing for the people, and seemed to take no account of the clinical history of the disease,—in this respect not unlike the Greek physicians who for four hundred years paid no attention to small-pox because they could find no description of it in the immortal works of Galen. The causes seemed to be uncleanliness, gluttony, immoderate drinking, and also severe inundations leaving decaying vegetation. Richmond's army has been considered a factor in the germination of the seeds of pestilent disorder Avhich broke out soon after in the camps of Litchfield, and on the banks of the Severn. Sweating sickness was an inflammatory rheumatic fever, with great dis- order of the nervous system, and was characterized by a profuse and injuri- ous perspiration. In the English epidemic the brain, meninges, and the nerves were affected in a peculiar manner. The functions of the pneumo- a " The Healing Art," London, 1887. b 597) Oct. 13, 1894. S WE A TING SICKNESS. 897 gastric nerves Avere violently disordered in this disease, as Avas shoAvn by the oppressed respiration and extreme anxiety, Avith nausea and vomiting,—symp- toms to Avhich modern physicians attach much importance. The stupor and profound lethargy shoAv that there Avas an injury to the brain, to Avhich, in all probability, was added a stagnation of black blood in the torpid veins. Probably decomposing blood gave rise to the offensive odor of the person. The function of the lungs Avas considerably impaired. The petechial fever in Italy in 1505 was a form of the sweating sickness. There Avere visitations in 1506 and in 1515 in England. In 1517 the disease lasted full six months and reached its greatest height about six Aveeks after its appearance, but was apparently limited to England. Meningeal symptoms Avere characteristic of the third visitation of the disease. In 1528 and 1529 there Avas a fourth visitation Avhich resulted in the destruction of the French Army before Naples. It is said that in 1524 a petechial fever carried off 50,000 people in Milan, and possibly this Avas the same disease. In 1529 the disease had spread all over Europe, attended with great mortality. Germany, France, and Italy were visited equally. The famine in Ger- many, at this time, is described by authorities in a tone of deep sympathy. SAvabia, Lorraine, Alsace, and provinces on the border of the loAver Rhine, were frightfully affected, so that the disease reached the same heights there as in France. In England Henry VIII. endeavored to avoid the epidemic by continual traveling, until at last he greAV tired of so unsettled a life and deter- mined to aAvait his destiny at Tytynhangar. It was not the inhabitants of the land alone Avho Avere affected, but even fish and the foAvls of the air sick- ened. According to Schiller, in the neighborhood of Freiburg in Breisgau, dead birds avc re found scattered under the trees with boils as large as peas under their wings,—indicating among them a disease, and this extended far beyond the southern districts of the Rhine. The disease was undoubtedly of a miasmatic infectious nature, as Avas proved by its rapid spread and the occa- sional absence of a history of contagion. It was particularly favored in its development by high temperature and humidity. The moral effect of the sweating sickness, similar to that of the black plague, AA-as again to increase religious fanaticism and recreate the zeal of persecution. On the loth of April, 1551, there was an outbreak of the fifth and last epidemic of SAveating fever in Shrewsbury, on the Severn. With stinking mists it gradually spread all over England, and on the 9th of July it reached London. The mortality was very considerable. The English residents were particularly susceptible, foreigners being comparatively exempt. The epidemic terminated about the 30th of September. Since that time the sweating sickness has never reappeared in England ; but in the beginning of the eighteenth century a disease very similar in symptoms and course broke out in Picardy, in Northern France. Toward the end of the century it spread 57 898 HISTORIC EPIDEMICS. to the South of France, and since that time has appeared epidemically, 195 distinct outbreaks having been observed in the course of one hundred and sixty-nine years, from 161S to 1787. The disease has frequently appeared in Italy since 1755, and in various parts of Germany since 1801. In Belgium it has been observed in a few places within the present century (Kobe). Chronologic Table of the Principal Plagues.—In December, 1880, H. P. Potter, F. R. C. S., published a chronologic table of some of the prin- cipal plagues on record.3 In comments on his table, Potter says that he has doubtless included mention of many plagues which, although described under that name, are probably a dissimilar disease, Avriters having applied the terms pestilential and pestilent in a generic sense to diseases specifically different. It must also be remembered that, in some cases, death must have been due to famine, Avant, and privation, which are so frequently coexistent with pestilence. Following the idea of Hecker, the dancing manias have been included in this table. TABLE OF PLAGUES. B.C. 1495, 1471, 1490, 1310, 1141, 1190, 1017. 790, 738, 710, 694, 671, 545, 594, 480, 476, 463, 452, 430, 427. 404, 393 and 383 366, . 362, . Locality. ,{ Egypt, Desert of Paran,..... In the wilderness, .... iEguia (island of), . . . . Ashdod, a place between") Guza and Joppa, . . J Troy (siege of),..... Canaan, Rome, Rome, Rome, Mortality. Velitrae,........ Jerusalem,......•< Army of Xerxes, .... Spain,......... Rome,......... Rome, Athens, Spain (from Egypt), . . . Carthage, ........ Gaul and Rome (armies \ of),........j Rome.......... Murviedro (Sicily), . . . 14,000 • { 70,000 f in three days, \ 185,000 | { Depopulated, . One-third of\ inhabitants, / 150,000 :he in-1 tants, ) Half the in-' habitants, Depopulated, 10,000 daily, During the reign of Pharaoh, King of Egypt, A.M. 2509.— Exodus xii. Numbers xi. Ovid's Metam., lib. vii. Among the Philistines, 1 Sam. v. and vi. In the Grecian camp, Homer's Iliad, lib. i. In the time of David, 2 Sam. xxiv. Plutarch's Life of Romulus. Assyrian armies at the siege of Jerusalem. Described by Livy. Small town near Rome. Livy, iii., 6. Livy, iii., 32. Continued without interruption for five years. —Thucydides. ii., 48. Justin, xix., 2; Diod. Sic, xiii. Livy, vii., 1 ; Short, On Air. a Jour. Statis. Soc. Lond., Dec, 1880. CHRONOLOGIC TABLE OF THE PRINCIPAL PLAGUES. 899 TABLE OF PLAGUES.—Continued. Date. B.C. 346, 332, 296, 291, 237, 218, 216, 213, 206, 182-177 144, 140, 134 and 130 126, 89, 88, 60, ,{ A.D. 68, .... 114, 187, . . . . 158, .... 175 and / 178,\ 252, . . 262, . . 310, . . 325, . . 365-394 400, . . 450-67 and \ 473, / 562, .... 517, .... 544, .... 565-610, . { 590, . . 654, . . 664, . . 665-683, 696, . . 703. and 713 717, 724 Locality. 1 729, } 732, 740, 762, 853, 896, 937, 940, ,} ,} •{ { Rome,......... Cadiz,......... Carthaginian armies, . . . Carthage,........ Carthaginian and Roman \ armies,.......J Capua,......... Rome and all Italy, . . . Rome,......... Rome,......... Italy, ......... Numidia,........ Seacoast of Carthage, . . Roman armies,..... Rome (people in), .... Spain,......... Rome,......... Wales,......... Rome and Italy,..... Arabia,......... Rome,......... Alexandria,....... Rome,......... England,........ Britain, ........ Italy and Syria,..... Asia, Africa, and Europe, . Rome, . . ...... Scotland,........ Palestine,........ France,......... Especially France, Ger- \ many, and Italy, . . J Rome,......... Constantinople,..... South Britain,...... England,........ Constantinople,..... Scotland,........ Constantinople,..... Norwich in England, and \ Syria,......./ Various parts of Europe! and the East, . . . . / Wales. In Chichester, . . Scotland,........ Gaul, Germany, and Italy, England,........ North of Europe, .... Mortality. 800,000 200,000 10,000 30,000 45,000 5,000 daily, 40,000 71 719 Remarks. 30,000 34,000 Livy. On their route to besiege Tagun- tum. Before Syracuse, Livy, xxv. Livy, xii., 21. Orosius, lib. v. ? Leprosy. Tacitus Annals, xv. Orosius, lib. vii. Zonaras, lib. xii. Nicephorus, xiii. ? Dysentery. A plague raging, with intermis- sions, in most parts of the world.—Niceph., xvii. With intermissions. Raged for 260 years. AfFecting chiefly the cattle. 900 HISTORIC EPIDEMICS. TABLE OF PLAGUES.— Contimud. Date. A.D. 964. . . . 1005, . . 1012-25, . 1027, . . 1029-31 and 1033, 1064, . . 1068, . . 1075, . . 1096-1111, 1120, . . 1126-28, 1133-46, 1172, . . 1183, . . 1193-96, 1200-1201, 1217, . 1235, . 1237, . 1278, . 1283, . 1:5:55, . 1345, . 1346, . 1347, . 1348, . 1350-51, 1352, . 1355, . 1363, . 1365, . 1368-70, 1371, . 1372, . 1374, . 1379, . 1383, . 13X4, 1387, . 1391, . Locality. ... { England and other parts) of Europe,...../ England and Gaul, . . . Saracen army,.....■< York and Durham, . . . Constantinople,..... Europe (various parts), . . Various parts of the globe, England,........ England,........ England and Rome, . . . England,........ Damietta, ..... London, ........ Egypt,......... Utrecht,........ Spain,......... England,........ Spain, and spread over! the whole world, . . 1 Florence,........ London, ........ Venice, ........ Lubeck,........ Spain,......... Syria, Greece, Italy, Cyprus, Ireland,........ China,......... London, ........ Florence,........ Norwich......... Yarmouth,....... Spain,......... Cologne,........ England and Ireland, . . Barcelona,....... Germany, Egypt, Greece, \ and all the East, . . . / Holland, France, and\ Rhenish provinces, . . / England,........ Seville,......... Mallorca,........ Portugal,........ England, York, and Nor-1 folk especially, . . . j Mortality. Remarks. Half the hu man race -} Many thou-J sands, . . \ Only 3 persons ~\ out of 70,000 \ survived, . J 20,000 4,000 \ Great mortality, Leaving 1 scarcely a ! quarter of the [ human race. J 60,000 50,000 100,000 90,000 200,000 900,000 50,000 100,000 37,104 7,502 20,000 Lubeck, 90,000 Emperor Otho's army. Raged for three years. With intermissions. Convulsive disease ; dance of St. Vitus. Marching to invade Rome ; raged for two years. Lasted 272 years. ? Dysentery. Dancing disease among the chil- dren. Dancing mania. King Philip of France invaded Spain with 20,000 infantry and 8,600 cavalry. Interred in one graveyard. Dancing disease of St. Vitus or St. John. CHRONOLOGIC TABLE OF THE PRINCIPAL PLAGUES. 901 TABLE OF PLAGUES.— Continued. Date. A.D. 1394, 1401, 1410, 1418, 1429, 1439, 1450, 1465, 1468, 1482, 1485, 1488, 1489, 1493, 1495, 1499, 1529, 1530. 1535, 1537-39 1541. 1543, 1547, 1556, 1558, 1562, 1564, 1565, 1566, 1570, 1572, 1574, 1579, 1580-81, 1582, . 1585-86, 1589, . 1590, . 1593, . . 1600-1602, 1603, . . 1606, . . 1609, . . 1610, . . 1613, . . 1616, . . Locality. Mortality. Spain,........ London, ........ Seville,......... Strasburg, ....... Barcelona,....... Huescar in the kingdom 1 of Aragon,....../ Italy, Gaul, Germany, \ and Spain,......J Italy, ......... Parma,......... France,......... Seville,......... Andalusia,....... Barcelona,....... Mallorca,........ Saragossa, ....... Britain,......... England,........ Germany,........ Cork and Dresden, .... England,........ Constantinople,..... Metz,.......... England, Holland, and \ Germany,......j Spain, ......... Murcia, ........ London and most of the 1 principal cities of Eu- j- rope,........J Barcelona,....... Lyons,......... " Morbus Hungaricus," Spain,......... Dresden,........ Spain and Italy,..... Rome,......... Lubeck,........ Hamburg, ....... Cairo and the East, . . . Spain, especially Cadiz, Narva and Revel, in Li-1 vouia,.......J Seville,......... Dresden,........ Malta,....... Muscovy,........ Livonia, ........ London,........ Paris, ......... Throughout Europe, . . . Seville,......... Granada......... Constantinople,..... France and Constantino- \ pie, ........i Germany, Denmark,! Egypt, and Levant, . J 30,000 London 30,000, Remarks. Dancing disease. "Sweating sickness" in Eng- land. Spread to Brabant Sweating sickness Spotted fever, Saragossa, 10,000 4,000 8,000 3,000 500,000 Revel, 6,000 70,000 in 1 Lisbon and > Spain, J 500,000 30,000 36,000 2,000 weekly, 200,000 Flanders, etc. 902 HISTORIC EPIDEMICS. TABLE OF PLAGUES.—Continued. Date. A.D. 1622, 1625, 1626, 1634, 1635, 1644, 1649, 1653, 1656, 1662, 1663, 1664, 1665, 1673, 1675, 1677, 1679, 1691, 1698, 1705, 1710, 1720, 1722, 1727, 1732, 1735, 1736, 1740, 1743, 1751, . 1751-60, 1761, 1762, 1763, 1769, 1770, Locality. London,.......-i Throughout England, . . Lyons,......... Dresden,........ Leyden and Nineguen, . . Madrid,........ Spain,......... Moscow,........ Riga,.......... Amsterdam,....... Leyden, ........ Naples,......... Benevento, ....... Genoa,......... Rome,......... Neapolitan territories, . . Venice,......... England,........ Amsterdam, ...... London, ........ Spain,......... Malta,......... Murcia and Carthagena, . Germany,........ Germany, ........ Spain,......... Ceuta, ......... Copenhagen, ...... Stockholm,....... Marseilles,....... Vienna, Hungary, and in \ the East,......j Spain,......... London, ....... < Egypt,........| Cairo,......... Ireland,........ Aleppo,......... Cordova,...... Ireland and France, . . < Carthagena,....... Aleppo, Jerusalem, and 1 Damascus,.....J Naples,......... Bengal,....... Poland and Russia, . . . Bohemia, . . ,..... Constantinople, . . . . -j Mortality. Remarks. 1st year, 8,0001 2d " 11,000 I 3d " 12,000 | 4th " 35,417 J London, 30,000 60,000 Leyden, 20,000 London, 10,000 200, 200, 9 13, 13, 240, 9, 10, 10, 400, 60, 000 000 000 200 000 000 000 000 000 000 000 24,000 68,596 i 1,300 25,000 | 30,000 1,500 in one \ week, . . j Many thou- \ sands, . . J 100,000 40,000 in Cairo] andConstan- > tinople, . . J 30,000 in Cy-1 prus, ... J 20,000 "3 millions and upward," 20,000 168,000 1,000 buried] daily for > some weeks, J Lasted lour years. Three-quarters of the inhabi- tants. In six months, the "sweating sickness.'' Epidemic mania. 7,000 buried daily for some days. SMALL-POX. 903 TABLE OF PLAGUES.—Continued. Date. A.D. 1771, 1783-85, 1792, . 1799, . 1809, '.' 1810, . 1812, . 1813, . 1815, . 1817, . 1841, . 1843, . 1844, . 1873-76, 1877, . Locality. Moscow,.......< Bassora,........ Egypt, Dalmatia, Con-1 stantindple, etc., . . / Egypt,......... Barbary, ........ Fez,.......... Portugal,........ Gibraltar,...... Constantinople,..... Malta,......... Corfu,......... Throughout the habitable \ globe,......./ Syria, especially about! Erzeroum,...../ Asiatic Turkey,..... Egypt,......... Mesopotamia,...... Resht, near the Caspian, . Mortality. 133,299 in 18 months, . 80,000 800,000 3,000 daily, 247,000 Out of 14,0001 only 28 es- > caped, . . J 160,000 4,483 20,000 in 1876, Remarks. In the French army in Egypt. Among British troops. Dancing mania. Small-pox.—From certain Chinese records it appears that small-pox, or a disease with similar symptoms, was known in China before the Christian era, and it was supposed to have been known at a very early period in India. Most likely it was introduced into Europe in the second century by a Roman army returning from Asia. Before the sixth century, the terrible century of the great plague, there seem to be no records of small-pox or other eruptive fevers. Neither Hippocrates, Galen, nor the Greek physicians who practised at Rome, mention small-pox, although it is now believed that the Emperor Marcus Aurelius died of this disease. According to Dupouy, the first docu- ment mentioning variola was in 570 A. D., by Marius, a scholar of Avenches, in Switzerland. ("Anno 570, morbus validus cum profluvio ventris, et variola, Italiam Galliamque valde affecit") Ten years later Gregory of Tours describes an epidemic with all the symptoms of small-pox in the fifth reign of King Childebert (580); it started in the region of Auvergne, which was inundated by a great flood; he also describes a similar epidemic in Touraine in 582. Rhazes, or as the Arabs call him, Abu Beer Mohammed Ibn Zacariya Ar-Razi, in the latter part of the ninth century wrote a most cele- brated work on small-pox and measles, which is the earliest accurate descrip- tion of these diseases, although Rhazes himself mentions several writers who had previously described them, and who had formulated rules for their cure. He explained these diseases by the theory of fermentation, and recommended the cooling treatment. Adams" remarks that although it is probable that small-pox existed for ages in Hindoostan and China, being completely isolated 904 HISTORIC EPIDEMICS. in those countries from the European world, it was not introduced into the West until the close of the seventh century. Imported into Kgvpt by the Arabians, it followed in the tracks of their conquests, and was in this way propagated over Europe. The foregoing statement disagrees with Dupouv and others. It is well known that small-pox was prevalent in Kurope before Rhazes's description of it, and after the Crusades it spread over Central and Western Europe, but did not extend to the northern countries until some years later. In 1507 the Spaniards introduced it into San Domingo, and in 1510 into Mexico, where it proved a more fatal scourge than the swords of Cortez and his followers, for according to Robertson it swept away in Mexico three millions and a half of people. In 1707 it appeared in Iceland, and carried off more than one-fourth of its inhabitants ; in 17->-5, according to Collinson, it almost depopulated Greenland. The Samoveds, Ostiaks, and other natives of Eastern Siberia, have frequently suffered from devastating epidemics. In Kamchatka the disease was introduced in 1767, and many villages were completely depopulated. According to Moore, at the beginning of the eigh- teenth century nearly one-fourteenth of the population died from small-pox in England, and at the end of the century the number of the victims had in- creased to one-tenth. In the last century the statement was made in England that one person in every three was badly pock-marked. The mortality of the disease at the latter half of the eighteenth century was about three to every thousand inhabitants annually. India has always been a fertile ground for the development of small-pox, and according to Rohea the mortality from small-pox has been exceedingly great for the past twenty years. From 1866 to 1869, 140,000 persons died in the Presidencies of Bombay and Calcutta, and several years later, from 1873 to 1876, 700,000 died from this disease. China, Japan, and the neighboring countries are frequently visited with small-pox, and nearly all the inhabitants of Corea are said to bear evidences of the disease. In the Marquesas Islands one-fourth of the inhabitants had fallen victims to the disease since 1863. It was first intro- duced into the Sandwich Islands in 1853, and it then carried off eight per cent. of the natives. Australia, Tasmania, New Zealand, and the Fiji Archi- pelago have to the present day remained exempt from small-pox ; although it has been carried to Australia in vessels, rigorous quarantine methods have promptly checked it. On the American continent it was believed that small- pox was unknown until the conquest of Mexico. It has been spread through various channels to nearly all the Indian tribes of both North and South America, and among these primitive people, unprotected by inoculation or vaccination, its ravages have been frightful. That small-pox—a disease so general and so fatal at one time—has, through the ingenuity of man, in civilized communities at least, become almost extinct, is one of the greatest triumphs of medicine. a " Text-Book of Hygiene," Phila., 1890. INOCULATION. 905 Inoculation was known in Europe about 1700, and in 1717 the famous letter of Lady Montagu from Adrianople was issued, containing in part the following statements :— " The small-pox, so fatal and so general amongst us, is here entirely harm- less, by the invention of ingrafting, which is the term they give it. There is a set of old women who make it their business to perform the operation every autumn in the month of September, when the great heat is abated. People send to one another to know if any of their family has a mind to have the small-pox ; they make parties for this purpose, and when they are met, the old woman comes with a nut-shell full of the matter of the best sort of small-pox, and asks what vein you please to have opened. She immedi- ately rips open that you offer her with a large needle, and puts into the vein as much matter as can lie upon the head of her needle, and after that binds up the little wound with a hollow shell, and in this manner opens four or five veins." Soon after this letter Lady Montagu had her son inoculated in Turkey, and four years later her daughter was to be the first subject inoculated in England. She made rapid progress notwithstanding the opposition of the medical profession, and the ignorance and credulity of the public. The clergy vituperated her for the impiety of seeking to control the designs of Provi- dence. Preaching in 1722, the Rev. Edward Massey, for example, affirmed that Job's distemper was confluent small-pox, and that he had been in- oculated by the Devil. Lady Montagu, however, gained many supporters among the higher classes. In 1721 Mead was requested by the Prince of Wales to superintend the inoculation of some condemned criminals, the Prince intending afterward to continue the practice in his own family ; the experiment was entirely successful, and the individuals on whom it was made afterward received their liberty (Adams). According to Rohe, inoculation was introduced into this country in 1721 by Dr. Zabdiel Boylston of Boston, who had his attention directed to the practice by Cotton Mather, the eminent divine. During 1721 and 1722 286 persons were inoculated by Boylston and others in Massachusetts, and six died. These fatal results rendered the practice unpopular, and at one time the inoculation hospital in Boston was closed by order of the Legisla- ture. Toward the end of the century an inoculating hospital was again opened in that city. Early in the eighteenth century inoculation was extensively practised by Dr. Adam Thomson of Maryland, who was instrumental in spreading a knowledge of the practice throughout the Middle States. Despite inoculation, as we have already seen, during the eighteenth century the mortality from small-pox increased. The disadvantage of inoculation was that the person inoculated was affected with a mild form of small-pox, which, however, was contagious, and led to a virulent form in uninoculated persons. 906 HISTORIC EPIDEMICS As universal inoculation was manifestly impracticable, any half-way measure was decidedly disadvantageous, and it was not until vaccination from cow-pox was instituted that the first decided check on the ravages of small-pox was made. Vaccination was almost solely due to the persistent efforts of Dr. Ed- ward Jenner, a pupil of the celebrated John Hunter, born May 17, 1749. In his comments on the life of Edward Jenner, Adams, in " The Heal- ing Art," has graphically described his first efforts to institute vaccination, as follows : " To the ravages of small-pox, and the possibility of finding some preventive Jenner had long given his attention. It is likely enough that his thoughts were inclined in this direction by the remembrance of the sufferings inflicted upon himself by the process of inoculation. Through six weeks that process lingered. He was bled, purged, and put on a low diet, until ' this barbarism of human veterinary practice' had reduced him to a skeleton. He was then exposed to the contagion of the small-pox. Happily, he had but a mild attack ; yet the disease itself and the inoculating operations, were probably the causes of the excessive sensitiveness which afflicted him through life. " When Jenner was acting as a surgeon's articled pupil at Sudbury, a young countrywoman applied to him for advice. In her presence some chance allusion was made to the universal disease, on which she remarked : ' I shall never take it, for I have had the cow-pox.' The remark induced him to make inquiries ; and he found that a pustular eruption, derived from infec- tion, appeared on the hands of milkers, communicated from the teats of cows similarly disordered ; this eruption was regarded as a safeguard against small-pox. The subject occupied his mind so much that he frequently men- tioned it to John Hunter and the great surgeon occasionally alluded to it in his lectures, but never seems to have adopted Jenner's idea that it might suggest some efficacious substitute for inoculation. Jenner, however, con- tinued his inquiries, and in 1780 he confided to his friend, Edward Gardner, his hope and prayer that it might be his work in life to extirpate small- pox by the mode of treatment now so familiar under the name of vaccina- tion. " At the meetings of the Alveston and Radborough Medical Clubs, of both of which Jenner was a member, he so frequently enlarged upon his favorite theme, and so repeatedly insisted upon the value of cow-pox as a prophylactic, that he was denounced as a nuisance, and in a jest it was even proposed that if the orator further sinned, he should then and there be ex- pelled. Nowhere could the prophet find a disciple and enforce the lesson upon the ignorant; like most benefactors of mankind he had to do his work unaided. Patiently and perseveringly he pushed forward his investigations. The aim he had in view was too great for ridicule to daunt, or indifference to discourage him. When he surveyed the mental and physical agony inflicted VACCINATION 907 by the disease, and the thought occurred to him that he was on the point of finding a sure and certain remedy, his benevolent heart overflowed with un- selfish gladness. No feeling of personal ambition, no hope or desire of fame, sullied the purity of his noble philanthropy. 'While the vaccine discovery was progressive,' he writes, < the joy at the prospect before me of being the instrument destined to take away from the world one of its greatest calami- ties, blended with the fond hope of enjoying independence, and domestic peace and happiness, were often so excessive, that, in pursuing my favorite subject among the meadows, I have sometimes found myself in a kind of reverie. It is pleasant to recollect that those reflections always ended in devout acknowledgments to that Being from whom this and all other blessings flow.' At last an opportunity occurred of putting his theory to the test. On the 14th day of May, 1796,—the day marks an epoch in the Healing Art, and is not less worthy of being kept as a national thanksgiving than the day of * Waterloo—the cow-pox matter or pus was taken from the hand of one Sarah Holmes, who had been infected from her master's cows, and was inserted by two superficial incisions into the arms of James Phipps, a healthy boy of about eight years of age. The cow-pox ran its ordinary course without any injurious effect, and the boy was afterward inoculated for the small-pox,—hap- pily in vain. The protection was complete; and Jenner thenceforward pursued his experiments with redoubled ardor. His first summary of them, after having been examined and approved by several friends, appeared under the title of ' An Inquiry into the Causes and Effects of the Variolae Vac- cinae,' in June, 1798. In this important work he announced the security against the small-pox afforded by the true cow-pox, and proceeded to trace the origin of that disease in the cow to a similar affection of the horse's heel." This publication produced a great sensation in the medical world, and vaccination spread so rapidly that in the following summer Jenner had the indorsement of the majority of the leading surgeons of London. Vaccination was soon introduced into France, where Napoleon gave another proof of his far-reaching sagacity by his immediate recognition of the importance of vac- cination. It was then spread all over the continent; and in 1800 Dr. Ben- jamin Waterhouse of Boston introduced it into America; in 1801, with his sons-in-law, President Jefferson vaccinated in their own families and those of their friends nearly 200 persons. Quinan a has shown that vaccination was introduced into Maryland at least simultaneously with its introduction into Massachusetts. De Curco introduced vaccination into Vienna, where its beneficial results were displayed on a striking scale ; previously the average annual mortal it v had been about 835 ; the number now fell to 164 in 1801, (51 in 1802 and 27 in 1803. After the introduction of vaccination in England the mortality was reduced from nearly 3000 per million inhabitants annually to 310 per million annually. During the small-pox epidemic in a 510, June 23 and 30, 1883. 908 HISTORIC EPIDEMICS. London in 1X63, Seaton and Buchanan examined over 50,000 school chil- dren, and among every thousand without evidences of vaccination they found 360 with the scars of small-pox, while of every thousand presenting some evidence of vaccination, only 1.78 had any such traces of small-pox to exhibit. Where vaccination has been rendered compulsory, the results are surprising. In 1874 a law was established in Prussia that every child that had not already had small-pox must be vaccinated in the first year of its life, and every pupil in a private or public institution must be revaccinated during the yrear in which his or her twelfth birthday occurs. This law virtually stamped small-pox out of existence ; and according to Frolich a not a single death from small-pox occurred in the German army between 1874 and 1882. Notwithstanding the arguments advanced in this latter day against vaccina- tion, the remembrance of a few important statistic facts is all that is neces- sary to fully appreciate the blessing which Jenner conferred upon humanity. In the last century, besides the enormous mortality of small-pox (it was com- * puted that, in the middle of the last century, 2,000,000 victims perished in Russia from small-pox), the marks of affliction, blindness, deafness, etc., were plain in at least one member of every family. Asiatic cholera probably originated centuries ago in India, where it is now endemic and rages to such an extent as to destroy 750,000 inhabitants in the space of five years. There is questionable evidence of the existence of cholera to be found in the writings of some of the classic Grecian and Indian authors, almost as far back as the beginning of the Christian era. In the sixteenth and seventeenth centuries travelers in the East gave accounts of this disease. Sonnerat, a French traveler, describes a pestilence having all the characteristics of A sialic cholera which prevailed in the neighborhood of Pondicherry and the Coromandel coast from 1768 to 1769, and which, within a year, carried off 60,000 of those attacked. According to Rohe, Jasper Correa, an officer in Vasco da Gama's expedition to Calicut, states that Zamorin, the chief of Calicut, lost 20,000 troops by the disease. Although cholera has frequently extended to Europe and America, its ravages have never been nearly as extensive as in the Oriental outbreaks. An excellent short historic sketch of the epidemics of the cholera observed beyond the borders of India has been given by Rohe.b In 1817 cholera crossed the boundaries of India, advancing southeasterly to Ceylon, and westerly to Mauritius, reaching the African coast in 1820. In the following two years it devastated the Chinese Empire and invaded Japan, appearing at the port of Nagasaki in 1822. It advanced into Asiatic Russia, and appeared as far east as St. Petersburg in 1830, from whence it spread north to Finland. In 1831 it passed through Germany, invading France and the western borders of Europe, entering the British Isles in 1832, and crossing the Atlantic Ocean for the first time, appeared in Canada, having been carried thence by some Irish emigrants. a " Militar-Medicin," p. 461. b Loc. cit., p. 315. ASIATIC CHOLERA. 909 From Canada it directly made its way to the United States by way of Detroit. In the same year (1832) it appeared in New York and rapidly spread along the Atlantic coast. "During the winter of 1832 it appeared at Xew Orleans, and passed thence up the Mississippi Valley. Extending into the Indian country, caus- ing sad havoc among the aborigines, it advanced westward until its further progress was stayed by the shores of the Pacific Ocean. In 1834 it reap- peared on the east coast of the United States, but did not gain much headway, and in the following year New Orleans was again invaded by way of Cuba. It was again imported into Mexico in 1833. In 1835 it appeared for the first time in South America, being restricted, however, to a mild epidemic on the Guiana coast. " In 1846 the disease again advanced beyond its natural confines, reach- ing Europe by way of Turkey, in 1848. In the autumn of this year it also appeared in Great Britain, Belgium, the Netherlands, Sweden, and the United States, entering by way of New York and New Orleans. In the succeeding two years the entire extent of country east of the Rocky Mountains was invaded. During 1851 and 1852 the disease was frequently imported by emigrants, who were annually arriving in great numbers from the various infected countries of Europe. In 1853 and 1854 cholera again prevailed extensively in this country, being, however, traceable to renewed importation of infected material from abroad. In the following two years it also broke out in numerous South American States, where it prevailed at intervals until 1863. Hardly had this third great pandemic come to an end before the disease again advanced from the Ganges, spreading throughout India, and extending to China, Japan, and the East Indian Archipelago, during the years 1863 to 1865. In the latter year it reached Europe by way of Malta and Marseilles. It rapidly spread over the Continent, and in 1866 was imported into this country by way of Halifax, New York, and New Orleans. This epidemic prevailed extensively in the Western States, but produced only slight ravages on the Atlantic Coast, being kept in check by appropriate sanitary measures. In the same year (1866) the disease was also carried to South America, and invaded for the first time the states bordering on the Rio de la Plata and the Pacific coast of the Continent. " Cholera never entirely disappeared in Russia during the latter half of the sixth decade, and in 1870 it again broke out with violence, carrying off a quarter of a million of the inhabitants before dying out in 1873. It spread from Russia into Germany and France and was imported, in 1873, into this country, entering by way of New Orleans and extending up the Mississippi Valley. None of the Atlantic coast cities suffered from this epidemic in 1873 and since that year the United States has been entirely free from the disease with the exception of a few imported cases in New York harbor in 1887 "(and in 1893). 910 HISTORIC EPIDEMICS. In 1883 an epidemic of cholera raged in Egypt and spread to many of the Mediterranean ports, and reappeared in 1885 with renewed violence. In Spain alone during this latter epidemic the total number of cases was over one-third of a million, with nearly 120,000 deaths. In 1886 cholera caused at lea.-t 100,000 deaths in Japan. In the latter part of 1886 cholera was carried from Genoa to Buenos Ayres, and crossing the Andean range invaded the Pacific coast for a second time. In Chili alone there were over 10,000 deaths from cholera in the first six months of 1887. Since then the entire Western hemi- sphere has been virtually free from the disease. In 1889 there was an epidemic of cholera in the Orient; and in 1892 and 1893 it broke out along the shores of the Mediterranean, invading all the lines of commerce of Europe, Hamburg in the North and Marseilles in the South being especially affected. In the summer of 1893 a few cases ap- peared in New York Bay and several in New York city, but rigorous quar- antine methods prevented any further spread. Typhus fever is now a rare disease, and epidemics are quite infrequent. It has long been known under the names of hospital-fever, spotted-fever, jail-fever, camp-fever, and ship-fever, and has been the regular associate of such social disturbances as overcrowding, excesses, famine, and war. For the past eight centuries epidemics of typhus have from time to time been noticed, but invariably can be traced to some social derangement. Yellow Fever is a disease prevailing endemically in the West Indies and certain sections of what was formerly known as the Spanish Main. Guiteras recognizes three areas of infection :— (1) The focal zone from which the disease is never absent, including Havana, Vera Cruz, Rio, and the other various Spanish-American points. (2) The perifocal zone, or regions of periodic epidemics, including the ports of the tropical Atlantic and Africa. (3) The zone of accidental epidemics, between the parallels of 45° north and 35° south latitude. In the seventeenth century Guadaloupe, Dominica, Martinique, and Bar- badoes suffered from epidemics of yellow fever. After the first half of the seventeenth century the disease was prevalent all through the West Indies. It first appeared in the United States at the principal ports of Boston, Philadel- phia, and Charleston, in 1693, and in 1699 it reappeared in Philadelphia and Charleston, and since that time many invasions have occurred, chiefly in the Southern States. The epidemic of 1793 in Philadelphia, so graphically described by Matthew Carey, was, according to Osier, the most serious that has ever prevailed in any city of the Middle States. Although the population of the city was only 40,000, during the months of August, September, October, and November the mortal- ity, as given by Carey, was 4041, of whom 3435 died in the months of Septem- ber and October. During the following ten years epidemics of a lesser degree LEPROSY. 911 occurred along the coast of the United States, and in 1853 the disease raged throughout the Southern States, there being a mortality in New Orleans alone of nearly 8000. In the epidemic of 1878 in the Southern States the mor- tality was nearly 16,000. South America was invaded for the first time in 1740, and since 1849 the disease has been endemic in Brazil. Peru and the Argentine Republic have also received severe visitations of yellow fever since 1854. In Cuba the disease is epidemic during June, July, and August, and it appears with such certainty that the Revolutionists at the present time count more on the agency of yellow fever in the destruction of the unaccli- mated Spanish soldiers than on their own efforts. Leprosy is distinctly a malady of Oriental origin, and existed in prehis- toric times in Egypt and Judea. It was supposed to have been brought into Europe by a Roman army commanded by Pompey, after an expedition into Palestine. Leprosy was mentioned by several authors in the Christian era. France was invaded about the second century, and from that time on to the Crusades the disease gradually increased. At this epoch, the number of lepers or ladres becoming so large, they were obliged to confine themselves to certain portions of the country, and they took for their patron St. Lazare, and small hospitals were built and dedicated to this saint. Under Louis VIII. 2000 of these hospitals were counted, and later, according to Dupouy, there were 19,000 in the French kingdom. Various laws and regulations were made to prevent the spread of the contagion. In 1540 it was said that there were as many as 660 lepers in one hospital in Paris. No mention is made in the Hippocratic writings of elephantiasis grseeorum, which was really a type of leprosy, and is now considered synonymous with it. According to Rayer, some writers insist that the affection then existed under the name of the Phoenician disease. Before the time of Celsus, the poet Lucretius first speaks of elephantiasis grseeorum, and assigns Egypt as the country where it occurs. Celsus gives the principal characteristics, and adds that the disease is scarcely known in Italy, but is very common in certain other countries. Galen supplies us with several particular but im- perfect cases—histories of elephantiasis grseeorum, with a view to demonstrate the value of the flesh of the viper, and in another review he adds that the disease is common in Alexandria. Aretseus has left a very accurate picture of the symptoms of elephantiasis grseeorum ; and Pliny recapitulates the principal features and tells us that the disease is indigenous in Egypt. The opinion of the contagiousness of elephantiasis grseeorum which we find announced in Herodotus and Galen is more strongly insisted upon by Cselius Aurelianus who recommends isolation of those affected. Paulus iEgenita discusses the disease. The Arabian writers have described elephantiasis grseeorum under the name of juzam, which their translators have rendered bv the word lepra. Later, Hensler, Fernel, Par6, Vesalius, Horstius, Fores- tus, and others have discussed it. 912 HISTORIC EPIDEMICS. The statistics of leprosy in Europe pale before the numbers affected in the East. The extent of its former ravages is unknown, but it is estimated that at the present day there are over 250,000 lepers in India, and the number in China is possibly beyond computation. According to Morrow, in 1889 in the Sandwich Islands there were 1100 lepers in the settlement at Molokai. Berger states that there were 100 cases at Key West; and Blanc found 40 cases at New Orleans. Cases of leprosy are not infrequently found among the Chinese on the Pacific coast, and an occasional case is seen in the large cities of this country. At the present day in Europe, where leprosy was once so well known, it is never found except in Norway and the far East. Possibly few diseases have caused so much misery and suffering as lep- rosy. The banishment from all friends and relatives, the confiscation of property and seclusion from the world, coupled with poverty and brutality of treatment,—all emphasize its physical horror a thousandfold. As to the leper himself, no more graphic description can be given than that printed in The Nineteenth Century, August, 1884 : "But leprosy ! Were I to describe it no one would follow me. More cruel than the clumsy torturing weapons of old, it distorts, and scars, and hacks, and maims, and destroys its victim inch by inch, feature by feature, member by member, joint by joint, sense by sense, leaving him to cumber the earth and tell the horrid tale of a living death, till there is nothing left of him. Eyes, voice, nose, toes, fingers, feet, hands, one after the other are slowly deformed and rot away, until at the end of ten, fifteen, twenty years, it may be, the wretched leper, afflicted in every sense himself, and hateful to the sight, smell, hearing, and touch of others, dies, despised and the most abject of men." Syphilis.—Heretofore the best evidence has seemed to prove that syphi- lis had its origin in 1594, during the siege of Naples by Charles VIII. of France ; but in later days many investigators, prominent among them Buret, have stated that there is distinct evidence of the existence of syphilis in pre- historic times. Buret finds evidence of traces of syphilis among the Chinese five thousand years ago, among the Egyptians at the time of the Pharaohs, among the Hebrews and Hindoos in biblic times, and among the Greeks and Romans after Christ. Some American writers claim to have found evidences of syphilitic disease in the skulls and other bones of the pre- historic Indian mounds, thus giving further evidence to the advocates of the American origin of syphilis. The Spaniards claimed that, returning from America in 1493, Columbus brought with him syphilis. Friend says: " One thing is remarkable; the Spaniards, upon their first expedition to America, brought home from thence this contagious disorder, and soon after carried another affection thither, the small-pox, of which the Indian Prince Montezuma died." The first descriptions of syphilis are given under the name of morbus gallicus, while the French in return called it morbus neapolitanus or mat d'Italic The name of syphilis was said to have been MODERN MOR TALITY FR OM INFECTIO US DISEASES. 913 first given to it by a physician of Verona, in a poem describing the disease. Inspired by heroic epics Fracastor places before us the divinities of pagan- ism, and supposes that a shepherd, whom he called Syphilus, had addressed words offensive to Apollo, and had deserted his altars. To punish him the God sent him a disease of the genitals, which the inhabitants of the country called the disease of Syphilus. " Syphilidemque ah eo labem dixtre cohni" a Buret traces the origin of the word syphilis from Statistics and Sociology, New York, 1885. 58 914 HISTORIC EPI DEM It \s. Austria of vaccination; diphtheria seems to be very fatal in Germany and Austria ; Italy has a large rate for typhoid fever, and the same is true of the other fevers; France, Germany, and Austria show a very large rate for tuberculosis, while Italy has a small rate. Deaths from Certain Diseases Per 10,000 Inhabitants. Country. Small- pox. Measles. Scarlet Fever. Diphthe- ria. Typhoid i Tubkrcc Fever. losis. Italy, .... France (cities), England, . . . Ireland, . . . Germany (cities), Prussia, . . . Austria, . . . Switzerland, Belgium, . . . Holland, . . . Sweden, . . . 3.86 2.3 0.11 0.01 0.04 0.03 4.43 0.06 1.52 0.02 0.01 6.17 5.18 4.68 2.01 2.8 3.2 5.36 1.53 6.2 3.93 2.3 2.99 3.1 2.31 1.22 2.15 2.46 5.57 1.22 1.62 0.38 3.69 6.08 6.66 1.74 0.76 10.21 14.17 13.2 3.53 5.77 1.45 3.89 7.49 5.32 1.9 2.33 2.11 2.26 5.42 1.47 3.83 2.5 2.22 13.61 33. 16.09 21.15 31.29 28.06 37.2 21.07 19.87 19.21 Based upon the Tenth Census Reports, we figure that of every 10,000 inhabitants of the United States the number of deaths for the census year from similar diseases was as follows :— Rural. Cities. Measles, .....................1.62 1.54 Scarlet Fever,...................2.84 5.54 Diphtheria,....................7.53 8. Croup,...................... 3.51 4.08 Typhoid Fever,..................4.75 3.46 Tuberculosis,...................16.29 28.55 The general average of deaths from small-pox was about 0.14. BIBLIOGRAPHIC INDEX. BEING A PARTIAL BIBLIOGRAPHY NUMERICALLY ARRANGED FOR PURPOSE OF REFERENCE.* A. 100. Abeille (L') medicale. Paris. 101. Abhandlungen der kbnigl. Schwe- dischen Akademie, etc. Vol. for 1763. Leipzig, 1768. 102. Abhandlungen der k. k. medizinisch- chirurgischen Josephs - Akademie zu Wieu. 1801. 103. Abhandlungen der physikalisch-medi- zinischen Sociefat zu Erlangen. 1810-. 104. Acad. nat. curios, ephemerides. Francofurti et Lipsse, 1712 ; Nori- bergae, 1715-17. (The Ephemeri- des.) 105. Acta Acad. Caesareae-naturae curio- sorum. Norimbergse, 1727-. 106. Acta Eruditorum. Leipzig. 107. Acta Helvetica physico-mathematico- botanico-medica. Basilar, 1751-77. 108. Acta medicornm Berolinensium, etc. Berolini, 1717-. 109. Acta regiae Societatis medicae Havien- sis. Havniae. 110. Acta medica Hafniensia, Prodromus, etc. Hafniae et Lipsae, 1775-. 111. Aerztliches Intelligenz-Blatt. Mun- chen. 112. Albertus (Michaelis). Dissertatio de Longevitati, etc. 1728. 113. Albertus (Michaelis). Systemajuris- prudentiae medicae. 6 vols., 4°. Halae, 1736-47. 114. Albinus (Bernhardus). Dissertatio de sterilitatis. 115. Albucasis. De chirurgia. Arabice 116. Aldrovandus (Ulysses). Opera. 13 vols. Bonon., 1646-48. 117. Allgemeine Literatur-Zeitung. Jena. 118. Allgemeine Wiener medizinische Zei- tung. Amatus Lusitanus (J. R.). Cura- tionum medicinalium medici phy- sici, etc. 8°. Venetiis, 1557. Amman (Paulus). Medicina critica. Erffurti, 1670. 121. American Gynaecological and Obstet- rical Journal. New York. American Homoeopathist. Chicago. American Journal of Insanity. Utica, N. Y. American Journal of Medical Science. Philadelphia. 125. American Journal of Obstetrics. New York. 126. American Journal of Science and Arts. New Haven, Conn. 127. American Journal of Syphilography and Dermatology. New York. 128. American Medical Monthly. New York. 129. American Medical Recorder. Phila- delphia. American Medical Times. New York. American Medical Weekly. Louis- ville, Ky. American Medico-Surgical Bulletin. New York. American Practitioner. Louisville, Ky. American Therapist. New York. Annalen der Entbindungs - Lehran- stalt auf der Universifat zu Gbt- tingen. Von Osiander. 119. 120. 122. 123. 124. 130. 131. 132. 133. 134. 135. et Latine. Oxford, 1778. * The numbers in this index have been used in all the reference foot-notes and in the text to indicate the corresponding authorities. 915 916 BIBLIOGRAPHIC INDEX. 136. Annalen der Staatsarzneikunde. Tii- bingen, 1836-. 137. Annalen der Staatsarzneykunde. Ziil- lichau, 1790-. 138. Annalen fur die gesammte Heilkunde. Karlsruhe, 1824-. 139. Annales de chimie et de physique. Paris. 140. Annales de gyndcologie. Paris. 141. Annales d'hygiene, etc. Paris. 142. Annales des maladies des organes g6nito-urinaires. Paris. 143. Annales de medecine beige et etran- gere. Bruxelles. 144. Annales medico - psychologiques. Paris. 145. Annales d'oculistique. Bruxelles. 146. Annales de la Societe de mddecine de Saint-Etienne et de la Loire. 147. Annales de la Society de medecine- pratique de Montpellier. 148. Annals of the Anatomical and Surgi- cal Society. Brooklyn. 149. Annals of Medicine. Edinburgh. 150. Annals of Surgery. New York. 151. Annali di medicina. Milano, 1802. 152. Annali di ostetricia, etc. Milano. 153. Annali universali di medicina. Mi- lano. (Omodei.) 154. Arand (Franciscus). Observationes medico - chirurgicae. 8°. Goet- tingae, 1770. 155. Archiv der Heilkunde. Leipzig. 156. Archiv der Pharmacie. Halle. 157. Archiv fur Anthropologic Braun- schweig. 158. Archiv fur praktische Medizin und Klinik. Berlin, 1807-. 159. Archiv fur medizinische Erfahrung. 1801-. (Horn.) 160. Archiv fur die Geburtshiilfe, etc. J. C. Stark, Jena. (1798-1800 as N. Archiv, etc.) 161. Archiv fur pathologische Anatomie und Physiologie, etc. Berlin. (Virchow's Archives.) 162. Archives generates de medecine. Paris. 163. Archives de medecine navale. Paris. 164. Archives provinciales chirurgie. Paris. 165. Archives of Pediatrics. 166. Archives of Surgery. London. (Hut- chinson.) 167. Archives of Surgery. New York. 168. Archives de tocologie. Paris. 169. Aristoteh■-<. Opera omnia. 5 vols. Parisiis, 1862-74. 170. Aristoteles. Historia de Animalibus. Tolos, 1619. 171. Art (L') medical. Bruxelles. 172. Arzneykundige Annalen von Tode. Kopenbagen, 1787-. 173. Asclepiad. London. 174. Ashhurst (John, Jr.). Principles and Practice of Surgery. Philadelphia, 1889. 175. Association Medical Journal. Lon- don. 176. Atlanta Medical and Surgical Journal. Atlanta, Ga. 177. Aurran (J. F.). E linguis feminae loquela. Argentina?, 1766. 178. Australasian Medical Gazette. Syd- ney. 179. Australian Medical Gazette. Mel- bourne. 180. Australian Medical Journal. Mel- bourne. 181. Autenrieth (J. F. H.). Handbuch der Physiologie. 3 vols. 8°. Tu- bingen, 1801. B. 182. Bacchetoni (H. L.). Anatomia medi- cinae, etc. Oeniponti, 1740. 183. Bailey (J. B.). Modern Methusalehs. 8°. London, 1888. 184. Baily (T.). Records of Longevity. 8°. London, 1857. 185. Ballonius (Guilielmus). Opera me- dica omnia. 4 vols. Geneva?, 1762. 186. Baltimore Medical Journal. 187. Baltimore Medical and Surgical Journal and Review. 188. Bartholinus (Thomas). Acta medica et philosophica. Hafniensia, 1671-79. 189. Bartholinus (Thomas). Epistolarum medicinalium. Hafnias, 1663. 190. Bartholinus (Thomas). Historiarum anatomicarum rariorum. Cent, i- vi. Hafniae, 1654-61. 191. Bateman (—). The Doome. 1581. (In the British Museum.) 192. Becker (J. C). De submersorum Morte, etc. Giessae, 1704. 193. Becker (Dan.). Cultrivori Prussiaci Curatio singulis. Lugd. Bat., 1640. BIBLIOGRAPHIC INDEX. 917 194. Bell (Charles). Institutes of Surgery, etc. 8°. Philadelphia, 1840. 195. Bellini (Laurentius). Opera omnia. 4°. Venetiis, 1732. 196. Benedictus(Crispus). Commentarium medicinale. 197. Benivenius (A.). Mem. observat. exempla rara colon., 1581. 198. Benivenius (A.). De abditis nonnu- lis ac mirandis Morborum et Sana- tionum Causis, 1521. 199. Berliner klinische Wochenschrift. 200. Berlinische Sammlungen zur Befb'r- derung der Arzneywissenschaft, etc. Berlin, 1768-79. 201. Bernstein (J. G.). Wien, 1805. 202. Berthold (A. A.). Ueber das Gesetz der Schwangerschaftsdauer. 4°. Gottingen, 1844. 203. Beytrage zum Archiv der medizini- schen Polizei, etc. Leipzig, 1789- 99. 204. Bianchi (Giovanni). De monstris, etc. Venetiis, 1749. 205. Bianchi (Giovanni). Storia del mon- stros di due Corp., etc. Turin, 1748. 206. Bibliothek fur die Chirurgie. Got- tingen. Von Langenbeck. 207. Bibliothek for Laeger. Kj^benhavn. 208. Bibliothek der praktischen Heil- kunde. Berlin, 1799-1843. 209. Bichat (M.-F.-X.). Anatomic gen6- rale appliquee a la physiologie et a la medecine. 210. Bierling (C. T.). Adversariorum curiosorum, etc. Jenae, 1679. 211. Bierling (C. G.). Thesaurus Theo- retico-practicus, etc. Jenae, 1694. 212. Blanc (L.). 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Sechs seltene Anatomisch - chirurgische Wahr- nehmungen. 4°. Konigsberg, 1774. (Same as 229.) c. 245. Cabrolius (Bartholomaeus). Observa- tiones. 246. California Medical Gazette. San Fran- cisco. 918 BIBLIOGRAPHIC INDEX. 247. Camerarius (J. R.). Sylloges memo- rabilium medicinae, etc. Tubingae, 1683. 248. Campbell (C-J.). De 1'accouchement des femmes qui meureut a une epoque avancee de la grossesse. Paris, 1849. (Thesis.) 249. Camper (Petrus). Demonstrationum anatomico - pathologicarum. Am- stelodami, 1760-. 250. Canada Lancet. Toronto. 251. Canada Medical Journal. Montreal. 252. Canada Medical and Surgical Jour- nal. Montreal. 253. Canadian Journal of Medical Science. Toronto. 254. Capuron (Joseph). La medecine legale relative a l'art des accouche- inents. Paris, 1821. 255. Cardanus (Jerome). Opera omnia. 10 vols. Lugduni, 1663. 256. Carolina Journal of Medicine, Science, and Agriculture. Charleston, 1825. 257. a Castro (Rodericus). De universa muliebrium morborum medicina. 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Guy and Ferrier. Principles of Foren- sic Medicine. London, 1875. 394. Guyot-Daubes. Leshommes—pheno- menes. Paris, 1885. H. 395. Haen (Antonius). Ratio medendi in noscomio practico. Parisiis, 1761. 396. Haller (Albertus). Bibliotheca ana- tomica. 397. Haller (Albertus). Bibliotheca medi- cinae practicae. 398. Haller (Albertus). Bibliotheca chi- rurgica. 8°. 1774. 399. Haller (Albertus). Disputationes ana- tomicae selectae. Gottingae, 1746. 400. Haller (Albertus). Elementa physio- logiae corporis humani. 8 vols. Lausanne and Berne. 401. Haller (Albertus). Epistolarum ab erudtis viris ad Hallerum scrip- turn. Bernae, 1773. 6 vols. 402. Hamburgisches Magazin. Hamburg, 1747-. 403. Hartmann (Petr. I.). De sudore unius lateris. Halae ad Sal am, 1751. 404. Harvey (William). Exercitiones de generatione animalium. London, 1651. 405. Harvey (William). The Works of. (Translated.) Sydenham Society, London, 1847. 406. Hasenest (J. G.). 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India Journal of Medical and Physi- cal Science. Calcutta. 435. Indian Medical Gazette. Calcutta. 436. Indian Medical Record. Calcutta. 437. Independent Practitioner. Baltimore, and continued elsewhere. 438. International Clinics. Philadelphia, 1891-. 439. International Encyclopedia of Sur- gery. Edited by John Ashhurst, Jr. 1881-84. 440. Iowa Medical Journal. Keokuk. 441. Insfeldt (J. C). De lusibus nature. 4°. Lugd. Bat., 1772. 442. Isenflamm et Rosenmuller. Beytrage fur die Zerg. J. 443. Jacobson (W. H. A.). Diseases of the Male Organs of Generation. 8°. London, 1893. 444. Jahrbuch der Staatsarzneikunde. Frankfurt a. M. (Kopp.) 445. Jeaffreson (William). A Practical Treatise on Diseases of the Eye. 8°. London, 1844. 446. Johns Hopkins Bulletin. Baltimore. 447. Jonston (Joh.). Thaumatographia naturalis. 1665. 448. Josephus (Flavius). Historia, etc. Paris, 1528. 449. Joubert (Laurentius). Trait6 du ris, etc. Paris, 1579. 450. Journal of the American Medical Association. 451. Journal of Anatomy and Physiology. London. 452. Journal der praktischen Arzneykunde und Wundarzneykunde. Heraus- gegeben von C. W. Hufeland. 453. Journal of the National Association of Railway Surgeons. Fort Wayne, Indiana. 922 BIBLIOGRAPHIC INDEX. 479. Laurent (E.). Les bisexu£s, gyneco- mastes, et hermaphrodites. Paris, 1894. 480. Laurentius (Andreas). 11 istoria ana- tomica humani corporis, etc. Francofurti, 1636. 481. Leavenworth Medical Herald. 482. Lebert (Herman). Ueber Keratose. 8°. Breslau, 1864. 483. Leigh (Charles). Exe re i tationes quinque. Oxonii, 1697. 8° 484. Lentilius (Rosinus). Misc. medico- practica, etc. Ulmae, 1698. 485. Lheritier (S.-D.). Traitc complet des maladies de la femme. 8°. Paris, 1838. 486. Licetus (Fortunius). De monstris. 4°. Amstelodami, 1665. 487. Loaring (H. J.). Epitaphs, etc. London. 488. Lobstein (J.-G.-C.-F.-M.). Traite d'anatomie pathologique. Paris, 1829. 489. Loeseke (J. L. L.). Observationes anatomico-chirurgico-medicae, etc. Berolini, 1754. 490. London Medical Gazette. 491. London Medical Record. 492. London Medical and Surgical Journal. 493. Lonsdale (E. F.). A Practical Trea- tise on Fractures. 8°. London, 1838. 494. Louisville Medical News. Louisville, Ky. 495. Lucina. Leipzig, 1802-11. Editor A. E. von Siebold. 496. Lycosthenes (Wolffhart) (C). Pro- digiorum ac ostentorum chronicon. Basileae, 1557. 497. Lyon medical. 498. Lyser (Michael). Observationes me- dicae. Hafniae, 1665. 454. Journal complementaire du diction- naire des sciences medicales. Paris, 1818-. 455. Journal of Cutaneous and Venereal Diseases. New York. 456. Journal fur die Chirurgie, etc. Von Loder. Jena, 1797. 457. Journal furGeburtshulfe, etc. Frank- furt a. M., 1813-. 458. Journal general de medecine, de chi- rurgie, et de pharmacie. Paris. 459. Journal of the Gynaecological Society of Boston. 460. Journal de med., chir., pharm., etc. Paris, 1754-93. 461. Journal de med., chir., pharm., etc. Paris, 1801-17. 462. Journal de m6decine. Paris. (See 460.) 463. Journal de medecine. Paris (con- tinued). (See 461.) 464. Journal de medecine militaire. Paris, 1782-. 465. Journal of Mental Science. London. 466. Journal of Nervous and Mental Dis- eases. New York. 467. Journal Politique de Manheim. 468. Journal der praktischen Heilkunde. Berlin, 1801-41. 469. Journal des Savans. Paris. 470. Journal de Scavans. etc. Paris. 471. Journal de la section de medecine de la Societe academique, etc., Loire- Inferieure. Nantes. 472. Journal da Sociedade das sciencias medicas de Lisboa. K. 473. Kerckringius (Theodoras). Spicile- gium anatomicum. Amstelodami, 1670. L. 474. de La Motte (G.M.). Traits com- plet des accouchements, etc. 4°. Paris. 1722. 475. Lancisi (J.-M.). De subitaneis mor- tibus. Romae, 1707. 476. Lancet, London. 477. Lanzoni (Josephus). Opera omnia. Lausanne. 1738. 478. Larrey (D.-J.). Memoires de chirur- gie militaire et campagnes. 4 vols. 8°. Paris, 1812-17. M. 499. Mackenzie (Sir M.). A Manual of Diseases of the Throat and Nose. etc. London, 1884. 500. Madras Quarterly Journal of Medical Science. 501. Magazin vor Aerzte. Von Baldinger. (AlsoN. Mag., etc.) 502. Magazin der auslandischen Literatur der gesammten Heilkunde, etc. Hamburg. (Julius und Gerson.) BIBLIOGRAPHIC INDEX. 923 503. Magazin fur die neuesten Entdeck- ungen in der gesammten Natur- kunde.. Berlin, 1807-. 504. Magazin fur die gesammte Heilkunde, etc. Berlin. (Herausgegeben von Rust.) 505. Mandelslo (J. A.). Schreiben von Olearium. Schlesswig, 1658. 506. Martin de Pedro (Ecequiel). Estu- dios de teratologia, etc. 8°. Ma- drid, 1879. 507. Marold (J. O.). De abortu per vomi- tum rejecto. Altdorff, 1669. 508. de Marque (Jacques). Traite des Bandages, etc. Paris, 1662. 509. Martialis (Marcus Valerius). Epi- grammata lib. xiiii. 510. Maryland Medical Journal. Balti- more. 511. 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Medical Herald. Louisville, Ky. 531. Medical Independent, etc. Detroit. 532. Medical Mirror. London. 533. Medical News. Philadelphia. 534. Medical and Philosophical Commen- taries. London, 1774-. 535. Medical and Physical Journal. Lon- don. 536. Medical Press and Circular. London. 537. Medical Quarterly Review. London. 538. Medical Record. New York. 539. Medical Records and Researches of a Private Medical Association. Lon- don, 1798. 540. Medical Reporter. Calcutta. 541. Medical Repository. New York. 542. Medical Standard. Chicago. 543. Medical Summary. Philadelphia. 544. Medical and Surgical History of the War of the Rebellion. 545. Medical and Surgical Reporter. Phi- ladelphia. 546. Medical Times. London. 547. Medical Times. Philadelphia. 548. Medical Times and Gazette. Lon- don. 549. Medico-Chirurgical Review. London. 550. Medico-Chirurgical Transactions. London. 551. Medicorum Silesiacorum Satyrae. Wratislaviae et Lipsiae, 1736. 552. Medicinische und chirurgische Ber- linische wochentliche Nach rich ten. Von Schaarschmidt. Berlin, 1738-. 553. Medizinische Jahrbiicher. Wien. 554. Medicinische Zeitung. Berlin. 555. Medicinisches Journal von Baldinger. Gbttingen. 556. Meditsinskiy Vestnik. St. Peters- burg. 557. Meditsinskoye Obozrainie. Moskva. 558. Medicinisch-chirurgische Bibliothek von Tode. Copenhagen, 1775. 559. Medicinisch - Chirurgische Zeitung. Salsburg, 1790-. 560. van Meek'ren (Job). Observationes medico-chirurgicae. Amstelodami, 1682. 561. Meibomius (H.). Dissertationes, etc. Helmaestadi, 1668. 562. Melanges biologiques, etc., de l'Aca- demie impeviale des sciences de St. Petersbourg. 563. Memoires de l'Academie royale de chirurgie. Paris. 564. Memoirs of the Medical Society of London. 565. Memoires de la Societe medicale d'emulation de Paris. 1796-. 924 BIBLIOGRAPHIC INDEX. 566. Mercurio delle scienze mediche. Li- vorno. 567. Meyer (—). Diss, de abortu epi- demico. 1780. 568. Meyer (J. C. H.). Grundriss der Physiologie des menschlichen Kor- pers, etc. Berlin, 1805. 569. Michigan Medical News. Detroit. 570. Miscellanea curiosa medico - physica Acad. Caesarae Leopoldino- Caro- linae naturae curiosorum. Lipsiae, 1670-. 571. Mississippi Valley Medical Monthly. Memphis, Tenn. 572. Molinetti (Antonius). Dissertationes anatomicae et pathologicae, etc. Patavii, 1669. 573. Monatsschrift fiir Geburtskunde und Frauenkrankheiten. Berlin. 574. Monitore med. marchigiano Loreto. 1889-. 575. Morand (S.-F.). Opuscules de chi- rurgie. Paris, 1768. 4°. 576. Morgagni (J. B.). De sedibus et causis morborum, etc. Patavii, 1765. 577. Mursinna(C. L.). Neue medizinisch- chirurgische Beobachtungen. Ber- lin, 1796. 578. Musitanus (Carolus). Chirurgia theo- retico-practica. 1698. N. 579. Nashville Journal of Medicine and Surgery. 580. Naturalist. London. 581. Nebraska Medical Journal. Lincoln, Nebraska. 582. Nelson's Northern Lancet. Platts- burg, N. Y. 583. Nemnich (P. A.). Opus. Tubingen, 1800. 584. Neubauer (J. E.). Describens obser- vationem de triplici nympharum ordine. Jenae, 1774. 585. Neue Bibliothek fur die Chirurgie und Ophthalmologic. Hannover, 1815-28. (Langenbeck.) 586. Neues Hannoverisches Magazin. 587. Neues medicinisches und physisches Journal. Von Baldinger zu Mar- burg, 1797-1802. 588. Neue Zeitschrift fur Geburtskunde. Berlin. 589. New England Journal of Medicine and Surgery. Boston. 590. New England Medical Gazette. Boston. 591. New Jersey Medical Reporter. Bur- lington. 592. New Orleans Medical News and Hos- pital Gazette. 593. New Orleans Medical and Surgical Journal. 594. New York Journal of Medicine. 595. New York Journal of Medicine and Surgery. 596. New York Medical Gazette. 597. New York Medical Journal. 598. New York Medical and Philosophical Journal and Review. 599. New York Medical and Physical Journal. 600. New York Medical and Surgical Brief. 601. Nordisches Archiv fur Natur- und Arzneiwissenschaft, etc. Kopen- hagen, 1779. 602. Nordiskt mediciniskt Arkiv. Stock- holm. 603. Norsk Magazin for Laegevidenskaben. Christiania. 604. North Carolina Medical Journal. Wilmington, N. C. 605. Northern Journal of Medicine. Edin- burgh. 606. Northwestern Lancet. St. Paul, Minn. 607. Nova acta physico-medica, etc. Er- langse. 608. Nuck (Antonius). Sialographia. Lugd. Bat., 1723. o. 609. Obstetrical Gazette. Cincinnati. 610. Obstetrical Journal of Great Britain and Ireland. London. 611. Oesterreichische medicinische Wo- chenschrift. Wien. 612. Ohio Medical and Surgical Journal. Columbus. 613. Ohio Medical Recorder. Columbus. 614. Orvosi helitap. Budapest. 615. Osiander (F. B.). Epigrammata, etc. 12°. Gottingae, 1807. P. 616. Pacific Medical and Surgical Journal. San Francisco. BIBLIOGRAPHIC INDEX. 925 617. Panaroli (Dominico). Iatrologismo- rum seu. med. observ. pentecostae, etc. Romae, 1652. 618. Par6 (Ambroise). GEuvres. Fifth Edition. Paris, 1598. 619. Pathological Museum of the British Medical Association at the Meeting in London, 1895. (Catalogue.) 620. Paullini (C. F.). Observationes medico-physicae rarae, selectae et curiosae, etc. 12°. Lipsiae, 1706. 621. Pechlin (J. N.). De aeris et alimenti defectu, etc. Kiloni, 1676. 622. Pechlin (J. N.). Observationum physico - medicarum, etc. Hani- burgi, 1691. 623. Pennsylvania Hospital Reports. Philadelphia. 624. Petermann and Albrecht. Scrutinium icteri ex calculi vesisculae, etc. Lipsiae, 1696. 625. Petit (J.-L.). Traite des maladies chirurgicales, etc. 8°. Paris, 1790. 626. Petrequin (J.-P.-E.). Traite d'ana- tomie medico-chirurgical, etc. 8°. Paris, 1844. 627. Peyer (J. C). Myrecologia. Basi- leae, 1685. 628. Pfaff's Mittheilungen aus dem Ge- biete der Medizin, Chirurgie, und Pharmacologic Kiel, 1832-. 629. Philosophical Transactions of the Royal Society of London. 630. Phlegon Trallianus. de Mirab. in Opuscula. 4°. 1620. 631. Photographic Review of Medicine and Surgery. 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Wood & Co., New York. 667. Revista medico-quirurgica. Buenos Aires. 668. Revista medica de Chile. Santiago- de Chile. 926 BIBLIOGRAPHIC INDEX. 669. Revue des cours scientifiques, etc. Paris. 670. Revue general de clinique et de thera- peutique. Paris, 1887-. 671. Revue de l'hypnotism, etc. Paris, 1886-. 672. Revue de medecine. Paris. 673. Revue medicale de Limoges. 674. Revue mensuelle des maladies de l'enfance. Paris. 675. Revue militaire de medecine et de chirurgie. Paris, 1881-. 676. Revue philosophique, etc. Paris, 1887-. 677. Reviie photographique des hopitaux de Paris. 678. Revue de therapeutique m6dico-chi- rurgicale. Paris. 679. Rhodiginus (L. C). Lectionum anti- quarium libri xxx. Basileae, 1524. 680. Rhodius (Joannes). Mantissa anato- mica. 8°. 1654. 681. Richmond and Louisville Medical Journal. Louisville, Ky. 682. Richter(A. G.). Chirurgische Biblio- thek. Gottingen, 1771-. 683. Riedlin (Vitus). Lineae medicae sin- gulos. 1695-. 684. Rif'orma (La) medica. Napoli. 685. Riolan (Jean) fils. Anthropographia. Parisiis, 1618. 686. Riolan (Jean) fils. Encheiridium anatomicum, etc. 16°. Paris, 1648. 687. Riverius (Lazarus). Observationes medicae et curationes insignes. Londini, 1646. 688. Rivista italiana di terapia ed igiene. Piacenza. 689. Roger of Wendover. Flowers of His- tory. Bohn's edition, 1849, vol. i. 690. von Rokitausky (Carl). Lehrbuch der pathologischen Anatomic 3 vols. 8°. Wien, 1855-. 691. Rosenbladt (A. C.). Dissertationes. 1781. 692. Rossius (P. M.). Observationes med. chirurg. et practical, etc. 12°. Francofurti, 1608. 693. Royal London Ophthalmic Hospital Reports. London. 694. Rudtoffer (F. X.). Abhandlungen, etc. 2 vols. 8°. Wien, 1805-. 695. Rudolph (J. P. J.). De partu sicco. Erlangae, 1790. 696. Rush (Beuj.). Medical Inquiries and Observations. Philadelphia, 1805. 697. Russkaya Meditsina. St. Petersburg, 1883-. 698. Ruysch (Fredericus). Adversariorum anatomico-medico-chirurgicorum. Decas tertia, 1723. 699. Ruysch (Fredericus). Opera omnia. 4 vols. 8°. Amstelodami, 1737. s. 700. Saint George's Hospital Reports. London. 701. St. Louis Clinical Record. St. Louis, Mo. 702. St. Louis Courier of Medicine, etc 703. St. Louis Medical and Surgical Jour- nal. St. Louis, Mo. 704. St. Petersburger medicinische Wochenschrift. 705. St. Thomas' Hospital Reports. Lon- don. 706. Salmuth (P.). Observationem medi- carum centuriae tres posthumae. 4°. Bruusvigae, 1648. 707. Salute (La). Genova. 708. Sammlung von Natur- und Medizin- Gesch., etc. Breslau. (Buchner.) 709. Sandifort (Eduard). Museum ana- tomicum, etc. Lugd. Bat., 1793. 710. Sandifort (Gerard). Tabulae anato- micse. 4 fasc. 1804. 711. Sangalli (Giacomo). La scienza e la practica della anatomia patologica. Milano, 1873-. 712. Savannah Journal of Medicine. Sa- vannah, Ga. 713. Saviard (Barth.). Observationes chi- rurgicales. Paris, 1784. 714. Savonarola (G. M.). Practica, in sex tractus. Venetiis impressum, 1497. 715. Scarpa (Antonius). De structura fenestrae rotundae, etc., 1772. 716. Schacher (P. G.). De polypis. Lip- siae, 1721. 717. Schacher (P. G.). De superfcetatione. Lipsiae, 1721. 718. Schenck (J.). Observationum medi- caruni, etc. 2 vols. 8°. Franco- furti, 1600. 719. Schlichting (J. D.). Traumatologia. Amsterdam, 1748. 720. Schmidt's Jahrb'ucher. Leipzig. BIBLIOGRAPHIC INDEX. 927 721. Schmucker (J. L.). Vermischte chi- rurgische Schriften. Berlin, 1772-. 722. Schrader (H. H. C). Observ. rario- rum, etc. Guelpherbyti, 1760. 723. Scribner's Magazine. New York. 724. Schurig (Martin). Parthenologia his- torico-mediea, etc. 4°. Dresden et Lipsiae, 1729. 725. Schurig (Martin). Gynaecologia, etc. Dresden et Lipsiae, 1730. 726. Schurig (Martin). Embryologia, etc. Dresden, 1732. 727. Science. Cambridge and New York. 728. Semaine (La) medicale. Paris. 729. Semi-monthly Medical News. Louis- ville, Ky. 730. Smetius (Heinrich). Miscellanea medica, etc. Franco!', a. M., 1611. 731. de Senac (J. B.). Traite de la struc- ture da coeur. Paris, 1749. 732. Sennert (Daniel). Paraphimosis. Wittebergae, 1642. 733. Sermon (William). English Mid- wifery. 8°. London, 1671. 734. Severinus (M. A.). De efficaci medi- cina. Francofurti, 1671. 735. von Siebold (J. B.).....chirur- gischen Clinicums. Wurzburg, 1814. 736. von Siebold (J. B.). Sammlung, etc. 3 vols. 12°. Rudolstadt, 1805-12. 737. Sinibaldus (J. B.). Geneanthropeiae, etc. Romae, 1642. 738. Skene (A. J. C). Diseasesof Women. New York, 1892. 739. Smellie (G.). Thesaurus medicus, etc. Edinburgi, 1778-. 740. Societatis medicae Havniensis collec- tanea. Havniae. 741. Solingen (Cornelius).....Byson- dere aanmerkingeu. Amsterdam, 1698. 742. Solingen (Cornelius).....Sonder- bare Anmerckungeu. Wittenber- ger, 1712. (Same as 741.) 743. de Sorbait (Paulus). Praxios medi- cae, etc. Viennae, 1680. 744. Southern Medical and Surgical Jour- nal. Augusta, Ga. 745. Sozinskey (T. S.). Medical Symbol- ism. Philadelphia, 1891. 746. Spallanzani (Lo). Modena. 747. Sperimentale (Lo). Firenze. 748. Spindler (Paulus). Observationum medicinalium centuria, etc. Fran- cof. ad M., 1691. 749. Spitalul. Bucuresci, 1881-. 750. Stalpart van der Wiel (Cornelius). Observ. rariorum. Lugd. Bat., 1687. 751. Stoll (Maximilian). Rationis me- dendi. Paris, 1787. 752. Storck (Antonius). Annus medicus. 753. Sue (Pierre). Essais historique, etc. Paris, 1779. 754. Suetonius. De xii Caesaribus. 755. van Swieten (G. L. B.). Commen- taria in Hermanni Boerhaave apho- rismos, etc. 1742-76. T. 756. Tardieu (A.). Etude medico-legale sur les attentats aux Moeurs. Paris, 1862. 757. Taylor (A. F.). A Manual of Medi- cal Jurisprudence. 758. Testa (A. G.). Bemerkungen iiber die per. Ver'anderungen, etc Leip- zig, 1790. 759. Teratologia. London and Edinburgh. Edited by Ballantyne. 760. Texas Courier-Record of Medicine. Dallas, Tex. 761. Todd(R. B.). Cyclopedia of Anatomy and Physiology. London, 1835-. 762. Tolberg (J. G.). Diss, de ovar. hymen. Halae, 1791. 763. Transactions of the Albany Institute. Albany, N. Y. 764. Transactions of the American Gyne- cological Society. Boston. 765. Transactions of the American Oph- thalmological Society. New York. 766. Transactions of the Associated Apoth- ecaries, etc. London. 767. Transactions of the Clinical Society of London. 768. Transactions of the College of Physi- j cians of Philadelphia. 769. Transactions of the Edinburgh Ob- stetrical Society. 770. Transactions of the Medical Associa- tion of the State of Alabama. 771. Transactions of the South Carolina Medical Association. 772. Transactions of the Medical Society of the State of Georgia. 928 BIBLIOGRAPHIC INDEX. 773. Transactions of the Medical Society of the State of New York. 774. Transactions of the Medical Society of Tennessee. 775. Transactions of the Medical and Chirurgical Faculty of Maryland. 776. Transactions of the Medico-Chirurgi- cal Society of Edinburgh. 777. Transactions of the Medical and Phy- sical Society of Bombay. 778. Transactions of the Obstetrical Society of London. 779. Transactions of the Pathological So- ciety of London. 780. Transactions of the Philadelphia Ob- stetrical Society. 781. Transactions of the Provincial Medi- cal and Surgical Association. Lon- don. 782. Transactions of the Ninth Interna- tional Medical Congress. Wash- ington, 1887. 783. Transylvania Medical Journal. Lex- ington, Ky. 784. Trioen (Cornelius). Observ. medico- chirurgicarum. Lugd. Bat., 1743. 785. Trnka de Krzowitz (W.). Historia Tympanitidis. 1788. 786. Trousseau (Armand). Clinique medi- cale, etc. 3 vols. Paris, 1865. 787. Tweedie(Alex.). Cyclopedia of Prac- tical Medicine. Philadelphia, 1845. u. 788. Union (L') medicale du Canada. Montreal. 789. Union (L') medicale. Paris. 790. United States Medical Investigator. Chicago. 791. Universal Medical Journal. Phila- delphia. 792. University Medical Magazine. Phila- delphia. V. 793. Valentini (M. B.). Novellas medico- legals, etc. Francof. ad M., 1711. 794. Valentini (M. B.). Polychresta exo- tica. Francof. ad M., 1700. 795. Vallee (Leon). Bibliographie des bib- liographies. Paris, 1883. 796. Vallisneri (Antonio). Opere fisico- mediche. Venezia, 1733. I 797. Van Oven (Barnard). On Decline of Life, Longevity, etc. London, 1853. 798. Vclschius (G. H.). Curationum exo- tericarum. Ulmae, Ki7b\ 799. Verduc (J. B.). Pathologie de Chi- rurgie. 12°. Paris, 1723. 800. Verhandlungen der Genootsch. t. I5e- vord. d. Heelk. te Amsterdam. 801. Verhandlungen der physikalisch-me diciuischen Gesellschaft in WUrz- burg. 802. Vermischte chirurgische Schriften. Berlin und Stettin, 1776-. 803. Vesalius (Andreas). Anatomia, etc. fol. Amstelodami, 1617. 804. Vesalius (Andreas). Suorum de humani corporis fabrica lib. epi- tome, 1543. 805. Veslingius (Joannes). Syntagma ana- tomicum. Patav., 1647. 806. Veterinary Journal and Annals of Comparative Pathology. London. 807. Vierteljahrsschrift fur gerichtliche Medicin, etc. Berlin. 808. Vierteljahrsschrift fiir die praktische Heilkunde. Prag. 809. Virginia Medical Monthly. Rich- mond, Va. 810. Virginia Medical and Surgical Jour- nal. Richmond, Va. 811. Vrachebniya Vaidomosti. St. Peters- burg. 812. Vrach. St. Petersburg. w. 813. Walford (Cornelius). The Insurance Cyclopaedia. London, 1871-80. 814. Walther (A. F.). De obstetricum erroribus, etc. 4°. Leipzig, 1729. 815. Walther (C. L.). Thesaurus medico- chirurg. observationum curiosa- rum, etc. Leipzig, 1715. 816. Western Journal of Medical and Physical Sciences. Cincinnati. 817. Western Journal of Medicine and Surgery. Louisville, Ky. 818. Western Medical Gazette. Cincinnati. 819. Western Medical and Physical Jour- nal. Cincinnati. 820. Wiener Klinik. 821. Wiener medizinische Blatter. Wien. 822. Wiener medizinische Presse. 823. Wienerische Bey tr'age zur praktischen Arzneykunde, etc. Wien, 1781. BIBLIO GRAPH 824. Willoughby (P.). Observations in Midwifery. Re-edited in War- wick, 1863. 825. Wilmer (Bradford). Cases and Re- marks in Surgery. 8°. London, 1779. 826. Wilson (Sir W. J. Erasmus). On Diseases of the Skin. 8°. Lon- don, 1867. 827. Wochenschrift fur die gesammte Heil- kunde. Berlin. 828. Wolff (Casp. F.). Theoria generati- onis. Halae, 1759. 829. Wood (H. C). Therapeutics, etc. Philadelphia, 1890. ADDEN ADDENDA. 837. Transactions of the Americau Surgi- cal Association. Philadelphia, 1888. 838. Wiener klinische Wochenschrift. 839. Archiv fur Gynakologie. 840. Devergie (Alph.). Medecine Legale. Paris, 1840. 841. Borellus (Peter). Historiam et ob- servat. medico-physicarum, 1676. 842. Tulpius (Nicolas). Observat. medicae. Fifth edition, 1716. 843. The American Year-Book of Medicine and Surgery. Gould. Philadel- phia, 1896. IC INDEX. 929 Z. 830. Zacchias (Paulus). Quaestiones me- dico-legales. Lugd., 1701. 831. Zacutus Lusitanus (Abraham). Pra- xis medica admiranda, etc. Lug- duni, 1637. 81 832. Zeitschrift fur Geburtshulfe und Gy- nakologie. Stuttgart. 833. Zeitschrift der k. k. Gesellschaft der Aerzte zu Wien. 834. Zeitschrift fur die Staatsarzneikunde. Erlangen, 1821. (Henke.) 835. Zittman (J. F.). Medicina Forensis. Francof. a. M., 1706. 836. Zoologist. London. 844. American Text-Book of Obstetrics. Norris. Philadelphia, 1896. 845. An American Text-Book of Surgery. Keen and White. Philadelphia, 1895. 846. Warren (J. C). Surgical Pathology and Therapeutics. Philadelphia, 1895. 847. Circular No. 3. War Department, Surgeon-General's Office, Washing- ton, August 17, 1871. 59 INDEX. A. Abbe on aneurysmal varix, 778 Abbot on hernia, 665 Abdomen, evisceration through, 650; foreign bodies in, 658 ; gunshot wounds of, 651 ; transfixion of, 648 ; walls of, spontaneous rupture of, 666 Abel aud Colman on brain injury, 547 Abernethy, William, 353 Abortion after anal operation, 105; attempts at, 695 : bloodless, 110 ; causes of, 109 ; caused by worms in the uterus, 112 ; epidemics of, 109 ; by the mouth, 52 ; in twin pregnancy, 110 Abstinence from food and drink, 413 Acanthosis nigricans, 841 Acheson on luxation of the cervical spine, 580 Achondroplasia, 602 Acne cornee, 825 Acrobats, 463 Acromegaly, 803 ; association with gigant- ism, 327 Acrophobia, 877 Acton on dos Santos, 196 Adams on a case of cut-throat, 577 ; on hemihypertrophy, 351 ; on Jenner, 906 ; on labial manipulation, 307 ; on varicose veins, 778 Addison an anomalous twin births, 142 Adenomata, 759 ; of the breast, 759 Adiposis dolorosa, 360 Adler on ocular injury, 528 Adrian, Emperor, on legitimacy, 68 Aetius on sloughing of the genitals, 138 African sleep-sickness, 872 Age, old, 365 ; ovariotomy in, 707 ; preg- nancy in, 39 Agnatbes, 251 Agnew on hemophilia, 816 ; on polyphazia, 637 I Agoraphobia, 877 Ahlfeld on combined fetation, 57 ; on fetal therapeusis, 92 : on polymazia, 299 Aichmophobia, 877 Ainhum, 828 Air, effects of working in compressed, 432 Aissaoui, 476 " Ajax," 468 "A-Ke," 193 Akers, Carrie, 342 Alard on elephantiasis arabum, 800 Albers on opium, 505 ; on pathognomonic dreams, 867 931 Albertus on abortion, 110 ; in vicarious menstruation, 25 Albes, Georgius, 218 Albinism, 220 ; in the lower animals, 222; in negroes, 220 ; partial, 221 Albosius on retention of the fetus, 63 Albrecht on anomalous spleens, 290 Albucasis on extrauterine pregnancy, 50 ; on multiple births, 152, 154 Alchemy, 368 Alderson on diaphragmatic hernia, 286 Aldrovandus on hirsuties, 231 ; on parasitic terata, 189 d'Alechanipius on multiple births, 152 Aleppo boil, 840 Alexander on double colon, 287 Alexeef on self-mutilation, 733 Algora on expulsion of the ectopic fetus, 53 Alibert on anomalous coloration of the hair, 239, 240 ; on vicarious menstruation, 24 Alix and Richter on rheumatism, 688 Allen on double ureter, 294 ; on precocious pregnancy, 38 ; on triple amputation, 597 ; on wound of the liver and lung, 653 Alley on molten lead in the ear, 540 Alleyne on elephantiasis of the scrotum, 801 Alligator-bite, 722 "Alligator-boy," 824 Allport on vicarious menstruatiou, 24 Alopecia, association with edentulousness, 227 ; congenital, 226 ; in lower animals, 232 ; strange causes of, 241 Alston on ovarian cyst, 783 Amatus Lusitanus on foreign body in the brain, 560; on hair on the tongue, 256 ; on vicarious menstruation, 20 Amazia, 297 Ambrosini on telegony, 89 Ambrosioni on combined fetation, 57 "American crow-bar case," 551 Ames on fasting, 415 Ammann on artificial penis, 319 ; on pro- tracted pregnancy, 69 Amos on a case of cut-throat, 574 Amputations, intrauterine, 94 ; by light- ning-stroke, 727 ; multiple, 596 ; in preg- nancy, 105 ; spontaneous, 597 Amussat on absence of the vagina, 303 Amyelia, 281 Anakhre, 769 Anal tags, 280 Anche on avulsion of the finger, 589 Anderson on easy birth, 118 932 INDEX. Andouard on blue bile, 385 Andrews on birth by the anus, 121 ; on needles in the body, 736 ; on presentiment of death, 8H9 Andrews, William Thomas, 249 Anencephalous monsters, living, 246 Anesthesia of the skin, 837 Aneurysm, 779 ; cure of abdominal, 658 Aneurysmal varix, 778 Angell and Eisner on anencephaly, 246 Anger causing abortion, 110 Angle on brain-injury, 550 d'Angouleme, on artificial impregnation, 43 Animation, suspended, 513 Aniridia, 259 Ankylosis of* the articulations, 787 Annandale on orbital injury. 529 ; on super- numerary digits, 273, 274 Anomalies of stature, size, and develop- ment, 324 Anomalous nervous and mental diseases, 852 Anomalous skin diseases, 823 Anomalous tvpes and instances of disease, 759 Anorchism, 319 Anorexia nervosa, 414 Anosmia, 874 Ausiaux on gynecomazia, 396 Antemortem digestion of the stomach, 628 Antenatal pathoiogy, 89 Antepartum crying, 127 Anthropophagy, 406 Anthropophobia, 879 Antimony, tolerance of, 499 Anuria, 792 Anus, artificial, operation for, 645; imper- forate, :18x, 794; parturition through, 121 ; passage of urine by, 675 Aorta, abdominal, ligature of, 658 ; double, 297 ; perforation of, 572 ; wounds of, 626 Aphasia, 872 ; snake-bite causing, 874 Apoplexy, birth during, 113 Appendix, vermiform, foreign body in, 642 Appetite, depraved, for human flesh, 409 ; excessive or canine, 403 ; perverted, 405 ; perverted in pregnancy, 81 Arand on excrement issuing from the vulva, 675 Archer on superfetation, 49 ; on wound of the stomach, 632 Aretaeos on fetus in fetu, 201 Argles on combined fetation, 57 Aristotle on divisions of life, 370 ; on men- strual superstitious, 17 ; on quintuplets, 147 ; on superfetation, 46 Arm, absence of, 265 ; avulsion of, 591 ; ele- phantiasis of, 798 ; foreign body in, 599 ; piercing the, 746 Armor on tapeworms, 818 Armstrong on discharge of fetal bones, 53 ; on mercuric chlorid, 504 Arnaud on intestinal resection, 643 Arndt on branchial fissures, 284 Arnold on anomalous urination, 383 ; on infantile menstruation, 30 Arnot on foreign body in the thorax, 614 Arnott on arrow-poison, 711 Arntzenius on anomalous suicide, 742 Aronsohnon foreign body in the larynx,581 Arrow-poison, 711 Arrow-wounds, 710 ; of the bladder through the buttocks, 672 Arsenic, idiosyncrasies to, 500 ; sources of poisoning by, 500 Arsenic-eating, 413 Arteries, wounds of some, 627 Articulation without a tongue, 254, 566 Articulations, ankylosis of, 787 : deformed, 603 Artificial impregnation, 42 Artificial limbs, 598 Arton on rupture of the stomach, ("29 Ascanius on the "porcupine-man," 824 Ascarides. 819 Ascites, 786 Ash on horns, 225 Ashburn on urethral calculus, 791 Ashby and Wright on absence of the penis, 314 Ashhnrst on avulsion of the leg, 59:2 ; on cholecystectomy, 655 ; on esophagotomy, 574 : on fracture of axis and atlas, 578 ; on ligature of the carotid artery, 575 ; on ligature of the iliac artery, 658 ; on mul- tiple amputations, 597 ; on rupture of the bladder, 670 ; on rupture of the heart, 625 ; on rupture of the lung, 608 ; on scalp-injury, 542 ; on splenectomy, 656 ; on vesical calculi, 790 Ashmead on leprosy from a fish-bite, 721 Asiatic cholera, 908 Asphyxia, birth during, 113 ; recovery after, 519 Assmuth on rupture of the bladder, 670 Astasia-abasia, 860 Astbury on vicarious menstruation, 26 Astrophobia, 878 Asymmetry, congenital, 350 Athenaeus on obesity. 356 Athetosis, 857 Athletes, dismembered, 599 Athletic feats, 455 Atkins on foreign body in the esophagus, 572 Atkinson on congenital alopecia, 227 ; on intrauterine fractures. 97 ; on polydipsia, 404 ; on prolificity, 157 Atlas, dislocation of, 578 Atlee on fetus in fetu, 201 ; on protracted pregnancy, 70 Attachment of the fetal head, 142 Auricles, supernumerary, 261 Auricular movement, 263 Autenrieth on injury during pregnancy, 98 Automatism, 887 Auvard incubator, 68 Aveling on postmortem births, 124 Aventium on protracted pregnancy, 70 Aversions, 481, 880 Avulsion of the arm, 589 ; of the finger, 590 ; of the leg, 592 ; of the male external genitals, 686, self-performed, 732 Aylesbury on foreign body in the esopha- gus, 570 Azema on absence of the vagina, 304 "Aztec children," 335 Aztecs, 248 INDEX. 933 B. Babbiugton and Curry on knife-swallow- ing, 635 Baber on premature birth, 68 Babington on cardiac injury, 617 " Baby Chambers," 352 Bachman on hyperidrosis, 387 Bacillophobia, 879 Back, foreign bodies in, 659 Bacon on abortion, 110 Bacon, Lord, on human combustion, 427 ; on longevity, 375, 378 ; on sympathetic male nausea, 79 ; on triple dentition, 243 Bacque on repeated Cesarean section, 130 Bader on belladonna, 501 Bainbridge on enlarged clitoris, 309 Bainbrigge on supernumerary spleen, 291 Bailey on impalement, 649 Bailey, J. B., on longevity, 371 Baillot on precocious menstruation, 30 Baker on small infants, 348 ; on tongue- injury, 566 ; on vicarious menstruation,20 Balade on absence of the uterus, 311 Balch on cardiac injury, 623 Baldness, congenital, 227 Baldwin, Barney, 579 Baldwin on Cesarean section, 129 ; on large infant, 349 Baldy on dermoid cyst, 203 Balfour on telegony, 87 Ball on aphasia, 873; on basal fracture, 559 Ballantyne on antenatal patrnTtOgy, 90 ; on the Biddenden Maids, 175 ; on coilings of the funis, 95 ; on fetomaucy, 213 ; on ma- ternal impressions, 81 ; on monsters, 161; on worms in the fetus, 112 Ballantyne and Skirving on diphallic ter- ata, 199 Ballingal on flogging, 481 "Balloon-man," 287 Ballowitz on absence of the kidney, 292 Bally on migration of foreign bodies in the esophagus, 571 Baly on epilepsy, 852 Bancroft on accidents during pregnancy, 101 Banerjec on multiple births, 156 Banks on Turkish baths, 424 Banou on speech without a tongue, 566 Barbadoes leg, 797 Barbee on vicarious menstruation, 26 Barbieux on transposition of the viscera, 291 Barclay on hair-pin in the ear, 542 Bardsley on monsters, 193 Bardt on premature rupture of the fetal membranes, 108 Barham on. vicarious menstruation, 19 Barkan on orbital injury, 529 Barkar on foreign body in the eye, 532 Barker on a case of cut-throat, 575 ; on pre- mature fetus, 66 ; on self-performed Ce- sarean section, 132 Barker, Fordyce, on fetal therapeutics, 92 Barkesdale on rupture of the bladder, 671 Barlow on ankylosed joints, 603 ; on hie cough, 813; on postmortem movements, 522" Barlow's disease, 817 Barnes on evisceration, 650 ; on vicarious menstruation, 20, 24, 25 Barrett on hiccough, 812 ; on vicarious men- struation, 26 Barrow on enlarged clitoris, 307 Bartels on human tails, 279 ; on rupture of the bladder, 670 Bartens on skin-grafting, 730 Barth on rupture of the heart, 625 ; on su- pernumerary nipple, 302 Bartholf, 607 ' Bartholinus on abortion by the mouth, 52 ; on anomalies of the nails, 241 ; on ante- partum crying, 128; on chromidrosis, 385 ; on dropsy, 786 ; on foreign body in the eye, 532 ; on horns, 224 ; on obesity, 353 ; on parasitic terata, 191; on polyma- zia, 299 ; on postmortem delivery, 125 ; on prolonged pregnancy, 69 ; on vicarious menstruation, 24, 25, 27 Bartlett on bullets voided by the anus, 651 Barton on vesical calculi in children, 790 Barwell on broken neck, 578 ; on exostoses, 768 ; on multiple fractures, 702 Basal fractures, 559 Bass, J. R., 787 Bassett on late dentition, 243 Bastianelli on ligature of the liver, 654 Bateman on bicephallic monster, 187 ; on craniopagus, 173: on double monster, 184 ; on ischiopagus, 181 ; on pygopagus, 174 Bates on abortion in twin pregnancy, 111 Bates, Captain, 332 Bath-tub, birth in a, 120 Battersby on lactation in infants, 392 Battey on multiple fractures, 702 ; on the Skoptzies, 758 Battle on basal fractures, 559 Baudeloque on superfetation, 47 Baudoin on the Blazek Sisters, 180 Baunir on twin-sympathy, 887 Baux on absence of the vagina, 303 ; on anomalous urination, 383 Baxter on foreign body in the pelvis, 078 Baxter-Tyrie on dislocation of the shoulder- joint, 595 Bayle on retention of ectopic fetus, 62 Baynes, Dr. R., 380 Baytraffon multiple birth, 154 Bazzanella on foreign bodv in the vagina, 694 Beach on combined fetation, 50 ; on large infants, 349 ; on multiple fractures. 702 Beale on maternal impressions, s4 ; on pregnancy with unruptured hymen, 42 Bean in the bronchus, 614 ; sprouting in the bowel, 641 Beard, long, 234 Bearded women, 228 Beardsley on epilepsy, 852 Beatty on accident to the fetus, 103 Beau on tartar emetic, 499 Beauchamp on abortion, 111 Beaudry and Brothers on cleft tongue, 255 Beaumont on brain-injury, 548 Beaupre on cretinism, 806 Beauvais, 228 934 INDEX. Bebe, 339 Bechlinger on monsters, 194 Beck on Cesarean section, 130 ; on preco- cious pregnancv, 35 ; on self-mutilation, 734 Beckett on impalement, 690 Beckman on postmortem Cesarean section, 136 Bedford on postmortem birth, 126; on quadruplets, 150 Bedor on gynecomazia, 395 Beehe on intestinal resection, 643 Bee-stings, 713 Begg on quadruple amputatiou, 597 Begin on idiosyncrasy, 481 Behrend on opium, 505 Behrends on tartar emetic, 500 Behrens on labor during sleep, 116 Beigel on anomalous coloration of the hair, 210 ; on cryptorchids, 321 Beilby on anomalous sneezing, 814 ; on hiccough, 813 Beirne on anomalous cure of epilepsy, 853 Beisone on the fate of ectopic children, 62 Bejan on horns, 224 de Belamizaran, on combined fetation, 57 Belin on injury during pregnancy, 101 Belinovski on human tails, 278 Bell on abortion, 110 ; on gastrotomy, 633 ; on anomalous suicide, 743 ; on human magnetism, 430 Belladonna, idiosyncrasy to, 501 Bellamy on horns, 226 Bellini on vicarious menstruation, 23 Belloste on cranial fractures, 558 Belluzzi on postmortem birth, 124 Belt on twin-labor, 111 Benedictus on protracted pregnancy, 69 Benham on discharge of fetal bones, 53 Benicke on fetal therapeutics, 92 Benivenius on male menstruation, 28 ; on rupture of the uterus, 137 ; on self-muti- lation, 732 ; on sloughing of the genitals, 138 ; on vicarious menstruation, 27 Bennett on ovariotomy in age, 707 Benvenuti on macrocephaly, 248 Benziu-poisouing, 501 Berard on absence of the vagina, 304 Berchon on diaphragmatic hernia, 286 Berdot on absence of the tongue, 254 Bergtold on brain-injury, 554 Berillon on lyssophobia, 879 Bernard on urethral calculus, 791 Bernard. Claude, on absence of the olfactory lobes, 246 Bernays on gastrotomy, 633 Berncastle on late restoration of sight, 535 Bernhardt on cervical ribs, 282 Bernstein on fecundity in the old, 39 ; on protracted menstruation, 32 Berry on the Hindoo Sisters, 168 Bertherand on enlarged clitoris, 308 Berthier on delivery during melancholia, 115 Berthold on precocious pregnancy, 34 Bertrandi on repeated Cesarean section, 130 Berwick on organ-handle swallowed, 640 Besse on bicephalic monsters, 187 Bessems on twin-birth, 143 Bestiality, 162, 163 Beyrat on protracted menstruation, 32 Bhadoory on evisceration, 651 Bianchini on spontaneous human combus- tion, 427 Biaudet and Buginon on double monster, 173 Bibliographic index, 915 Bicephalic monsters, 187 Bichat on canities, 236 ; on hirsuties, 232 Biddenden Maids, 174 Bidel on worms in the uterus. 111 Bid well on precocious boy. 345 Bielschowsky on canities unguium, 847 Bierling on vicarious menstruation, 20 Biffi on cardiac injury. 623 Bigelow on the '(row-bar case," 533; on foreign body in the bladder, 078 ; on horns, 225 Bijoux on depraved appetites, 411 Bile, blue, 385 Bill on arrow-wounds, 711 Billard on blue coloration of the skin, 844 ; on infantile menstruation, 29 Billroth on avulsion of the arm, 591 ; mar- velous operation by, 708 ; on opium, 505 ; on teeth swallowed, 639 Binet on double consciousness, ss4 ; on fetichism, 401 ; on rudimentary penis, 315 Biondi on surgery of the lung, 608 "Biped armadillo," 823 Birch on retention of ectopic fetus, 62 Bird on brain-injury, 557 Birds, injury to the eye by, 533 Birth through the abdominal wall, 122; during apoplexy, 113 ; during asphyxia, 113; in awkward places, 116; by cattle- horns, 133; in epileptic convulsions, 113 ; during intoxication, 114 ; with mem- branes intact, 122; painless, 113; in paraplegia, 116 ; through perineal per- foration, 121 ; postmortem, 123 ; prema- ture, 65 ; by the rectum, 120 ; retarded, 68 ; during somnambulism, 116 ; at stool, 116, 117, 118, 119; unconscious, 113; unusual places of, 115, 119 Biskra button, 840 Bisset on triple dentition, 243 Bissieu on fetus in fetu, 201 Bites, alligator-, 722 : animal-, 719, 721 ; fish-, 721 ; fowl-, 719 ; insect-, 713; shark-, 721 ; snake-, 715 ; spider-, 713 Bixby on conception after ovariotomy, 46 ; on ovarian cyst, 783 Bizzen on coiling of the funis, 95 Black Death, 892 ; in London, 895 ; moral effect of, 894 ; mortality of, 893 ; nobility stricken by, 894 Black on hydrochloric acid, 498 ; on lipoma, 766 ; on self-mutilation, 734 Bladder, anomalies of, 295 ; calculi in, 788 ; exstrophy of, 295 ; fetus in, 53, 63 ; fis- tula of, 675 ; foreign bodies in, 676 ; gun- shot wounds of, 671 ; injuries of, 670 ; menstruation from, 26 ; penetration through anus, buttocks, or vagina, 671 ; rupture of, 670 ; triple, 295 ; worms in, 676, 819 INDEX. 935 Blaikie, Brunton, on telegony, 86, 87, 89 Blair on vicarious menstruation, 24 Blake on intrauterine amputation, 94 ; on menstruation during pregnancy, 29 Blanc on precocious boys, 346 Blancardi, 32 Blanchard on conception with hymen in- tegrum, 40 ; on fecundity in the old, 39 ; on gynecomazia, 395 ; on lactation in the aged, 394 Blandin on anomalous growth of nails, 589 Blasius on triple monsters, 167 Blatner on postmortem Cesarean section, 137 Biaudet on protracted sleep, 869 Blaxland on perforation of the aorta, 572 Blazek Sisters, 179 "Bleeders," 815 Bleeding, extensive, 709 ; self-performed, 745 de Blegny, on protracted pregnancy, 69 ; on retention of ectopic fetus, 62 Blenkinsop on rupture of the vagina, 138 Blind, extraordinary sense-development in the. 433 "Blind-Tom," 433 Block on urethral calculi, 791 Blok on cyclopia, 258 Blondin, 450 Blood, great loss of, 709 Blood-vessels, anomalies of, 297 "Bloody sweat," 388 Blot on absence of the oviducts, 310 Blower on passage of a nail swallowed, 638 Blumenthal on intrauterine amputation, 95 Blundel on mercury, 504 Blundell on fetus in fetu, 200 Boardman on nail in the bowel, 638 Bochut on precocious lactation, 392 Boddington on absence of the tongue, 254 Bodinier on delivery of ectopic fetus, 54 Bodkin on exophthalmos, 527 Bodwitch on diaphragmatic hernia, 286 Boehm on operation on double monsters, 173 Boerhaave on rupture of the esophagus, 628; on spontaneous amputation, 597 ; on vicarious menstruation, 25 Boerstler on ovarian cyst, 783 Bohemian Twins, 180 Boling on cranial fractures, 559 Bolsot on fasting, 415 Bone, anomalous growth of, 605 ; tumors of, 768 Bone-grafting, 729 Bonet on postmortem birth, 126 Bonhoure on protracted menstruation, 33 Bonnain on anomalous vaginal opening, 306 Bonuar on short pregnancy, 65 Bonnet on multiple fractures, 702 Bontius on brain-injury, 554 Bookey on gunshot wound of the penis, 681 ; on horse-bite of the penis, 680 Boone on cardiac injury, 619 Booth on infant-vitality, 706 ; on priapism, 685 Boqnis on unilateral sweating, 388 Bordat on parasitic terata, 191 Bordenave on triple monster, 167 Borellus on antepartum crying, 128; on chromidrosis, ?>ti.~) ; on hypertrophy of the heart, 759 ; on multiple birth, 153 ; on triple monster, 167 Borgeois on ascarides, 820 Borghini, 249 Boric acid, idiosyncrasy to, 497 Borsini on ovariotomy in age, 707 Borthwick on wound of the kidney, 667 Borwilaski, 339 Bosquet ou absence of the vagina, 303 ; on deficient uterus, 311 Bot-fly, 821 Bothwell on twin-labor, 111 Botocudos, 749 Botta on obesity, 355 Bouchacourt on fetus in fetu, 202 Bouchaud on anomalous diaphragm, 285 Boulger on vicarious menstruation, 20 Boullard on anomaly of the jaw, 251 Bouillon on rupture of the uterus, 137 ; on superfetation, 49 Bouilly on rupture of the lung, 609 Boulting on multiple fractures, 702. Bourke on menstrual superstitions, 17 ; on scatologic rites, 406 Bourton on postmortem Cesarean section, 135 Bousquet on quadruplets, 149 Bouzal on expulsion of ectopic fetus, 53 Bowel-injuries, 642 Bower on orbital injury, 529 Bowling ou cardiac injury, 618 Boxing the ears, 537 Boyer on deficient uterus, 311 ; on gangrene of the penis, 682 ; on hypertrophy of the heart, 759 Boyle on shark-bite, 721 Bradley on dislocation of the humerus, 594 ; on premature rupture of the fetal mem- branes, 108 Braid on supernumerary digits, 275 Braid wood on dajaksch, 711 Brain, anomalies of, 245; double, 249; foreign bodies in, 559 ; gunshot injuries of, 549 ; injuries of, 545, with loss of cerebral substance, 551 ; largest, 249 ; life without, 246 ; penetration and trans- fixion of, 545 : study of wounds of, 550 ; tumors of, 557 Brain-substance, loss of, 551, 700 Braine on anomaly of the tongue, 256 Braman on neck-injury, 576 Bramann on dermoid cyst, 204 Branch on extraoral dentition, 245 Branchial fissures. 284 Brand on opium, 505 Brander on fibrolipoma, 764 Brandis on partial canities, 238 Brasavolus on brain-injury, 553 Brau, Hans, 329 Braun on intrauterine fracture, 97 ; on pregnancy with unruptured hymen, 42 Breast, adenoma of, 759 ; anomalies of, 297 ; diffuse hypertrophy of. 759 ; menstrua- tion from, 19 ; removal of, during preg- nancy, 105 ; supernumerary, 298 Breeding, influence of telegony in, 87 936 INDEX. Breisky on foreign body in the vagina, 694 Breniuse on rupture of the diaphragm, 612 Brendelius on injury during pregnancy, 98 Brentano on anomalous esophagus, 285 Breschet on foreign body in the nose, 564 Bricc, the giant, 330 Bricheteau on accidental growth of hair, 235 ; on anomaly of the nails, 241 Briddon on ovarian cyst, 782 Brides, injuries to, 692 Bridgman, Laura Dewey, 434 Brierre de Boismont on precocious men- struation, 31 ; on protracted menstrua- tion, :V.i ; on suicide, 744 ; on vicarious menstruation, is Brieude on human odors, 398 Briggs on a wine-glass in the rectum, 648 Brigham on avulsion of the genitals, 686 ; on a nail in the bronchus, 614 Bright, Edward, 357 Bright on hydrocephaly, 250 Briguatelli on foreign body in the uterus,695 Brill on pregnancy with unruptured hjfmen, 42 Brincken on vicarious menstruation, 25 Brissaud ou myxedema, 807 Brissaud and Meige on gigantism, 328 Bristowe on aphasia, 874 Broca on fetus in fetu, 201 ; on hemihyper- trophy, 350 ; on Jacques Inaudi, 439 ; on James Leedgwood, 265 Brochin on opium, 505 ; on tumors in the pregnant uterus. 106 Brodhurst on absence of the vagina and uterus, 304 Brodie on chromidrosis, 385 ; on expulsion of the ectopic fetus, 53 ; on fetus in fetu, 200 Brokaw on chest-injuries, 611 Broken back, 659 Bronchi, foreign bodies in, 614 ; injuries of, 606 Bronchocele, 761 Brooke on acne cornee, 825 Brouzet on premature fetus, 66 Brown on birth through the perineum, 121 ; on impalement, 610 ; on perineal testicle, 322 : on pregnancy after ovariotomy, 46 ; on protrusion of the fetal membranes, 107 ; on teeth in the larynx, 582 ; on un- usual birth, 120 Brown-Sequard on epilepsy, 852 ; on sudden canities, 236 Browne on elephantiasis of the scrotum, 802 ; on ectopic fetus, 57 Bruce, Mitchell, anomalous discoloration of the skin and mucous membranes, 843 Bruce on priapism, G^> Brucker on suicides, 744 Brugh On avulsion of the testicles. 686 Brulev on anomalous coloration of the hair, 240' Brunet on anencephalous child, 246 Brunton on death from fear, 525 Bruyesinus on perverted appetites of preg- nancy, 80 Bryan on protracted pregnancy. 70 Bryant on lightning-stroke, 727 ; on wound of the kidney, 668 Bryce on anuria, 793 Bryk on dermoids. 204 Bubendorf on discharge of the fetal skele- ton, 53 Bubonic plague, 892, 896 Bucchetoni on diphallic monster, 195 Buchanan on brain-injury, 555 ; on intra- uterine amputation, 96 ; ou orbital injury, 529; on the Scottish Brothers, 18 J : on vicarious menstruation, 26 Buchner on injury during pregnancy, 98 ; on protracted pregnancy, 69 ; on reten- tion of the fetus, 64 Buck on hydatid in the heart, 624 Buckler on foreign body in the appendix, 642 Bud in on premature fetus, 67 Buffon on albinism, 221 ; on dwarfs, 340 ; on giants, 327; on longevity, 374; on strength of* jaws, 469 Buhl on anomalous extremities, 267 Buhl's disease, 817 Buhring on bicephaly, 246 Bulatoff on polyorchism, 320 Bulimia, 403 ; in pregnancy, 81 Bull on supernumerary feet, 270 Buller on lightning-stroke, 726 Bullet in the brain, 561 ; voided by bladder or bowel, 651 Bullock on cardiac injury, 619 Bumm on large infant, 349 Burchard on priapism, 085 Burdach on telegony. 89 Buret on syphilis, 912 Burge on imperforate anus, 289 Burgess on large infant, 348 ; on pregnancy with unruptured hymen, 42 Burial, premature, 519 Burke on twins, 143 Burman on hydrocyanic acid, 499 Burr on lingual hemiatrophy, 860 Burrall on dry birth, 123 Burroughs on bulimia, 403 Burrows on odors of the insane, 400 Bursting from over-eating, 628, 629 Burton on venesection, 709 Bury on fetus in fetu, 201 Busch on phenol, 498 Bush on twins, 143 Bussiere on triple bladder, 295 Butcher on discharge of fetal bones, 53 Butler on anuria, 793 Buxtorf on infantile menstruation, 30 ; on parasitic terata, 189 Buzzard on accident during pregnancy, 103 Buzzell on retention of fetus, 64 Byrne on tumor in the pregnant uterus, 106 c. Cabrolius on coitus, 512 Cachot on fecundity in the old, 39 Caddy on torsion of the penis, 316 Cadet de Gassicourt on hypersensitiveness of smell, 398 Caen on anomalous suicide, 736 Caesar on hyperthermy, 422 INDEX. 937 Cagots, 808 Caille, Rene, on albinism, 221 "Calculating boy," 439 Calculi, 788; cardiac, 792 ; extra vesical, 790 ; after penetration of the bladder, 672, 674 ; pineal, 792 ; renal, 790 ; saliv- ary, 792 ; spontaneous discharge of, 790 ; umbilical, 792 ; urethral, 791 ; uterine, 792; vesical, 788 Caldani on anomalies of the ossicles, 263 Calder on vicarious, menstruation, 25 Caldwell on postmortem growth of hair, 523 ; on retention of fetus, 64 Calhoun on exophthalmos, 529 ; on maggots in the ear, 539 Callender on cardiac injury, 624 Camby on lightning stroke, 725 Camden on foreign body in the brain, 561 "Camel-boy," 603 Camerer on infantile menstruation, 29 ; on retention of fetus, 64 Cameron on gynecomazia, 396 ; on labial manipulation, 307 ; on obesity, 354 Camp on self-mutilation, 732 Campaignac on hirsuties, 233 Campbell on delivery of ectopic fetus, 53 ; on extrauterine pregnancy, 50, 51; on fistula-operation during pregnancy, 105 ; on postmortem Cesarean section, 135 ; on a precocious boy, 346 ; on precocious menstruatiou, 29 ; on premature rupture of the fetal membranes, 108; on pro- tracted pregnancy, 70 ; on snake-bite, 717 ; on viable ectopic fetus, 57 Campbell, William, 333, 359 Campbell de Morgan on plexiform neuroma, 771 Camper on bladder injury, 671 ; on intes- tinal fistula, 675 Camuset and Planes on protracted sleep, 870 Canities, sudden, 235 ; temporary and par- tial, 238 Canities unguium, 847 Cannibalism, 406 Cannon-ball, delivery by, 134 Cantharides, poisoning by, 501 Canton on anomaly of the jaw, 252 Capers on accidental conception, 44 Capuron on fecundity in the old, 39 ; on perineal birth, 122 ; on premature fetus, 67 Carbolic acid, poisoning by, 498 ; tolerance of, 498 Carcinoma, 772 Cardanus on injury to the pericardium, 624 Cardiac injuries, 616, nonfatal, 620; sur- vival after, 617 Cardiac surgery, 616 Cardinal, James, 249 Carey on pregnancy with unruptured hy- men, 42 ; on protracted pregnancy, 71 ; on yellow fever, 910 Carhart on injury during pregnancy, 99 Carlisle on anomalous urination, 384 Carmichael on ovariotomy in old age, 707 Cam on precocious pregnancy, 35 Carnochan on cardiac injury, 619 ; on hy- pertrophy of the heart, 566 Carnot, President, injury of, 653 Carotid artery, ligature of, 575 Carpenter on the Aissaoui, 476 ; on brain injury, 548 ; on sudden birth, 116 ; on tartar emetic, 499 ; on tattooing, 750 ; on , teeth in the bronchus, 616 /Carper on absence of the lungs, 285 Carre on triple dentition, 243 Carson on twin birth, 142 Carter on avulsion of the leg, 592 ; on late dentition, 243 ; on short pregnancy, 65 Carver on extraoral dentition, 245 Casals, Gaugirau, on precocious menstrua- tion, 31 Case on birth during sleep, 114 Caso on vicarious menstruation, 24 '' Cassandra,'' 635 Cassano and Pedretti on enlarged clitoris, 309 Cassidy on birth through the perineum, 121 Castor oil, untoward action of, 504 Castellanos on wound of the kidney. 667 "Castrata," 785 Castration, ceremonial, 755 ; for excessive cupidity, 756 ; as a religious rite, 756 ; self-performed, 732 ; sexual desire after, 687 a Castro on cannibalism, 410 ; worms in the heart, 820 Catalepsy, 867 Caterpillars swallowed, 637 Catesby on obesity, 358 Cathell on pregnancy complicated with both uterine fibroids and measles, 107 Cattle-horns, delivery by, 133 ; injuries to pregnant women by, 99 Caudmont on foreign body in the bladder, 677 Cavalier family, 221 Cazenave on sloughing of the genitals, 138 ; on vicarious menstruation, 20 Cazin on anal operation causing abortion, 105 Cazzan on canities, 236 Cecil on precocious menstruation, 30 Celiotomies, six on one woman, 707 Celliez on injury to the penis, 680 Centenarians, censuses of, 366 ; operation on, 707 Centipede in the ear, 539 ; in the nose, 565 Cerebellum, defective, 246 Cerebrum, anomalies of, 245 ; foreign bodies in, 559; injuries of, 545; life without, 245 ; tumor'of, 557 Cervical ribs. 282 Cervical vertebrae, injuries of, 578 Cesarean section, 128 ; in Africa, 131 ; on a dwarf, 129 ; history of, 128 ; postmortem, 135 ; repeated, 130 ; self-performed, 131 ; with twins, 129 Chabert on combined fetation, 57 Chaffee on morphin, 506 Chaldean teratoscopy, 214 Chalk on hvpertrophv, 567 Chalk-eating, 412 Chambers on belladonna, 501 ; on bloody sweat, 390 ; on vicarious menstruation, 18 Chambon on quintuplets, 150 938 INDEX. Chamouni, 424 Champenois on multiple amputations, 596 Champion on impregnation with hymen in- tact, 41 Chance on gangrene of the penis, 682 Chandler on laceration of the liver, 141 Chang, 331 Channing on self-mutilation, 735 Chantreuil on aural anomaly, 261 Chapman on abortion, 110 ; on dilatation of the colon, 288 ; on extensive hemor- rhage, 710 Charcot ou fetal variola, 91 Chariere on horns, 224 Charlton on repeated Cesarean section, 131 Charpentier on polymazia, 300; on pre- mature birth, 07 Charrin on obesity, 356 Chasser on combined fetation, 55 Chastity-gird les, 753 Chatard, Jr., on expulsion of fetal mem- branes, 108 Chateaubriand, 304 Chaumeton on wasp-sting, 713 Chaupier ou intrauterine fractures, 97 Chaussier on absence of ovary, 309 Chenisse on syphilis from tattooing, 751 Chelius ou brain-injury, 548 ; on injury during pregnancv, 102 ; on transfixion of the chest, 610 Cheselden on avulsion of the arm, 591 ; on retention of fetus, 63 Chesney on premature rupture of the fetal membranes, 108 Chest, foreign bodies in, 613 ; injuries of, 606 ; transfixion of, 610 Chester on retention of ectopic fetus, 63 Chevalier on quinin, 509 "Chevalier Cliquot," 636 Chevers on asphyxiation, 519, on eunuch- making, 756; on fish in the pharynx, 507 ; on injuries to the testicle, 685 ; on precocious pregnancy, 37 ; on self-mutila- tion, 733 Chiari on wound of the aorta, 627 Chicken-pox in fetus, 91 Chiene ou ovariotomy in a child, 707 Child-bearing after the menopause, 29 Child-marriages in India, 18, 37 Child-mothers, 34; in India, 37; with twins, 38 Children, operations on, 706 ; resistance of, to injury, 705 Chinese foot-binding, 737 Chipault on laminectomv, 661 ; on lipoma, 766 Chiromegaly, 805 Chisholm on foreign body in the eye, 532, 535 ; on multiple Cesarean sections, 131 Chitten on dermoid cyst, 204 Chloasma uterinum, 841 Cholecystectomy, 655 Cholecvstotomy, 655 Cholera. 908 Chomel ou anomalous coloration of the skin, 843 Chondromata, 766 Chopart on polyphagia, 637 Chorea, 853 Chretien on penis palme, 316 Christison on cardiac injury, 623 Chromidrosis, 385 Chronology, ancient, 368 Chubb on large infant, 349 Church ou cardiac injury, 620 Churchill on absence of the vagina, 303 Chylothorax, 657 Cigarette in the bronchus, 615 Ciuquevelli, Paul, 451 Circular insanity, 881 Circumcision, 754 ; in the female, 308 Clark on combined fetation, 55 ; on foreign body in the eye, 533; on paternal im- pression, 86 ; on precocious menstruation, 30 ; on rupture of the stomach, 630 Claustrophobia, 878 Clay ou pseudocyesis, 79; on vicarious menstruation, 26 Clerc on maternal impression, 85 Clericus on absence of the cerebrum, 245 Clements on wound of the stomach, 632 Cleveland on anomalous membranes, 49; on coiling of the cord, 95 ; on postmortem Cesarean section, 137 Clevenger on Oscar Moore, 440 Clitoris, absence of, 307 ; ceremonial cir- cumcision of, 308 ; double, 309 ; enlarged, 308 ; ossified, 309; rupture of, 691 Cloquet on fetichism, 402 ; on foreign body in the vagina, 693 Closmadenc on polyphagia, 638 Clot-Bey on elephantiasis of the scrotum,801 Club-foot, 276 ^— Coats on rupture of the bladder, 670 Cobbe on opium-eating, 507 Cobleigh on premature rupture of fetal membranes, 108 Cock on wound of the kidney, 668 Cody on elephantiasis of the scrotum, 802 Coe on multiple Cesarean section, 131 ; on obesity, 358 Coen on removal of the breast in pregnancy, 105 Coeyue on double ureter, 294 Coffey, J. W., 364 Cohen on tongue-swallowing, 565 Coilings of the umbilical cord, 95 Coitus, anomalous, 513 ; death during, 513 ; with a dog, injury from, 692 ; excessive, 512 ; hemorrhage after, 692 ; idiosyncrasy in, 511 ; injuries in, 679, 680, 691 ; odor of breath after, 399 ; temperature during, 512 Cold causing abortion, 109 ; effects of, 430 Cole on pregnancy with unruptured hymen, 42 ; on supernumerary penis, 198 Coleman on sudden birth, 119 Colles on foreign body in the esophagus, 572 ; on rupture of the urethra, 679 Collette on foreign body in the orbit, 531 Collier on infibulation, 753 Coilings on rupture of the heart, 625 Collins on anomalous lung, 285 ; on fasting, 419 ; on keloids, 764 ; on protracted pregnancy, 72 ; on rupture of the stomach, 629 Collins and Leidy on birth of a monster by Cesarean section, 131 II INDEX. 939 Colloredo, 191 Colly on precocious menstruation, 30 Coloboma, 260 Colomb on twins borne beyond the meno- pause, 40 Colon, dilatation of, 287 ; double, 287 Colostomy, 645 Col ton on unusual birth, 119 Columbus on hermaphroditism, 207 Colzi on anomalous ureter, 294 Coinbettes on absence of the cerebellum,247 Combined intrauterine and extrauterine ges- tation, 54 Combustion, spontaneous, of the human body, 426 Compague on canities, 238 Compensatory development of the senses, 432 Compressed air, effects of working in, 432 Conant on terata, 166 Conarmond on precocious menstruation, 30 Conception with deficient organs, 45 ; opera- tion to prevent, 754 ; after ovariotomy, 45 ; precocious, 34 ; soon after a preceding pregnancy, 46 ; during sleep, 45 Conklin on splenectomy, 657 Consbruch on fasting, 415 Consciousness, double, 883 Constantinedes on absence of the nymphae, 306 Constipation, persistent, 794 Contortionists, 473 Cook on intrauterine amputation, 94 Cooke on combined fetation, 56 Cooke and Laycock on brain-iujury, 556 Cooper on belladonna, 501 ; on hermaphro- ditism, 210 Cooper, Sir Astley, on diaphragmatic hernia, 612 ; on elephantiasis of the scrotum, 801 ; on precocious menstruation, 31 ; on precocious pregnancy, 34 Copeland on maternal impression, 84 Copulation (see Coitus) Cord, anomalies of, 109 ; coilings of, 95 ; knots in, 109 Cordaeus on extrauterine gestation, 50 Cordier on renal calculi, 791 ; on retention of ectopic fetus, 63 Corey on injuries during pregnancy, 99 Corneal grafting, 728 Corpora callosum, 246 Corrosive sublimate, untoward action and tolerance of, 504 "Corsican Brothers," 887 Corson on hiccough, 812 Cosentino on dry birth, 123 Cosmetic mutilations, 746 Costa on excessive dentition, 244 da Costa Simoes on retention of ectopic fetus, 63 Cotter. Patrick. 331 Coughing causing abortion, 110; causing rupture of the abdominal walls, 666 Conper on wound of the bladder, 672 Couriers, 456 ; in India, 458 Cousins on hemophilia, 816 Couveuse, 66 Cowan on hiccough, 812 ; on scalp-develop- ment, 218 Cowger on birth in membranes, 123 Cowles on neck-injury, 576 Cowley on scalp-injury, 543; on self-per- formed Cesarean section, 131 Cox on prolonged pregnancy, 64 Craddock on retention of ectopic fetus, 63 Crandall on injuries in coitus, 692 Craniopagi, 173 Cranium, deficiency of, 250 ; fracture of, basal, 559 ; extensive, 558 ; internal, 559 ; injuries to, 551 Cranz on large infants, 348 Crawford on lightning stroke, 722 ; on un- conscious birth, 114 Crawford aud Yule on hirsuties, 231 Creaser, Thomas, 416 Crede on splenectomy, 657 Cretinism. 805 ; sporadic, 806 Crichton on " leaping ague," 856 Cridland on effects of cold, 431 Crippled beggars, manufacture of, 737 Cripps on absence of the ovary, 309 ; on colostomy, 645 ; on constipation, 795 ; on painless parturition, 115 Crisp on abortion, 110 Critchett ou foreign body in the eye, 532 Crocker on albinism, 220 ; on anomalous coloring, 382, 383 ; on anomalous color- changes of the hair, 240 ; on chromidrosis, 386 ; on hyperidrosis, 387 ; on canities, 237, 238 ; on dermatolytic growths, 234 ; on harlequin fetus, 825 , on pigmented skin, 841, on skin-shedding, 833; on tinea nodosa, 849 ; on xeroderma pigmen- tosum, 842 ; on yaws, 840 Crocodile-bite, 722 Croft on preputial calculus, 791 de la Croix on flatus from the penis, 675 Crollius on knife-swallowing, 632 Cromerus on 36 children at a birth, 147 Crompton on endurance of pain, 479 Cronyn on foreign body in the brain, 561 Crooks on anomalous stomach, 287 Crooni on ischuria, 792 Croon on pseudocyesis, 79 Cross on anomalous tears, 384 ; on vesical calculus, 789 Croston on delivery of a monster by Cesa- rean section, 129 Croton oil, on tolerance of, 504 Crouch on conception after ovariotomy, 46 Crouzit on foreign body in the uterus, 695 '' Crow-bar case,'' 551 Crowdace on injury during pregnancy, 100 Crowell on unconscious pregnancy, 72 Crumb on epistaxis through the eyes, 535 Cruveilhier on defective cerebellum, 246 ; on horns, 226 Crying of the fetus, 127 Cryptorchism, 321 Crystalline lens, anomalies of, 260 ; disloca- tion of, 533 ; inj uries to, 533 Csurgay on postmortem birth, 124 Cnevas on uterine calculi. 792 Cullere on kleptomania, 879 Cullingworth on dermoid cyst, 203 ; on in- jury during pregnancy, 99 ; on ovarian cyst, 784 ; on vaginal septa, 305 940 INDEX. Cunningham on retention of ectopic fetus, 63 Cunyghame on retention of urine, 792 Cupidity, castration for, 756 Curling on hypertrophy of the digits, 276 Curran on an armless woman, 265 ; on car- diac surgery, 618 ; on cranial surgery, 559; on "eaten of worms," 821 ; ou eunuch-making, 756 ; on injury to the vagina, 689 Curtis on precocious pregnancy, 36 Cuthbert on coiling of the funis, 95 Cutliffe on alligator-bite, 722 Cutter on conception after ovariotomy, 46 Cut-throat, cases of nonfatal, 574 Cyclopia, living, 258 Cystotomy during pregnancy, 105 ; self- performed, 708 Cysts, dermoid, 202 ; echinococcus, removal of during pregnancy, 105 ; ovarian, 782 Czar ten, Setrasch, 373 D. Dade on hernia, 665 Dagan on ascarides, 820 Dagron on perforation of the esophagus, 573 D'Aguanno on larvae in the ear, 539 Dajaksch, 711 D'Alben on sudden canities, 237 Dal by on rupture of the tympanum, 537 Dalton on injury to the pericardium, 624 Daly on tumor of the pregnant uterus, 107 D'Amador on perverted appetites, 410 Damascene on maternal impressions. 82 Dana on African sleep-sickness, 872 ; on facial hemiatrophy, 859 ; on giants, 327 ; on pathognomonic dreams, 867 " Dance of the eggs," 452 Dancing mania, 853 D'Andrade on vicarious menstruation, 19 Danthez on absence of the funis, 109 Dantra on fish in the pharynx, 569 Danyau on intrauterine fracture, 97 Danz on congenital alopecia, 226 Dareste on teratogenesis, 166 Dargan on lactation in the aged, 393 D'Aube on albinism, 220 Danbenton on craniopagus. 174 Dave on extraoral dentition, 245 Davidson on flogging, 481 Davies on loss of memory, 886 ; on prema- ture rupture of membranes, 107 ; on short pregnancy, 65 Davies-Colley on transfixion of the neck, 575 Davis on an armless monster, 265 ; on poly- pus in the pregnant uterus, 107 ; on trans- position of the viscera, 291 Day-blindness, 536 Dayot on foreign body in the bladder, 677 ; on ovarian cyst. 784 Dayral on unconscious pregnancy, 73 D' Azara on longevity, 374 Deafness, sudden, 538 Deason on tumor of the pregnant uterus, 107 Death presentiments, 889 De Beck on congenital defect of the eye, 260 Debes on fecundity in the old, 39 Debierre on double uterus, 313 ; on hernia of the uterus, 313 ; on hernia of the ovary, 310 Deblois on web of the vocal bands, 256 De Bosch on twin parturition, 142 Debout on anomalous extremity, 267; on vaginal anomaly, 307 DeBrun deBois Noir on discharge of fetal bones, 53 Decapitation, self-performed, 576 Deciduous skin, 832 " Deerfoot," 457 Deever on precocious menstruation, 30 DeFuisseaux on reunion of the tongue, 565 Deguise on coitus, 512 Delafield and Prudden on munilocular echi- nococcus, 820 Delaistre on hornet-sting, 714 Delamatcr on a large tumor, 759 De la Vergne on protracted pregnancy, 72 Delens on biperforate hymen, 303 De Leon on quadruplets, 148 Delhi boil, 840 Delivery by a cannon-ball, 134 ; by cattle- horn, 133 ; of extrauterine fetus, 57; postmortem, 123; by the rectum, 120; during sleep, lethargies, and trances, 115 ; sudden, 116 Delmas on superfetation, 49 Delpech on extraoral dentition, 245 De Luna on intrauterine fracture, 97 Del Vecchio on cardiac suture, 617 Demarquay on bloody semen, 3W5 Demonomania, 880 Denaux de Breyne on menstruation during pregnancy, 29 Denby on foreign body in the intestine, 641 Deneux on delivery by a bull's horn, 133 Dentition, anomalies of, 242 ; excessive, 244 ; extraoral, 244 ; fetal, 242 ; late, 32 ; sixth, 243; triple, 243 Depasse on fecundity in the old, 39 Depaul on delivery during syncope, 115; on discharge of fetal bones, 53 Depilatory customs, 747 De Quincey, Thomas, 496, 506 "Derates," 461 Dercum on adiposis dolorosa, 360 Dermatitis exfoliativa neonatorum, 835; epidemic exfoliative, 835 ; universal, 851 Dermatolysis, 217 Dermatolytic growths, 232 Dermoid cysts, 202 Dermoids, multiple, 205 Desaguliers on strong men, 464 Desbarreaux-Bernard on fasting, 415 Desbois on rupture of the uterus, 137 Desbrest on bee-sting, 714 ; on protracted pregnancy, 72 Descendants, numerous, 159 De Schweinitz on canities, 238 Desgranges on fish-spine in the abdomen, 659 ; on superfetation, 47 Desmond, Countess of, 243, 375 Desormeux on protracted menstruation, 32 Desquamation, antepartum, 217 Detbardingius on-postmortem birth, 125 De Thou on stigmata, 388 INDEX. 941 Devergie on combined fetation, 55 De Vilde on ischuria, 793 Devilliers on postmortem birth, 124 Dewees on fecundity in the old, 39 ; on pro- longed pregnancy, 64 ; on protracted men- struation, 32 ; on sudden canities, 237 ; on superfetation, 48 Dewey on multiple fractures, 701 Dexter on hiccough, 812 Diamond in the ear, 541 Diaphragm, anomalies of, 285 ; hernia of, 286, 012 ; rupture of, 612 ; wounds of, 612 Dibot on combined fetation, 57 Dickinson on colored saliva, 383 ; on human tails, 279 ; ou imperforate anus, 675 ; on large infant, 349 ; on parasitic terata, 191 Dickson on fasting, 419 de Diemerbroeck ou cardiac injuries, 617 ; on conception with hymen intact, 40 ; on gastrotomy, 633 Digitalis, idiosyncrasy to, 502 Digits, anomalies of, 271; reunion of sev- ered, 588 ; supernumerary, 273 Dimples, manufacture of, 746 Diphallic terata, 194 Diphthongia, 257 Dirt-eating, 412 Dislocations, anomalous, 594 ; congenital, 595 ; of the neck, 578 ; treatment of, 594 Dismukes on wound of the subclavian artery, 627 Dittel on anomalous diaphragm, 286 Divers, 514 Dives from heights, 704 Diving in shallow water, 559 Dix on precocious lactation, 393 Dixon on aniridia, 259 ; on anomalous tears, 384 Dodd on precocious pregnancy, 35 Dodonaeus on vicarious menstruation, 23 Dog-bite, 719 ; of the penis, 680 "Dog-boy," 162 Dolaeus on double tongue, 255 Dolbeau on intrauterine fractures, 97 Domonceau on horns, 226 Donatus, Marcellus, on antepartum crying, 128 ; on colored saliva, 383 Donkey-bite, 590 ; of the penis, 680 Donlon on epistaxis, 534 Donne on priapism, 683 Doran on horns, 225 ; on supernumerary oviducts, 310 ; on supernumerary ovaries, 310 Double consciousness, 883 Doubting mania, 879 Dougherty on wound of the bladder, 675 Doughty on evisceration, 650 Douglas on twin birth, 143 Douglass on a precocious boy, 346 ; on sub- mersion, 513 Dover on venesection, 709 Doyle on a bullet in the brain, 561 ; on dis- location of the neck, 578 Drake on epilepsy and aphasia, 853 ; on sword-swallowing, 636 Dreams, pathognomonic, 867 Drewry on athetosis, 857 ; on circular in- sanity, 881 Driver on postmortem birth, 124 Dropsies, 786 Drouin Twins, 186 Drowning, recovery from, 513 Drugs, tolerance and untoward action of, and idiosyncrasy to, 496 Drummond ou infantile menstruation, 30 Dry births, 123 Dryden on rupture of the esophagus, 628 Dual personality, 883 Dubois on human horns, 223 ; on super- numerary eyelid, 259 Dubrisay on brain-injury, 545 Dubuc on ischuria, 793 Ducachet on bullet voided by the anus, 651 Du Chaillu, Paul, on pigmies, 334 Duchesne on vicarious menstruation, 19 Ducornet, Caesar, 265 Ductus communis choledochus, obliteration of, 290 Dudley on perforation of the esophagus, 572 Duer on postmortem birth, 124 ; on post- mortem Cesarean section, 135 Duffy on hypotherniy, 424 Dufour on hirsuties, 233 ; on postmortem Cesarean section, 135 Dnhouset ou circumcision of the clitoris, 308 Duhring on keloids, 764 ; on neuroma cutis dolorosum, 839 Duke on unconscious pregnancy, 73 Dumas on fetal dentition, 243 ; on intestinal coalition, 288 Dumas, Blanche, 194 Dumeril ou supernumerary limbs, 269 Duncan on absence of the vagina, 303 ; on conception with unruptured hymen, 42 ; on epilepsy, 852 Dundore on laminectomy, 660 Dunglison on expulsion of ectopic fetus, 53 ; on gynecomazia, 397 Dunlap on hemophilia, 816 Du Peyrou de Cheyssiole on protracted men- struation, 33 Duplication of the lower extremities, 193 Dupont on hyperidrosis, 387 ; on ventrilo- quism, 453 Dupouy on black death, 892; on leprosy, 911 ; on small-pox, 903 Dupuytren on birth through the perineum, 122 ; on fetus in fetu, 200 ; on foreign body in the vagina, 695 ; on obesity, 358 ; on vicarious menstruation, 26 Durston on hypertrophy of the breast, 759 Du Saulle on appetite for blood, 411 Dusenbury on wound of the kidney, 667 Duverney on conception without sexual desire, 45 Duyse on dermoids, 204 Dwarfs, 333 ; ancient popularity of, 336 ; artificial production of, 335 ; celebrated, 338 ; Cesarean section on, 129; intel- lectual, 337 ; longevity among, 339 ; species of, 338 ; women predisposed to bear, 337 942 INDEX. E. Ear, anomalies of, 261 ; foreign bodies in, 539, 540 ; injuries to, 537 ; insects in, 539 ; menstruation from, 24 ; nitric acid in, 540 ; piercing, 749 ; power to move, 263 "Ear-sneezing," 815 Eastman on fibroma of the uterus, 781 Easton on teeth swallowed, 639 '' Eaten of worms," 821 Ebersbach on ectopic fetus, 53 Ebstein on obesity, 353 Echinococcus cyst, 820 ; in the eye, 534 ; removal of, during pregnancy, 105 Ecker on bearded women, 229 Eckley on supernumerary lung, 285 Ectopic children, ultimate fate of, 62; gestation of, 50 ; multiple, 57 Eddowes on large infant, 349 Edentulousness, 243 ; association with alo- pecia, 227 Eder on opium-eating, 507 Edge on chorea in pregnancy, 103 Edwards on impregnation with the hymen intact. 41 Eggs, idiosyncrasy to, 490 Ehrl on spontaneous gangrene of the skin, 837 Eight children at a birth, 153 Eikam on short pregnancy, 67 Eiscnmenger on prolificity, 157 "Elastic-skin man," 217 Elder and MacCormac on rupture of the spleen, 656 Eldredge on a ferrule in the bronchus, 614 Eld ridge on separation of the symphysis pubis, 140 Electric anomalies, 429 "Electric Lady," 430 Electric light, injuries of the eyes by, 537 Elephantiasis arabum, 795 ; of the face, 800 ; of the lower extremities, 798 ; of the scalp, 798 ; of the scrotum, 800 ; of the upper extremities. 798 "Elephant-man," 81, 827 Eleven children at a birth, 153 Elliotson on hydatid disease of the liver, 786; on obesity, 352 ; on unilateral sweating, 388 Elliott on dermatitis exfoliativa neonatorum, 835 Ellis on ischiopagus, 183 ; on ligature of the carotids, 575 ; on oxalic acid, 499 Ellison on anomalous sneezing, 814 "Elixir of Life," 368 Elvert on protracted pregnancy, 70 Ely on chalk-eating, 412 Emeryaki, 855 Emmet on protracted menstruation, 33 Emond on pregnancy with unruptured hymen, 42 Emotions causing death, 524 Empedocles on prolificity, 146 Enchondromata, 766 Engelmann on fistula-operation in preg- nancy, 105 Engleman on obstetric customs, 113 Englisch on double penis, 198 Enguin on protracted pregnancy, 69 Enos on absence of the epiglottis, 256 Ensor on shark-bite, 721 Enterostomy, 045 Enucleation of the eye, self-performed, 735 Epidemics, 891; of abortion, 109; chrono- logic table of the principal, 898 Epidermis, congenital defect of, 217 Epigastrium, blows upon the, 520 Epiglottis, anomalies of, 250 ; double, with double voice, 357 Epignathus, 193 Epilepsy, 852 ; birth in, 113 ; peculiar forms of, 852 Epispadias, 318 Epistaxis, extensive, 710 ; through the eyes, 534 Epithelioma, 772 Epley on painless labor, 116 Epsom salts, idiosyncrasy to, 496, 503 Equestrians, 460 Equilibrists, 449 Erba, Luigi, experiments of, 158 Erection of the penis, long continued, 683 Ergot, idiosyncrasy to, 502 Ergotism, 502 Erich on expulsion of ectopic fetus, 53 Erichsen on exostoses, 768 ; on hemophilia, 816 ; on foreign body in the abdomen, 659 ; on multiple fractures, 702 Esophagismus, 863 Esophagotomy for foreign bodies, 574 Esophagus, anomalies of, 284 ; foreign bodies in, 570 ; perforation of, 573 ; rupture of, 628 ; wounds of, 575 Esquimaux, menstruation among, 29 Estrus, larvae of the, 821 Eunuch-making, 755 Eustaches and Tzctzes on jumping, 462 Evans on birth in membranes, 123 ; on for- eign body in the esophagus, 571 Evans, William, 329 Eve, birth of, 200 Eve on injury to the spinal cord, 661 ; on a nail in the bronchus, 614 ; on rupture of the bladder, 671 ; on thoracic wounds, 610 Eventration, 650 ; congenital, 292 Evisceration, 650 Evrard, Gustav, 269 Ewald on obesity. 356 Exophthalmos, 527 Exostoses, 768 Exostosis on the sacrum, 138 Exstrophy of the bladder, 295 Extrauterine pregnancy, 50 ; combined with uterine, 54 ; discharge of the fetus in, 52 ; long retention of the fetus in, 62 ; successful delivery in, 57 ; termination of, 51 Extremities, absence of, 263; menstrua- tion from, 25 ; supernumerary, 269 Eyelid, supernumerary, 259 Eyer on rupture of the thoracic duct, 659 Eyes, congenital absence of, 257 ; congeni- tal defects of the muscles of, 260 ; enu- cleation of, 527 ; self-performed, 735; epistaxis through, 534 ; foreign bodies in, 532 ; injuries to, 527 ; by birds, 533 ; INDEX. 943 lightning-injuries to, 727; menstruation from, 23 ; rupture of, 528 ; two, in one orbit, 258 Eyles on ainhum, 831 F. Fabre on tapeworms, 718 Fabricius Hildanus on abortion, 110 ; on burn of the spermatic vessels, 689 ; on a glass ball in the ear, 539 ; on horns, 222 ; on injury to the penis, 680 ; on injury to a pregnant woman, 98 ; on male menstru- ation, 28 ; on a postmortem Cesarean sec- tion, 135; on spontaneous hemorrhage, 709 ; on stigmata, 389 ; on vesical cal- culi, 790 Fabricius on horns, 222 Face, injuries of the, 585 ; gunshot, 697 Facial hemiatrophy, 859 Fahnestock on birth in somnambulism, 116 Fakirs of India, 517 Falla on anomalous limbs, 273 Fallopian tubes, anomalies of the, 310 Falls from heights, 703 Falot on tartar emetic, 499 Fancon on injury during pregnancy, 101 ; on operations during pregnancy, 105 Fano on supernumerary eyelid, 259 Fantou on hypnotism in labor, 114 Fanton-Touvet on edentula, 243 Fantoui on quintuple bladder, 295 Farber and McCassy on high fall, 704 Farquharson on birth through the abdomi- nal wall, 122 ; on rupture of the uterus, 137 Farr on longevity, 366 Fascial sarcomata, 772 Fasters, modern, 420 Fasting, 413 ; modern cases of, 419 ; older cases of, 414 Fasting girls, 413, 418, 419 Fat children, 352 Fatti ou fetus in fetu, 201 Fauconneau-Dufresne on ascarides, 819 Favell on anomalous heart, 020 Faye on lactation in infants, 392 Fayrer on elephantiasis of the scrotum, 803 ; on shark-bite, 721 ; on wolf-bite, 722 Fear of child-birth, death from, 525 Fear-psychoses, 877 Fecundity in the old, 38 : in the young, 34 Feet, anomalies of the, 270 Felkin on Cesarean section in Africa, 131 ; on fetal malaria, 91 Fenger on elephantiasis of the scrotum, 802 Ferdinandus on neurosis of the skin, 837 Fereol on ischuria, 792 ; on tapeworm. 819 Fergus on rupture of the gall-bladder, 655 Ferguson on absence of the vagina, 303 Fern on large infants, 348 Fernandez on gynecomazia, 397 Ferrari on rupture of the lung, 610 Ferraton and Rivington on rupture of the bladder, 671 Ferre on spermatophobia, 880 Ferry, Nicholas, 339 Fertilization of plants, 43 Fetichism, 401 Fetomancy, 213 Fetus, anomalous discharge of, 53 ; eaten by a worm, 110, 111 ; enclosed in mem- branes, 122 ; in fetu, 199 ; medication of, 92 ; movements of, long-continued, 64 ; movements of, simulation of, 6r>, 74-79 : worms in, 111, 112 F6vre on human odors, 400 Fevrier on branchial fissures, 284 Fibro-lipoma, 764 Fibromata, 762 ; molluscum, 762 ; of the uterus, 781 Ficker on exophthalmos, 527 Field on polydipsia, 404 ; on vicarious men- struation, 24 Fields, Rube, 443 Fielitz on fecundity in the old, 39 Fienus on telegony, 89 Fifteen at a birth, 154 Filaria sanguinis hominis, 820 Filippi on intrauterine fracture, 97 Fillion on foreign body in the intestines, 641 Finger, absence of, 271 ; avulsion of, 589 ; ceremonial amputation of, 746; re- union of severed, 588 ; supernumerary, 273 Finlayson on hemihypertrophy, 350 Finley on vicarious menstruation, 20 Finley Twins, 183 Fire-worship, 425 Fischer on anomalous growth of bones, 605 ; on avulsion of the arm, 591 ; on cardiac injuries, 616, 620 Fish, alive, in the pharynx, 567 Fish-bite, leprosy from, 721 Fisher on anorchism, 319 ; on the Hunga- rian sisters, 178 ; on Santos, 197 Fitz on rupture of the esophagus, 628 Flachsland on absence of the limbs, 263 Flagellation, 480 Flea, syphilis from a bite of a, 714 Fleck on anomalous constipation, 795 Fleishman on unconscious pregnancy, 73 Flemming on menstrual superstitions, 17 Fleury de Clermout on foreign bodies in the ear, 541 Flint on rupture of the esophagus, 628 ; on telegony, 88 Floating liver, 655 Flogging, 481 Flour, idiosyncrasv to, 492 " Folie de d'oute," 879 Folker on albinism, 221 Foil and Warynski on teratogenesis, 166 Foil on torsion of the penis, 316 Fontaine on infibulation, 754; on intestinal injury, 642 ; on ischuria, 793 Fontanelle on worms in the bladder, 819 Food-superstitions, 493 Foods, idiosyncrasy to, 489 Foot, foreign body in the, 600 Foot on hiccough, 812 Foot-binding, 737 Foot-race, 455 Foramen ovale, patent, 296 Forbes on African sleep-sickness, 872 944 INDEX. Ford on brain-injury, 549 ; on cardiac in- jury, 623 ; on gynecomazia, 397 ; on in- jury to the spinal cord, 661 ; on lactation in the aged, 394 ; on ovarian cysts, 782 ; on vicarious menstruation, 26 Fordere on premature births, 08 Foreign bodies in the abdominal cavity, 658 ; in the alimentary canal, 636 ; in the back, 659 ; in the bladder, 676 ; in the brain, 545, 559 ; in the bronchi, 614 ; in the chest, 613 ; iu the ear, 539 ; in the esophagus, 570 ; in the extremities, 599 ; in the eye, 532 ; in the heart, 624 ; in the intestines, 641 ; in the larynx, 580 ; in the nose, 502 ; in the orbit, 531 ; in the pelvis, 078 ; iu the pharynx, 570 ; in the rectum, 645 ; in the tongue, 566 ; in the trachea, 580 ; iu the urethra, 676 ; in the uterus, 695 ; in the vagina, 692 ; in the vermiform appendix, 642 Forel on male menstruation, 28 Formad on the " balloon-man," 287 Forman on birth with unruptured hymen, 123 Fornix, double, 249 Forster on vicarious menstruation, 25 Fortunatus Fidelis on absence of the penis, 314 Forwood on arrow-wound of the bladder, 673 Foucard on ischuria, 793 Fouquet on spontaneous human combustion, 427 "Four-eyed man of Cricklade," 258 Four-legged monsters, 193 Fournier on anomalies of the tympanum, 263 ; on bloody sweat, 390; on displace- ment of the heart, 297 ; on hermaphrodi- tism, 209 ; on imperforate anus, 289 ; on large tongue, 256 ; on macrocephaly, 249 ; on menstruation in the male, 28 ; on obes- ity, 359 ; on ossified clitoris, 309 ; on per- verted appetite of pregnancy, 80 ; on su- persensitiveness of smell, 397 ; on urethral anomalies, 318 Fowl-bites, 719 Fowler on canities, 237 ; ou skin-grafting, 730 Fox on expulsion of ectopic fetus, 53 ; on hydrophobia, 719 ; on unconscious preg- nancy, 73 ; on chromidrosis, 386 Fractures, of the cervical vertebrae, 578 ; in- trauterine, 97 ; multiple, 699 ; of the skull, 551, 558 ; basal, 559 ; spontaneous, 594 Fraipont on hysteropaxy, 106 Frambesia, 839 Francis on pregnancy with unruptured hy- men, 42 Frank on rupture of the urethra, 679 ; on skin-shedding, 832 Franklin on twins by Cesarean section, 129 Franzolini on six celiotomies on one woman, 707 Fraser on defective cerebellum, 246 ; on multiple fractures, 700 Frazer on wound of the liver, 653 French on double voice, 257 ; on longevity, 366 Frenum, absence of the, 317 Frblich on vaccination, 908 Frommann on menstrual superstitions, 17 Fuchs on corneal grafting, 728 Fuller on belladonna, 501 Fuller, Sarah, on Helen Kellar, 4:56 Fullerton on bloody sweat, 390 Fulton on depraved appetite, 411 ; on rup- ture of the stomach, 029 Furunculosis orientalis, 840 G. Gabb on epistaxis, 534 Gaetano-Nocito on fetus in fetu, 200 Gairdner on protracted sleep, 869 Gaither on fetus in fetu, 200 Galabin on combined fetation, 57 ; on ovari- otomy during pregnancy, 104 ; on galac- torrhea, 394 Gale, William, 459 Galeazzi on chromidrosis, 385 Gall-bladder in a hernial sac, 055 ; opera- tions on the, 6^r> ; rupture of the, 655 Galle on pregnancy in a bicorn uterus, 49 Gallieni on circumcision of the clitoris, 308 Gal tier on the " Living Angel," 844 Galvagni on a triple monster, 107 Gambardella, Teresa, 231 Games, Grecian, 455 Gamgee on perforation of the tympanum, 538 ; on rupture of the heart, 625 Gann on wound of the liver, 652 Gapper on hiccough. 812 Garcia on a long swab swallowed, 640 Gardane on milk metastasis, 392 Gardiner on polymazia, 299 ; on teeth swal- lowed, 639 Garesky on postmortem Cesarean section, 135 Garfinkel on tapeworms, 818 Garlick on absence of the limbs, 263 Gamier on fetichism, 402 Garroway on tapeworm, 819 Garthshore on quintuplets, 150 Gassendus on maternal impressions, 82 Gastaher on horns, 222 Gastrectomy, 644 Gastric fistula, 631 Gastrostomy, 644 Gastrotomy, 632 Gaubius on. opium, 505 Gaultier on intrauterine fractures, 97 Gautier on fetal measles, 91 ; on pigmented skin, 841 Gay on foreign body in the back, 659 ; on torsion of the penis, 316 Gayet on cystotomy during pregnancy. 105 Gazdar on foreign body in the nose, 505 Gelineau on morbid fears, 877, 878, 879 Gellius, Aulus, on protracted pregnancy, 68 Gelly on menstruation during pregnancy,29 Genetic anomalies, 17 Genitals, avulsion of the, 686; self-per- formed, 732 ; injuries of the, during pregnancy, 98 Geoffroy-Saint-Hilaire on albinism, 220 ; on animal terata, 166 ; on craniopagi, 173 ; INDEX. 945 on cryptorchism, 321 ; on diphallic mons- ter, 196, 197; on extrauterine pregnancy, 50 ; on ischiopagus, 182 ; on precocious menstruation, 31 ; on triple monster, 167 Geoghegan on rupture of the uterus, 137 Gerard on fasting, 415 ; on sclerema neona- torum, 827 Gerberon on infantile beard, 228 Germain on coiling of the funis, 95 Gerster on imperforate anus, 289 Gervis on polypus of the pregnant uterus, 107 Gestation, congenital, 200 ; extrauterine, 50 ; precocious, 34 Getchell on foreign body in the vagina, 695 Giants, 324 ; ancient, 324 ; discovery of the bones of, 325 ; celebrated, 328 ; general opinions relative to, 326 ; of history, 333 ; in Patagonia, 325 Gibb on injuries during pregnancy, 98 ; on lactation in infants, 392 Gibbons on longevity, 376 Gibbs on automatism, 888 ; on avulsion of the genitals, 687 Gibney on rupture of the quadriceps ten- don, 593 Gibson, Richard, 338 Gibson and Malet on presternal fissure, 283 Gigantism, association with acromegaly, 327 Gihon on syphilis, 913 Gilbert on impregnation with hymen in- tact, 41 Gilkrist on transfixion of the abdomen, 648 Gil land on discharge of the fetal bones, 53 Gillilam on intrauterine amputation, 95 Gilman on multiple fractures, 702 Gilmore on ovariotomy during pregnancy, 104 Giovannini on canities unguium, 847 Giraldes on double hand, 271 ; onedentula, 244 Girard on pseudocyesis, 77 Girault on artificial impregnation, 43 Girdwood on foreign body iu the arm, 599 Girl grandmothers, 38 Glandorp on gastrotomy, 632 Glass on dropsy, 786 Glass-blowers, excessive thirst of, 405 Glazebrook on cardiac injury, 619 Gleaves ou precocious pregnancy, 35 Gloninger on male menstruation, 28 Gmelin on the effects of cold, 430 " Go as-you-please " pedestrians, 459 Gockelius on dropsy, 786 Goddard on arrow-wounds, 712 Godfrey on lightning-stroke, 726 Goiter, 701 Golden on belladonna, 501 Goldschmidt, 409 Gooch on injury to the spleen, 656 ; on knife-swallowing, 633 ; ou sloughing of the genitals, 138 ; on thoracic injury, 606 Good on late menstruation, 32 Goodell on ischiopagus, 183 Gooding on absence of the vagina, 304 Goodman on elephantiasis of the scrotum, 801 Goodwin on belladonna, 500 60 Gordon on anomalous ribs, 282 ; on delivery of ectopic fetus, 54 Gore on diphallic monster, 196 Gorodoichze on claustrophobia, 878 Goschler on small penis, 314 Gosseiin on absence of the vagina, 304 ; on foreign body in the vagina, 693 ; on tails, 278 ; on rupture of the lung, 608 "Gouging," 528 Gould on electric-light injuries of the eyes, 5:57 ; on horns, 229 Goundron, 769 Gourges on vesical calculi, 790 Graftings, 728 Graham on maternal impressions, 83 Grandider on hemophilia, 816 Granger on a leech in the pharynx, 569 Grant on cardiac injury, 618 ; on fasting,419 Graves on anosmia, 875 ; on dermoid cyst, 203 Gravis on perineal birth, 122 Gray on acute palmus, 855 ; on dermoids, 200 ; on fear-psychoses, 877, 879 ; on hypnotism, 870; on Meniere's disease, 861 ; on an artificial penis, 318 ; on som- nambulism, 865 ; on stigmata, 389 ; on strychnin, 510 Grecian games, 455 Green on absence of the kidney, 293 ; on postmortem Cesarean section, 136 ; on precocious pregnancy, 37 ; on prolonged lactation, 394 ; on submersion, 513 ; on wounds of the aorta, 626 Greenhow on amazia, 297 ; on epilepsy, 852 ; on vagabond's disease, 841 Gregory on delayed menstruation, 34 ; on ovarian cyst, 783 Grellois on foreign bodv in the esophagus, 571 Grief causing death, 524 Griffith on absence of the vagina, 303 Griffiths on elephantiasis arabum, 797 ; on premature rupture of the fetal membranes, 108 Griffon on double ureter, 294 Griswold on hiccough, 813 Gros-nez, 769 Gross on adenoma of the breast, 759 ; on gastrotomy, 632, 644 ; on intrauterine fractures, 97 ; on scalp-injury, 545 Grove on foreign body in the nose, 564 Growth, rapid, 347 Gruber on monorchids, 319 Gruger on gynecomazia, 396 Gruner on depraved appetite for human flesh, 409 Guattani on foreign body in the esophagus, 571 Gueniot on multiple Cesarean section, 131 Guepin on vicarious menstruation, 24 Guerard on impregnation with imperforate vagina, 41 ; on suspended animation, 513 Guerin on supernumerary leg, 269 Guerranton absence of the fetal membranes, 109 Guersant on rupture of the esophagus, 628 Guilford on edentula, 243 Guillemeau on conception with imperforate vagina, 40 946 INDEX. Guillemont on injury during pregnancy, 98 Guinard on displacement of the kidney, 294 Guiteras on yellow fever, 910 ; on ectopia of the testicle, 689 Guiteras and Riesman on absence of one kidney, 293 Gull on anorexia nervosa, 414 ; on myxe- dema, 807 ; on the odor of syphilis, 400 Gullmannns on abortion, 110 Gunning on foreign body in the eye, 532 Gunshot injuries, recovery after many, 699 Gunson on protracted sleep, 80S Gurlt on injury during pregnancy, 102 Gusserow on fetal therapeutics, 92 Guthrie on atrophy of the testicles, 087 Gutteridge on rupture of the clitoris, 691 Guy-Patin on anomalous spleens, 290 Guyon on postmortem priapism, 523 Guyot Daubes on divers, 515 ; on equili- brists, 449 ; on strength, 403 ; on strength of jaws, 469 ; on supernumerary digits, 274 ; on sword-swallowing, 634 Gynecomazia, 394 H. Habershon on aphasia, 873 Haen on painless birth, 113 Hagedorn on male menstruation, 28; on partial canities, 238 ; on postmortem birth, 125 Haig on pregnancy with hymen integrum, 42 Haines on maggots in the vagina, 11 Hair, absence of, 220 ; accidental growths of, 235 ; anomalies of, 226 ; anomalous color changes of, 235, 239 ; in the blad- der, 678 ; chemic coloration of, 240 ; ex- aggerated development of, 230 ; cere- monial extraction of, 747; long, 234 ; mottled, 238 ; sudden changing of the color of, 235 ; on the tongue, 256 "Hair-eaters," 641, 849 Hair-growth and sexualism, 228, 232 Hair-pin in the ear, 542 Hairy people, 230 Hajek on supernumerary tongue, 255 Hale, Robert, 330 Hall on analogy to the " Corsican Brothers," 887 ; on cardiac injuries, 616 ; on extra- oral dentition, 245 ; on hair in the blad- der, 678 ; on precocious pregnancy, 37 ; on a study of gunshot wounds of the brain, 550 ; on supernumerary mamma, 301 Haller on death from joy, 524 ; on fasting, 415 ; on fecundity in the old, 39 ; on hermaphroditism, 206 ; on longevity, 367 ; on polyorchids, 320 ; on precocious im- pregnation, 36 ; on protracted menstrua- tion, 32 ; on teeth at birth, 242 ; on triple monster, 167 ; on vicarious menstruation, 18 Halliburton on male menstruation, 28 Halsted on brain-injury, 557 Halton on lightning-stroke, 723 Hamelin on hair in the bladder, 678 Hamill on male nausea of pregnancy, 80 Hamilton on abortion in twin pregnancy, 111 ; ou cardiac injury, 619, 623 ; on fast- ing, 416 ; ou hypertrophy of the breast, 760 ; on impalement, 649 ; on nostalgia, 876 ; on pseudocyesis, 78 Hammond on fasting girls, 413, 41 s ; on fear-psychoses, 878, 879 ; on human odors, 398 ; on merycism, 802 ; on odors of nervous lesions, 400 Hancock on vicarious menstruation, 23 Hand, anomalies of, 270 ; elephantiasis of, 798 ; foreign bodies in, 599 ; reunion of a severed, 588 ; strength in, 470 Handford on digestion of the stomach, 028 Handles swallowed, 040 Hanging, recovery after, 519 Hanks on antepartum desquamation, 217 Hannaeus on retention of ectopic fetus, 62, 64 Hansell and Clark on late restoration of sight, 546 Hard on monsters, 163 Hardie on dwarfs, 341 Harding on conception after ovariotomy, 46 Hardy on longevity, 366 Hare on a legless child, 2(56 ; on supernu- merary mamma, 301 Hare-lip, 254 Hargens on opium, 505 Harlan on epithelioma of the orbit, 772 Harle on anomaly of the gall-bladder, 290 ; on precocious menstruation, 30 Harlequin fetus, 825 Harley on fakirs, 518 ; on hibernation, 517 Harley and Tanner on superfetation, 48 Harlow on the "crow-bar case," 551 ; on uterine calculi, 792 Harris on bearded women, 229 ; on a Cesar- ean section upon a dwarf, 129 ; on horns, 226 ; on injury to the pericardium, 625 ; on injury during pregnancy, 100 ; on postmortem Cesarean section, 135 ; on premature expulsion of the fetal mem- branes, 108 ; on statistics of cattle-horn injuries in pregnancy, 133 Harrison on birth by the rectum, 121 ; on foreign body in the intestines, 642 Hart on anomalous stomach, 287 ; on the case of Santos, 197 Harte on skin-grafting, 731 Hartmann on exostoses, 769 Hartung on supernumerary mamma, 301 Harvey on conception with the hymen in- tact, 40 ; on fetus enclosed in its mem- branes, 122 ; on postmortem birth, 126 ; on pseudocyesis, 77 ; on sudden birth, 116 ; on superfetation, 46 ; on Thomas Parr, 373 Hasenet on short pregnancy, 65 Hashimoto on tooth-brush swallowed, 640 Haslam on artificial penis, 319 ; on injury to the penis, 680 ; on self-mutilation, 735 Hastings on absence of the limbs, 263 Hatte on supernumerary feet, 270 Haug on a tic in the ear, 539 Haultain on pseudocyesis, 79 Hauser on milk-metastasis, 392 Hawkins on abortion in twin pregnancy, INDEX. 947 111 ; on anomalous hepatic ducts, 290 ; on herniotomy upon a centenarian, 707 Hawley on abortion, 110 Hay on pregnancy with the hymen intact, 42 Head, anomalies of the, 245 ; injuries of, with loss of cerebral substance, 551 Healey on a leech in the nose, 563 Hearing, idiosyncrasy through the sense of, 484 Heart, anomalies of, 296 ; calculi in, 792 ; displacement of, 626 ; foreign body in, (524 ; hypertrophy of, 626 ; injuries of, 617; inversion of, 297; nonfatal, 620; rupture of, 625 ; surgery of, 616 ; worms in, 820 Heat, endurance of, 424 Heath on wounds of the iliac artery, 627 Heaton on the Biddenden Maids, 174 ; on brain-injury, 553 Hebra on antimony, 499 ; on bloody sweat, 391 Hecker on the dancing mania, 853 ; on plagues, 891 Heidenhain on hiccough, 813 Heil on wound of the aorta, 627 Heisberg on tapeworms, 818 Heister on birth during sleep, 114 ; on post- mortem Cesarean section, 135 Helen and Judith, 177 Heliodorus on maternal impressions, 82 Hell wig on vicarious menstruation, 23 van Helmont on maternal impression, 82 Helmuth on ovarian cyst, 782 Hematemesis, extensive, 710 Hematophobia, 878 Hemeralopia, 536 Hemiatrophy of the face, 859 ; of the tongue, 860 Hemihypertrophy, 350 Hemoglobinuria, epidemic, 816 Hemophilia, 815 Hemoptysis, extensive, 410 Hemorrhages, extensive, 709 Hemorrhagic diseases of the new-born, 816 Hemorrhoidal bleeding, 710 Heudenberg and Packard on tumor of the pregnant uterus, 106 Henderson on protracted pregnancy, 72 Hendrichseu on contraction of the levator ani in coitus, 512 Hendy on elephantiasis of the scrotum, 802 Henley on injury to the spiual cord, 661 Hen nig on neck-injury, 578 Henning on fetal therapeutics, 92 Henry on filaria sanguinis hominis, 821 ; on foreign body in the esophagus, 570 ; on vicarious menstruation, 25 Henschel on protracted pregnancy, 70 Hensler on ancient chronology, 369 Hentzschel on aniridia, 259 Herbolt on "needle-girls," 735 Hercules, modern, 463 Heredity in absence of the uterus, 311 ; in congenital defects of the eye, 260 ; in gynecomazia, 395 ; Hippocrates' expla- nation of, 82 ; in longevity, 379 ; in obes- ity, 356 : in polymazia, 302 ; in sexdigi- tism. 275 ; in urethral malformations, 318 D'Hericourt on pineal calculi, 792 Herman of Berne on postmortem births, 12(5 Hermann on multiple births, 157 Hermaphroditism, 204 ; double, 165 ; law of evolution in, 211 ; legal aspect of, 212 ; neuter, 212 ; spurious, 207, 211 Hernia, 662; congenital umbilical, 662; diaphragmatic, 28(5, 612 ; multiple, 662 ; of the ovaries, 310 ; remarkable examples of, 665 ; of the uterus, 313 ; ventriculi, 612 Herniotomy in a centenarian, 707 ; during pregnancy, 105 Herodotus on giants, 325 ; on mutilation of the genitals, 754 Herrick on precocious pregnancy, 37 ; on transposition of the viscera, 291 Hersman on enlargement of the hands, 804 Hertz on a tooth in the larynx, 581 Heschl on a monster, 193 ; on the sexual in- fluence of odors, 402 Hesse-Wartegg on obesity, 355 Heuremann on urethral anomalies, 318 Heusinger on neuromata, 770 ; on quinin, 509 Hevin on a pig-tail in the rectum, 645 Heyerdahl on discharge of fetal bones, 53 Heysham on absence of the cerebrum, 246 Hibernation, 517 Hiccough causing abortion, 110; persistent, 811 Hickinbotham on impregnation with im- perforate hymen, 41 Hickman on foreign body in the nose, 564 Hicks, Ben, 331 Hicks on rupture of the lung, 609 Hide-bound disease, 826 Higgens on multiple pupils, 260 Higgins on protracted menstruation, 32 Hildman on obesity, 355 Hill on bloody sweat, 391 ; on congenital abortion, 227 ; on wound of the aorta, 627 Hillairet on obesity, 355 Hillier on diaphragmatic hernia, 286 Hind on phenol, 498 Hindoo Sisters, 1(58 von Hippel on corneal grafting, 728 Hippocrates on abortion, 110 ; on a bearded **" woman, 228 • on coiling of the funis, 95 ; on the divisions of life, 370 ; on maternal impressions, 81; on monsters, 161 ; on prolificity, 146 ; on superfetation, 46 ; on worms in the fetus, 112 Hippona, origin of, 163 Hirschfeld on intrauterine fractures, 97 Hirshberg on canities, 238 Hirst on hemorrhage in first coitus, 692 ; on polymazia, 298, 300 ; on pseudocyesis, 77 Hirst and Dorland on symphysiotomy, 141 ; on the fate of ectopic children, 62 Hirsuties, 230 Hislop on a case of cut-throat, 576 Historic epidemics, 891 Hoag on a bullet voided by the anus, 652 Hoare on paternal impression, 86 Hobbes on fasting, 415 Hobbs on tongue-injury, 565 948 INDEX. Hochstetter on cutaneous defect, 217 Hockenhull on stones in the rectum, 648 Hodgen on combined fetation, 55 Hoffman on accidental extraction of the genitalia, 141 ; on postmortem birth, 127 ; on postmortem Cesarean section, 136 Hoffman, Catherine or Charles, 207 Hofmokl on injuries during coitus, 692 Hogg on vicarious menstruation, 25 Hogner on boric acid, 497 Hohlberg on polyorchids, 320 Holdefrund on delayed menstruation, 34 Hole on maggots in the uterus, 111 Hollander on double uterus, 311 Hollerius on birth through the abdomen, 122 Holly on cardiac surgery, 619 Holman on molten lead in the ear, 540 Holmes on absence of the eyes, 257 ; on a bottle in the vagina, 693 Holmes, Oliver Wendell, on human tails, 279 Holston on hiccough, 812 Homans on a wound in the vagina, 690 Home-sickness, 876 Home on hermaphroditism, 212 ; on a small infant, 348 ; on a two-headed boy, 187 Horn melius on double aorta, 297 " 1'Homme a la tete de cire," 697 "l'Homme-chien," 231 "l'Homme-lapin," 248 "l'Homme-oiseaux," 247 "l'Homme-poisson," 614 " 1'Homme protee," 475 Honigberger on fakirs, 518 Hooks on ovariotomy in children, 707 Hooper on vicarious menstruation, 26 Horlbeck on avulsion of the leg, 592 Horn in the rectum, 647 " Horned men of Africa," 223 Horns, human, 22 ; of cattle, injuries by, during pregnancy, 99 ; delivery by, 133 ; multiple, 226 Horrocks on anal tags, 280 Horton on pregnancy with hymen integrum, 42 Horse-bite, of the penis, 680 Horse-shoe kidney, 293 Horsley on operations on anomalous testi- cles, 322 Horstius on extrauterine gestation, 50 ; on retention of fetus, 64 ; on somnambulism, 864 Hotchkiss, Dr. William, 381 Hottentot females, labial appendages of, 307 Hough on anomalous position of the testi- cle, 321 Houghton on conception with hymen in- tact, 41 Houston on a spoon in the bowel, 641 Howard on a thimble in the nose, 565 Howarth, Philip, 344 Howe on foreign body in the appendix, 642 : on impalement, 690 Hoyer on delayed menstruation, 34 ; on postmortem birth, 12(5 Hoyland on transfixion of the chest, 610 Hubbard on fetal varicella, 91 ; on rupture of the spleen, 141 Hubbauer on foreign body in the vagina, 693 Hubert on postmortem Cesarean section, 136 Hudson, Geoffrey, 'X\x Hufeland on longevity, 'M'^, 370, 372. 374 Huff on ischiopagus, 183 Hugier on hermaphroditism, 210 Hulke on atresia of the vagina, 304 ; on her- nia, 665 ; on a limbless child, 2(54 ; on multiple fractures, 701 ; on a tube in the bronchus, 615 Hulse on a spider-bite, 713 "Human flowers," 398 Human hibernation, 517 "Human pyramids," 451 " Human succubus,'' 80 Humboldt on gynecomazia, 397 Humphreys on accidents in labor, 141 ; ou transfixion of the abdomen, 649 Hungarian sisters, 177 Hunger causing abortion, 110 ; excessive morbid, 403 Hunt ou maternal impression, x\\ ; on poly- phagia, (538 ; on urethral calculi, 792 Hunter, John, and the Irish giant, 331 Hunter on birth by the rectum, 121 ; on double vagina, 304 ; on gynecomazia, 397 ; on horn in the rectum, 647 ; on tor- sion of the penis, 316 ; on wound of the diaphragm, 613 Huppert on foreign body in the brain, 561 Hurxthal on long retention of pessaries, 094 Huse on superfetation, 48 Hutcheson on anomalous position of the tes- ticles, 322 Hutchinson on absence of the limbs, 264 ; on congenital alopecia, 227 ; on edentu- la, 243 ; on exophthalmos, 527 ; on gan- grene of the penis, (582 ; on gynecomazia, 396 ; on hyperidrosis, 387 ; on idiosyn- crasy to parsley, 491 : on nasal osteomata, 770 ; on obesity, 359 ; on supernumerary digits, 273 ; on syphilis from a flea-bite, 714 ; on tuberculosis from tattooing, 751 Huxham on colored saliva, 383 ; on fetus in fetu, 200 ; on intestinal coalition, 288 Huxley on automatism, 887 Hydatid cyst in the heart, 624 ; in the liver, 780 ; multilocular, 820 Hyde on naevus pilosus, 233 Hydroadipsia, 405 Hydrocele, 689 Hydrocephaly, 249, 786 Hydrochloric acid, tolerance of, 498 Hydrocyanic acid, tolerance of, 499 Hydronephrosis, 786 Hydrophobia, 719 Hymen, absence of, 302 ; biperforation of, 302 ; duplication of, 302 ; integrum, preg- nancy with, 40 Hyneaux on postmortem birth, 124 Hyperesthesia of the skin, 837 Hyperidrosis, 386 Hyperosmia, 875 Hyperthermy, 420 Hypertrichosis, 233 Hypertrophy of the digits, 276 ; of the lips, 254 ; unilateral, 351 INDEX. 949 Hypnotism, 870 ; in child-birth, 114; in hyperidrosis, 387 Hypochondria, 876 Hypospadias, 318 Hypothermy, 424 Hysteropaxy, effect of, on subsequent preg- nancies, 106 I. Iris, absence of the, 259; bicolored, 260; ossification of the, 259 Irish giant, 330 Irish women, ancient obstetric customs of, 113 " Iron-jaw," 468 Irvine on twin birth, 142 Irwin ou attachment of the fetal head, 142 Ischiopagi, 181 Ischuria, 792 Isham on unconscious pregnancy, 73 Israelites, knowledge of telegony among the, 89 Ivanhoff on death from shock, 525 ; on re- traction of the penis, 682 J. Jackson on aphasia, 874 ; on arsenic, 500 ; on discharge of fetal bones, 53 ; ou double consciousness, 885 ; on long retention of a pessary, 694 ; on wound of the bladder, 671 Jacob on a foreign body in the eye, 532 ; on human tails, 278 Jacobi on a double monster, 180 ; on hyper- thermy, 423 Jacobs on spontaneous human combustion, 428 Jacobson on gangrene of the penis, 682 ; on giant-growth, 351 ; on lithotomy during pregnancy, 104 ; on vicarious menstrua- tion, 20 Jacques, Alexander, 420 Jaffe on protracted pregnancy, 70 James on retention of ectopic fetus, 63 Jameson on twin labor, 111 Jamieson on dermoids, 205 ; on eunuch- making, 756 ; on mycosis fungoides, 850 ; on self-mutilation, 737 Janovsky on acanthosis nigricans, 841 Jansen ou twin parturition, 142 Jar vis on maggots in the nose, 564 Jauffret on restoration of sight, 535 Jaw, anomalies of the, 251 ; strength of the, 468 Jdanoff on polyorchids, 320 Jeaffreson on ossification of the penis, 259 Jefferies on protracted pregnancy, 72 Jefferson, Thomas, on albinism in negroes, 221 Jeftichew, Adrian, 231 Jenisch on diphallic monster, 195 Jenkins, Henry, 373 Jenner, Edward, 906 Jennings on cranial fractures, 558 Jessop on multiple aneurysm, 779 ; on rup- ture of the eye, 528 ; on viable ectopic fetus, 57 Jewett on brain injurv, 549, 553 ; on horns, 225 Jinrickisha-men, 457 Joch on a bearded woman, 228 Joints, deformed, 603 "Jo-Jo," 232 Johnson on cryptorchids, 321 ; on horns, 229 ; on hydrochloric acid, 499 ; on pre- Ibbetson on excessive dentition, 244 Ichthyosis, 823 Idiosyncrasy, 481 ; to certain foods, 489 ; in coitus, 511; to objects, 487; to odors, 482 ; to sounds, 484 ; to touch, 488 ; tol- erance, and untoward action in relation to drugs, 496 "Ignis Sacer," 502 Iliac artery, ligature of, 658 ; wound of the external, (527 111 on birth through the abdominal wall, 122 Imaginary pregnancy, 73 Imbert de Lannes on double nose, 563 Impalement through the abdomen, 648 ; through the chest, 610 ; by the vagina, 690 Impregnation, accidental, 43 ; in the aged, 38 ; artificial, 42 ; by a bullet (Caper's case) 44 ; without complete entrance, 40 ; with hymen integrum, 40,- precocious, 34 ; during sleep, 45 ; unconscious, 45 Impressions, maternal, 81 ; paternal, S'^ Inaudi, Jacques, 439 Incubator, 68 Indian runners, 457 Infantile menstruation, 29 ; spinal paraly- sis, 604 Infants, beard on, 228 ; large, 348 ; small, • 347 ; vitality of, 117, 706 Infectious diseases, modern mortality from, 913 Infibulation, 752; to prevent masturbation, 754 Ingham on anomalous semen, 385 Ingleby on tumor in the pregnant uterus, 106 Innominate artery, ligature of, 575 Inoculation, 905 Insanity, anomalous, 880 ; endurance of cold in, 430 ; odors of, 400 Insect-stings, 713 Insects in the ear, 5:59 ; in the nose, 564 Intestinal anastomosis, 645 Intestines, anomalies of, 287 ; coalition of, 288 ; foreign bodies in, 641 ; extensive hemorrhage from, 710 ; injuries of, 642 ; obstruction of, 794 ; operations on, 644 ; resection of, 643 ; rupture of, (544 ; slough- ing of, after intussusception, 643 Intoxication, birth during, 114 Intrauterine amputations, 94 ; fractures, 97 Intussusception of the intestines, sloughing after, 643 Iodin iireparations, untoward action, and tolerance of, 503 Iodoform-poisoning, 503 950 INDEX. cocious boys, 345 ; on retention of ectopic fetus, 63 ; on rupture of the heart, 625 Johnson, Tom, 465 Johnston on bulimia, 403 ; on a large in- fant, 349 ; on a triple heart, 296 Joly on diaphragmatic hernia, 286 July and Peyrat ou double mouster, 177 Jones on foreign bodies in the pelvis, 679 ; on rupture of the bladder, 070 ; on pro- tracted sleep, 869 Jones twins, 183 Jonston on antepartum crying, 127 ; on artificial penis, 319 ; on blind savants, 433 ; on maternal impressions, 82 ; on protracted pregnancy, 70 : on short preg- nancy, 05 ; on vicarious menstruation, 24 Josephi on retention of ectopic fetus, 63 Josephus on giants, 325 Jouilleton on male menstruation, 28 ; on vicarious menstruation, 24 Joy, death from, 524 Joyce ou injury to the penis, 680 Judkins on morning nausea in the male, 80 Jugglers, 451 Jumpers, 402. ^r->r> Jumps from heights, 704 Jurine on phosphorescent urine, 429 Jurist on mobility of the tongue, 255 Jussieu on absence of the tongue, 254 ; on supernumerary mamma, 301 K. Kaestner on obesity, 354 Kaltschmid on dropsy, 780 Kameya Iwaon horns, 224 Kaposi on pigmented mole, 841 "Kara," 451 Kartulus on a high fall, 704 ; on hyper- thermy, 422 Katatonia, 882 Kauffmann on objective tinnitus aurium, 538 ; on rudimentary penis, 315 Kay on a girl grandmother, 38 Kealy on perforation of the tympanum, 538 Keelan on lithotomy during pregnancy, 104 Keen on amputation during pregnancy, 105 ; on double fornix, 249 ; on injury to cervical vertebrae, 578 ; on wounds of the thoracic duct, 658 Keen and Da Costa on cardiac surgery, 616 Keetley on a spelling-book in the groin, 659 Keith on ovarian cyst, 683 Kellar, Helen, 435 Keller on intrauterine fracture, 97 Kelly on ovarian cyst, 783 ; on postmortem birth, 124 ; on vesical calculi, 790 Keloids, 7(54 Kelvin, Lord, on longevity, 371 Kennard on protracted menstruation, 33 Kennedy on fecundity iu the old, 39 ; on profuse lactation, 394 ; on quintuplets, 150 ; on self-mutilation, 731 ; on shark- bite. 721 ; on tapeworms, 818 Kenophobia, ^77 Kenthughes on the feet of Chinese ladies, 738 Keratodermia, 825 Keratolysis. 832 Keratosis, contagious follicular, 825 | Kerckring on scrotal anomaly, 321 ; on vicarious menstruation, 25 Kerr on maternal impression, 83 Kesteven on brain-injury, 38 Ketchum on a young grandmother, 38 Keysler on obesity. 358 Kick causing abortion, 110 Kidd on operations upon children, 707 Kidney, absence of, 292 ; anomalies of, 292 ; calculi in, 790 : displacement of, 294 ; operations on, (568 : during pregnancy, 104, 105 ; rupture of, 653, (507 : super- numerary, 293 ; wound of, 667 Killian on perforation of the uterus, 141 Kilpatrick on precocious pregnancy, 37 Kimura on ectopic gestation, 54 King on amazia, 297 ; on fasting, 420 ; on male menstruation, 28 ; on precocious pregnancy, 37 Kinney on precocious pregnancy, 37 ; on absence of the eyes, 258 Kirby on vesical calculi, 789 Kirchner on wounds of the thoracic duct, 657 Kirilow, 156 Kirmisson on anomaly of the liver, 290 Kisel on tapeworm, 819 Kiss on the ear causing deafness, 537 Klein on milk-metastasis, 392 Kleptomania, 879 Kleptophobia, 879 Klob on supernumerary mamma, 301 Knaggs on vicarious menstruation, 26 Knapp on merycism, 802 ; on quinin, 510 Knehel on twins born to an old woman, 40 Knies on lightning-blindness, 537 Knife-blade in the chest, 614 Knife-swallowing, 632, 635 Knoll on avulsion of the genitals, 686 Knots in the umbilical cord, 109 Knott on ceremonial ovariotomy, 755 Koeberle on intestinal resection, 643 Koehler on gangrene of the penis, 682 Kohler on anomalies of the digits, 271 Kohler on phenol. 498 Kbhnhorn on digitalis, 502 Kolster on hemophilia, 815 Kbnig on operation on a monster, 172 ; on retardation of putrefaction, 523 Kopp on premature birth, 66 ; ou dernia- tolysis, 218 Korin, Jean, 373 Koser on cerebral tumor, 558 Krabbel on wound of the thoracic duct, 657 Krafft-Ebing on anthropophagy, 410 ; on fetichism, 402 ; on perverted appetite in pregnancv, 80 "Krao," 231 Kraus on hypertrophied liver, 655 Kreutzman on ovariotomy during preg- nancy, 104 Krishaber on vicarious menstruation, 25 Kugler on arrow-wound, 712 Kuhn on congenital defects of ocular move- ments, 260 Kunst on bee-stings. 713 INDEX. 951 Kiiss on maternal impressions, 85 Kussmaul on precocious pregnancy, 35 Kiister on injuries of the sciatic nerve, 592 Kustermann on hyperidrosis, 387 Kyle on foreign body in the abdominal parietes, (559 Kyphosis, 281 L. Labia, absence of, 306 ; of the Hottentot females, 307 Labor, accidents incident to, 141 ; hypnot- ism in, 114 ; postmortem, 124 ; rapid, 116; retardation of, 58 Laborde and Lepine on hiccough, 813 Lachausse on superfetation, 47 Lactation in the aged, 393 ; anomalies of, 391 ; in infants, 392 ; male, 397 ; preco- cious, 392 ; prolonged, 394 " La dame a quatrc jambes," 192 " Lady with a mane," 2:53 Lafontaine on plica polonica, 848 Laget ou supernumerary liver, 290 Lall on horns, 224 Lallemand on rupture of the stomach, 629 "Laloo," 192 Lamb on submersion, 513 Lambert, Daniel, 357 Lambert family, 823 Laminectomy, 660 de La Motte on precocious pregnancy, 37 ; on premature birth, 68 Lamprey on "horned men," 223 Lancisi on anomalous sneezing, 814 Landes on absence of the eyes, 258 Landois on sudden canities, 236 Lane on polyorchism, 320 Lang on Epsom salts, 503 Lange on double penis, 198 Langenbeck on atrophy of the maxilla, 251 Langenbuch on gastrectomy, 644 ; on resec- tion of the liver, (554 Langlet on hemihypertrophy, 350 Langmore on superfetation, 48 Langston on sudden birth, 119 Lanigan on postmortem birth, 126 Lapeyre on cigarette in the bronchus, 615 La Peyronia on anomalous urethra, 317 Lapiada, 466 Lapointe on demonomania, 880 Larkin and Jones on supernumerary limbs, 269 Larrey on atrophy of the testicles, 687 ; on elephantiasis of the scrotum, 801 ; injury to the external genitalia, 686 ; on sarco- cele, 6*9 Laryngectomy, 584 Larynx, artificial pouch in, 584 ; excision of, 584 ; foreign bodies in, 580 ; impac- tion of artificial teeth in, 582 Lateau, Louise, 389 Latham on skin-shedding, ^'X.\ Latimer on knots in the funis, 109 Laughter, death from violent, 524 Laughton on ascarides, 820 Langier on venesection, 709 Laurent on gynecomazia. 395 Laurentius on vicarious menstruation, 20 Lauth on absence of the ovaries, 309 Laveran on tapeworm, 818 Law on vicarious menstruation, 24 Lawrence on anencephaly, 246 ; on anoma- lous diaphragm, 285 ; on rupture of the uterus, 138 Lawson on coitus, 512 ; ou foreign body in the brain, 560 ; on impregnation with un- ruptured hymen, 41 Lazzaretto on dislocated atlas, 578 Leach, Harvey, 2(56 Leach on bullet in the chest, 614 Lead-pencil in the arm, 600 Lead-poisoning, 503 Lead-wire in the arm, 600 "Leah, the giantess," 332 Leale on skin-grafting, 730 Leanness, 363 Le Beau on operation for monster, 172 ; on precocious pregnancy, 31 Lebedeff on ovariotomy during pregnancy, 104 Lebert on horns, 223 Leblond on bearded women, 229 Le Brun on multiple birth, 154 Lebrun on perineal birth, 122 Le Carpentier on snake-bite, 717 Le Cat on anomalous pigmentation, 842 ; on blind savants, 433 ; on hydrophobia, 719 Le Conte on lightning-stroke, 723 Lediberder on double aorta, 294 Le Due on absence of the brain, 246 Lee on anomalous sneezing, 814 Leech in the nose, 563 ; in the pharynx, 569 ; swallowed, 637 ; in the vagina, 694 Leedgwood, James, 265 Lefebvre on precocious pregnancy, 35 Lefort, Marie-Madeline, 207 Leg, absence of the, 266 ; avulsion of the, 592 ; reunion of an almost severed, 593 ; supernumerary, 2(59 Leg-breaker, professional, 741 Leger, 410 Legg on anosmia, 874 Legitimacy, 65, 68, 69 Leichtenstein on obesity, 356 Leichtenstern on polymazia, 298 Leidy on terata, 166 Leigh on hydrocele, 689 Leisenring on pregnancy with unruptured hymen, 42 Lejoucourt on longevity, 369 Leukemia, priapism in, 684 Leukoderma, 845 Lemaire, Jacob, on giants, 325 Lemery on anuria, 793 Lenormant on fetomancy, 213 Lenox on bullet voided by the bowel, 652 Lens, dislocation of the, 533 ; injury to the, 533 Lente on dry births, 123 Leonard on long beard, 234 Leonhard on unusual birth, 120 Leontiasis ossea, 805 " Leopard-boy," 845 Le Page on neuropathic plica, 849 Leprosy, 911 ; from a fish-bite, 721 Lereboullett and Knochon teratogenesis,166 952 INDEX. Lesbian love, 308 Lesser on albinism, 220 Lethargy, protracted, 867 Lettsom on polyphagia, 638 Levator ani, spasmodic contraction of, in coitus, 512 Levisou on fetal dentition, 243 Lewin ou idiosyncrasy to drugs, 497 ; on quinin, 509 ; on opium-eating, 507 Lewin and Heller on horns, 226 Lewis on unilateral sweating, 388 Lheritier on vicarious menstruation, 17 Licetus on ischiopagus, 181 ; on double monster, 167 Lidell on basal fracture, 559 Liebreich ou vicarious menstruation, 24 Lieutaud on absence of the liver and spleen, 290 Life, divisions of, 370 Lightning-stroke, 722 ; amputation by, 726 ; blindness from, 537 ; effect on the nervous system, 725 ; ocular injuries from, 726 ; photographic properties of, 727 ; recovery after, 723 ; therapeusis of, 726 Lile on tapeworm, 819 Lilliputians, 342 Limbless athletes, 599 Limbs, absence of, 263 ; artificial, 598; foreign bodies in, 599 ; supernumerary, 269 Linsmayer on acromegaly, 804 Lion-tamer, injury to a, 591 Lipomata, 764 ; diffuse, 766 Liprandi on the Skoptzies, 758 Lips, anomalies of, 254 Liquor amnii, absence of, 123 Lisfranc on foreign bodies in the uterus, 696 Lison on sixth dentition, 243 Lister on longevitv, 379 Lithopedion, 50, 03, 64 Lithotomy during pregnancy, 104 ; self- performed, 708 Litten on hermaphroditism, 211 Little on self-decapitation, 575 Littre on Hippocrates. 90 Liver, anomalies of, 290 ; floating, 655 ; hy- datid disease of, 78(5; hypertrophy of, 055 ; laceration of, 141 ; ligature of, 654 ; regeneration of, 655 ; resection of, 654 ; supernumerary, 290 ; surgery of, 653, 654 ; suture of, 652 ; wounds of, 652 " Living angel," 844 " Living skeletons," 363 Lizard in the nose, 564 ; swallowed, 637 Lloyd on aural anomaly, 261 ; on laminec- tomv, 661 Loakes, Wybrand, 339 Lobstein on intussusception, 643 Locke on horns, 226 Lockier, Joseph, 416 Locomotive (toy) in the subglottic cavity, 614 Lodge on mercuric chlorid, 504 Logan on hemihypertrophy, 350 Loin on maternal impressions, 85 Lombard on pregnancy with unruptured hymen, 42 Lombroso on hirsuties, 231 ; on micro- cephaly, 247 Lomer on fetal measles, 91 London plague, 895 Longevity, 3(55 ; iu active military service, 379 ; activity in, 371 ; in actors, 377 ; among the ancients, 309 ; in a deaf mute, 377 ; diet in, 379 ; in dwarfs, 339 ; effect of class-influence, occupation, etc., on, 367 ; generative ability compatible with, 376 ; among the Greeks, 370 ; heredity in, 379 ; in hermits and ecclesiastics, 370 ; among Indians, 376 ; influence of mental culture in, 371 ; influence of personal habits, 372 ; influence of stimulants, 377 ; in Ireland, 378 ; among the Jews, 309 ; in physicians, 380 ; possession of faculties in, 377 ; recent instances of, 382 ; re- markable instances of, 373 ; among the Romans, 370 : in rulers, 372 ; statistics of, 365, 366, 367 Longhi on sloughing of the vagina, 691 Longmore on transfixion of the chest, 611 Longworth on inversion of the diaphragm, 286 Lopez on precocious boys, 345 Lordosis, 281 Loreta on abdominal aneurysm, 659 Loring on gunshot wound of the abdomen, 651 Lorry on canities, 238 Lospichlerus on retention of ectopic fetus, 63 Louis and Louise, 181 Louis on birth by the rectum, 121 Louise, L., 192 Loushkin, 331 Lousier on polymazia, 302 Lovort on enucleation of the eye in preg- nancy, 105 Lowe on injury to the lens, 533 Lozes on horns, 224 ; on unconscious preg- nancy, 73 Luce on injury during pregnancy, 100 Ludwig on canities, 238 Lumbricoides, 819 ; in the uterus, 111 Lumby on twin birth, 143 Lundie on protracted pregnancy, 71 Lungs, anomalies of, 285 ; injuries of, 606 ; rupture of, without fracture of a rib, 608 ; spontaneous rupture of, 609 ; surgery of, 608 ; transfixion of, 610 "Lurline," 513 Lusk on delivery of ectopic fetus, 54; on tumor in the pregnant uterus, 106 Lust-murder, 410 Lycosthenes on monsters, 162-164 Lyford on hypertrophy of the tongue, 567 Lymphedema, 795 Lyssophobia, 879 M. Maas on painless births, 113 Macann on polyorchids, 320 Macaulay on tetanus neonatorum, 817 McCallum on double monster, 186 M'Clellan on fracture of the penis, 679 INDEX. 953 MacClellan on ossification of the penis, 316 McClellan on penetration of the ureter, 670 McClintock on fear of child-birth, 525 ; on fetal therapeutics, 92 ; on lithotomy dur- ing pregnancy, 106 MacCormac oh basal fracture, 559 ; on hemophilia, 816 McCosh on recovery after multiple injuries, 699 McCreery on tartar emetic, 500 MacDonald on lightning-stroke, 725 McDowall on scalp-development, 218 McKlmail on anomalous position of the tes- ticle, 322 McElroy on polydipsia, 405 McGee on combined gestation, 55 MacGillibray on ceremonial ovariotomy, 755 McGillicuddy on ovarian cyst, 783 ; on supernumerary mamma, 301 MacGowan on " wild-boys," 448 McGrath, Cornelius, 330 McGraw on vicarious menstruation, 26 Macgregor on vesical calculi, 790 Macgrigor on shark-bite, 721 McGuire on wound of the bladder, 675 Machinery, recovery after injuries from, 699 Mclntyre on fetus in fetu, 201 ; on uterine tumors, 780 Mackay on maternal impression, 85 McKee on wound of the liver, 653 Mackenzie on arsenic, 500 ; on hemophilia, 816 ; on hyperthermy, 421 ; on idiosyn- crasy to eggs, 490 ; on polydipsia, 404 ; on protracted pregnancy, 71 ; on web of the vocal bands, 257 McKeown on late restoration of sight, 535 Mackey on long retention of pessaries, 694 Mackinlay on pregnancy with unruptured hymen, 42 Macknus on birth in membranes, 123 Macland on gros-nez, 769 MacLauren on fish in the pharynx, 568 McLean on amputation during pregnancy, 105 ; on antepartum crying, 128 MacLean on avulsion of the arm, 591 MacLoughlin on fasting, 420 McMillan on wound of the liver, 653 Macnab on diaphragmatic hernia, 286 Mac Nab on hyperthermy, 422 Macnal on arseuic, 500 McNaughton on fasting, 418 ; on obesity, 353 McNutt on ovariotomy in age, 707 Macpherson on wounds of the liver, 652 Macrocephaly, 248 Macroglossia, 567 Macrostoma, congenital, 253 Madden on avulsion of the testicles, 686 ; on fissure of the sternum, 283 ; on foreign body in the intestines, 641 ; on pseudo- cyesis, 77 Maddox on belladonna, 501 Madigan on self-performed Cesarean section, 132 Magalhaes on elephantiasis of the scalp, 798 Maggots in the ear, 539 ; in the nose, 564 ; in the uterus, 111 Magitot on microcephaly, 248 Magnetism, human, 429 Magruder on discharge of fetal bones, 53 Mahomed on hyperthermy, 423 Maisonneuve on pregnancy with imperfor- ate hymen, 42 ; on short pregnancy, 65 Major on foreign body in the nose, 565 ; on tongue-swallowing, 565 Major terata, 161 Malacarne on anencephaly, 246 Malaria in the fetus, 91 ; splenectomy in, 657 Maldemeure, family of, 154 de Maldigny, Clever, 708 Mamma, abdominal, 301 ; adenoma of, 759 ; anomalies of, 297 ; axillary, 301 ; diffuse hypertrophy of, 759 ; erratica, 302 ; on the thigh, 301 "Man-boys," 343 " Man-mothers," 202 Mandelshof on precocious menstruation, 31 von Mandelslo on precocious pregnancy, 35 Mane on a woman's back, 233 Mangiagalli on supernumerary ovary, 310 Manifold on bifurcated epiglottis, 256 Manley on rupture of the thoracic duct, 658 Mann on lithotomy during pregnancy, 105, 106 ; on operations during pregnancy, 103 Manzini on high falls, 703 Marc on a hermaphrodite, 212 Marcacci on a bean in the bronchus, 614 Marchal de Calvi on foreign bodies in the ear, 541 Marey on albinism, 221 Marie on chiromegaly, 805 Marie-Adele, 173 Marie-Dorothee, 212 Marie-Louise and Hortense-Honorine, 182 " Market Harborough fasting girl," 419 Marks on cardiac injury, 622 Marksmen, 452 Maroldus on abortion by the mouth, 52 Marriages, early, in India, 18, 37 ; multiple, 159 ; statistics of, 146 Marsa on fecundity in the old, 38 Marsden on anomalous urination, 384 Marsh on delivery by cow-horn, 134 Marshall on anomalous position of the testi- cle, 322 ; on rupture of the femoral artery, 594 Marteau on protracted pregnancy, 69 Martial on infibulation, 752 Martin on ichthyosis, 824 ; on injuries dur- ing coitus, 692 ; on longevity, 5574 ; on protracted pregnancy, 71 ; on skin-graft- ing, 730 ; on supernumerary mamma, 301 Martineau on ovarian cysts, 782 Martinez, 424 Martyn on bulimia, 403 Marvand on wounds of the kidney, 667 Marville on somnambulism, 804 Marx on delayed menstruation, 34 Mascha on cannibalism, 411 Masochism, 480 Mason on bulimia, 403 ; on foreign body in the intestine, 641 ; on supernumerary digits, 275 ; on tartar emetic, 500 Massie on wound of the liver, 053 Masters on intestinal coalition, 288 954 INDEX. Mastin on cardiac injury. 022 ; on foreign body in the brain, 561 ; on maternal im- pression, Ko Masturbation, infantile, 345; infibulation to prevent, 754 Matas on tumor of the parotid, 768 Matches in the rectum, 648 Maternal impressions, 81 Mathieson on delivery of ectopic fetus, 54 Matthaeus on postmortem delivery, 125 Matthyssens on coiling of the funis, 95 Maurice on anomaly of the jaw, 252 Mauriceau on abortion, 110 ; on extrauterine pregnancy, 50 ; on fetal variola, 90 ; on postmortem Cesarean section, 135 ; on superfetation, 47 Maury and Dulles on syphilis from tattoo- ing, 751 Mauvezin on croton oil, 504 Maxilla, anomalies of, 251 Maximilian, Emperor, 325, 464 Maxson on combined fetation, 57 Maxwell on injury to the nose, 562 May on ovariotomy during pregnancy, 104 Mayer on postmortem birth, 126 Maygrier on absence of the digits, 271 ; on precocious pregnancy, 36 Mayham on fecundity in the old, 39 Mayo on transplantation of the ureter, 669 Mayo-Smith on marriage, 145 ; on modern mortality from infectious diseases, 913 ; on multiple births, 147 ; on prolificity, 145 Maziuus on antepartum crying, 128 Mead on male menstruation, 28 Meadows on large infants, 348 Mears on conception after ovariotomy, 46 Mease on bee-stings, 714 Measles in the fetus, 91 Meckel on supernumerary digits, 275 ; on triple monsters, 167 Medicines, action of, on the fetus in utero, 92 Meek on pregnancy with unruptured hy- men, 42 van Meek'ren on brain injury, 555 ; on dermatolysis, 217 Meeres on mercuric chlorid, 504 Megacolon congenito, 288 Megalocephaly, 805 Mehliss on gynecomazia, 397; on male menstruation, 27 ; on late dentition, lac- tation, and menstruation, 32 Meibomius on vicarious menstruation, 24 Meigs on protracted pregnancy, 70 ; on re- tention of fetus, 64 ; on twins borne by a child-mother, 38 Meisner on vicarious menstruation, 18 Mekeln on birth by the rectum, 121 Melanism, 222 Melasma, 845 Mellichamp on cardiac injury, 623 Membranes, absence of fetal, 109 ; anom- alies of fetal, 107 ; enclosing fetus un- ruptured, 122 ; expulsion of fetal, 108 ; premature protrusion of fetal, 107 Memorv, feats of, 439 ; peculiar loss of, 88:-;-880 Menard on lactation in infants, 392 Mendenhall on brain-injury, 554 Menesclou, 410 Meniere's disease, 861 Meningitis from foreign bodv in the brain, 540 Meningocele, 251 Menopause, delayed, 32 Mensen, Ernest, 460 Menstruation, 17 ; anomalies of, 18 ; black, 27 ; from the bladder, 26 : from the breasts, 19 ; after death, 27 ; from the ears, 24 ; from the extremities, 25 ; from the eyes, 23 ; by hematemesis, 27 ; late establishment of, 33 ; from the male ure- thra, 27 ; migratory. 27 ; from the mouth, 24 ; from old ulcers, wounds, or cicatrices, 25 ; after ovariotomy, 20 ; precocious, 29 ; during pregnancy and lactation, 28 ; protracted, 32 ; from the rectum, 20; after removal of the uterus and ovaries, 26 ; from the skin, 18 ; simulating stig- mata, 25 ; superstitions relative to, 17 ; suppression of, 27 ; from, the urinary tract, 26 ; vicarious and compensatory, 18 Mental and nervous diseases, anomalous, 852 Mentzelius on triple dentition, 243 Menzie on protracted pregnancy, 71 Mercurialis on imperforated anus, 289 ; on protracted pregnancy, 70 Mercury, tolerance of, and idiosyncrasy to, 504 Merensky on Hottentot females, 307 Merinar on repeated Cesarean section, 130 Merlatti, 420 Merlet on alopecia, 241 Merriman on multiple births, 154 ; on un- conscious pregnancy, 73 Mery on anencephaly, 346 Merycism, 862 Meschede on automatism, 888 ; on foreign bodies in the uterus, 695 Mesnet on automatism, 887 ; on somnam- bulism, 865 Meyer on abortion, 110 ; on avulsion of the finger, 590 ; on precocious pregnancy, 35 ; on rupture of the heart, 625 ; statistics of protracted menstruation, 32 "Mexican wild-boy," 248 Mezeray on stigmata, 388 Mibelli on keratodermia, 825 Michaelis on multiple Cesarean section, 131 Michel on telegony, 88 Michelson on mottled hair, 239 Mickle on unilateral sweating, 387 Micklucho-Maclay on ceremonial ovariot- omy, 755 Microcephaly, 247 ; artificial, 248 Micromazia, 298 Microstoma, 253 Middleton, John, 330 Middleton on retention of ectopic fetus, 63 ; on snake-bite, 717 Milk, colored, 391 ; metastasis of, 391; anomalies of the secretion of, 391 Miller on human tails, 279 "Millie-Christine," 179 " Millie Josephine," 355 INDEX. 955 Millingtou on aversions, 880 Mills on injury to the spinal cord, 661 Milne on hemihypertrophy, 351 Milner on injury during pregnancy, 101 Mineer on gunshot wound of the abdomen, 651 Miner on fetus in fetu, 202 Minna and Martha Finley, 183 Minor terata, 213 Minot on horns, 225 ; on hydrocephaly, 250 ; on impalement, 649 Mirabeau on triplets, 148 Mirandulae, Franciscus Picus, on multiple birth, 153, 154 Miryachit, 855 Miscellaneous surgical anomalies, 697 Mitchell on anosmia, 875; on Newport twins, 108 Mitchell, Weir, on double consciousness, 583 ; on male nausea of pregnancy, 79 ; odor of nervous diseases, 400 ; on perver- sion of the tactile sense, 875 ; on pro- tracted sleep, 869 ; on pseudocyesis, 73 Mitra on ascarides, 820 Mittehauser on large infant, 348 Moffitt on quintuplets, 150 "Moi Boy," 279 Moldenhauer on luxation of the penis, 681 Mole, hairy, 232 Molinetti on multiple ureters, 294 Molinier on foreign body in the nose, 565 Molitor on precocious pregnancy, 35 Moll on automatism, 888 ; on hypnotism, 871 Molodenkow on boric acid, 497 Money swallowed, 639 Monin on human odors, 399 Monophobia, 879 Monorchids, 319 Monsters, 161 ; ancient explanation of, 161 ; artificial production of, 166, 448, 737 ; de- livered by Cesarean section, 129 ; double 167 ; triple, 167 Montagu, Lady, ou inoculation, 905 Montare and Reyes on parasitic terata, 192 Montegre on lactation in the aged, 393 Montgomery on birth during sleep, 114; intrauterine amputation, 94 ; on ischio- pagus, 182 ; on premature rupture of fetal membranes, 108; on presentiment of death, 889 ; ou twins borne by a child- mother, 38 ; on twins borne beyond the menopause, 40 "Moon-blindness," 537 Moore on abortion, 111 ; on hiccough, 812 ; on nasal sarcoma, 777 : on premature fetus, 66 ; on priapism, 083 Moore, Oscar, 440 Moorehead on accident to the eye, 533 Moosmau on constipation, 794 Morand on cardiac injury, 617 ; on dropsy, 786 ; on foreign bodies in the bladder, 070 ; on ovarian cyst, 782 Mordake, Edward, 188 Mordie on recto-vaginal septa, 305 Moreau de la Sarthe on hair-growth, 228 Moreau on monsters, 187 ; on parasitic ter- ata, 191 Morgagni on fatal sneezing, 814 Morgan on gynecomazia, 396 ; on injury to the penis, 680 ; on macrostoma, 253 Morisani on birth by the rectum, 121 ; on symphysiotomy, 141 Morison on white spots on the nails, 847 Moritz on postmortem birth, 127 Moritz, Miss M., 343 Morland on ascarides, 820 ; on iujury dur- ing pregnancy, 99 Morphea, 820 Morris on rupture of the bladder, 070 ; on tongue sucking, 565 ; ou universal derma- titis, 851 Morrison on nitric acid in the ear, 540 "la Mortalega," 892 Mortar-pestle in the rectum, 646 Mortimer on bulimia, 403; on double tongue, 255 Morton on brain-injury, 557 ; on leg-injury, 593 Moscati on spontaneous human combustion, 427 Moseley on self-performed Cesarean section, 132 Moses on vicarious menstruation, 25 Motte on knots in the fuuis, 109 Mounsey on retention of ectopic fetus, 63 Mouronval on unconscious pregnancy, 73 Mourray on crocodile-bite, 722 Mouth, anomalies of the, 253 ; atresia of the, 254 ; menstruation from the, 25 Movements, fetal, 64 ; in pseudocyesis, 73 Moxhay on supernumerary auricles, "263 Muhlig on cardiac; injury, 621 Muirhead on thoracic defects, 284 Mulheron on idiosyncrasy to drugs, 497 Muller on arrow-wounds, 712 ; on multiple amputations, 597 ; on protracted sleep, 868 Muller, Rosine-Marguerite, 229 Multiple births, 147 ; in the aged, 40; repetition of, 154 ; over six, 152 Munde on Cesarean section with twins, 129 ; on vulvar operation during pregnancy, 105 Munro on aural anomalies, 261 Munster, Christopher, 329 Murfee on retention of ectopic fetus, 63 Murillo on precocious pregnancy, 37 Murphy on absence of the penis, 314 Murray on double hand, 271 Mursick on small infant, 348 Mnrsinna on hvdrocele, 689 ; on tapeworm, 819 Musseus on anomalous nails, 242 Muscle-transplantation, 728 Musculo-spiral nerve, plexiform neuroma of, 771 Music, idiosyncrasy to, 485; therapeutic value of, 485 Musser on anomalous stomach, 287 Mussey on aural anomaly, 261 ; on avulsion of the arm, 591 Mutilations, cosmetic, 746 ; religious and ceremonial, 743 ; self-performed, 731 Muzenthaler on unconscious pregnancy, 73 Mya on megacolon congenito, 288 Mycosis fungoides, 850 Myoma of the uterus, 781 956 INDEX. Myrtle on hyperidrosis, 387 Misophobia, 878 Myxedema, 807 N. Naegele on injury during pregnancy, 102 ; on precocious menstruation, 30 Naevus pilosus, 232 Nail in the bronchus, 614 ; swallowed, 638 Nails, anomalies of the, 241 ; reproduction of the, 589 ; white spots on the, 847 Nankivell on multiple fractures, 702 Napper on amputation during pregnancy, 105 Nares, occlusion of the, 253 Nasal sarcoma, 777 Naumann on postmortem birth, 126 Nausea of pregnancy in the male, 79 Nebel on anomalous ureters, 294 Nebinger on intrauterine amputations, 96 Neck, broken and dislocated, 578 ; injuries of the, 574 ; transfixion of the, 575 Necrophobia, 879 Nedham on intestinal resection, 643 Needle in the bladder, (576 ; fall on a, caus- ing death, 627 "Needle-girls," 735 Neiman on brain injury, 549 Nelaton ou absence of the penis, 314 ; on luxation of the penis, (581 Nemnich on longevity, 375 Neoplasms, 759 Nephrolithotomy, 668 Nephrorrhaphy, 668 Nephrotomy in pregnancy, 104 Nerve-grafting, 729 Nervous diseases, anomalous, 852 Netter on fetal pneumonia, 91 Neubauer on triple nymphae, 306 Neuhof on anomalous nails, 241 Neugebauer on injury during pregnancy, 102 ; on supernumerary nipples, 302 Neuro-fibroma, 770 Neuroma cutis dolorosum, 839 Neuromata, 770 ; plexiform, 770 New-born, hemorrhagic diseases of the, 816 Newell on skin shedding, 833 Newington on premature twins, 66 Newlin on superfetation, 48 Newman on knots in the umbilical cord, 109 Newnham on abortion in twin pregnancy, 11 "Newport Twins," 168 Neyronis on alopecia, 241 Nicholson on maggots in the ear, 564 Nicod on amputation during pregnancy, 105 Nicolls on intestinal injury, 643 Nicotin-poisoning, 511 Night-blindness, 536 Night vision, 536 Nigrities. 842 Niles on bubonic plague, 896 Nine children at a birth, 153 Nipple, avulsion of, 728 ; deficient, 302; supernumerary, 302 Nitric acid in the ear, 540 ; tolerance of, 499 Nitzsch on triple dentition, 243 Nivison on bee-sting, 714 Noble on cardiac injury, 619 Nolde on the funis, 109 " Noli-me-tangere," 772 Norris on gunshot wound of the penis. 681 Nose, anomalies of, 252 ; congenital division of, 252 ; deformity of, 563 ; double, 563 ; foreign bodies in, 563 ; injuries to, 561 ; larvae in, 822 ; restitution of a severed, 502 ; tooth in, 224 Nose-making. 561 Nostalgia, 870 Notta on anosmia, 874 Noyes on horns, 225 ; on foreign body in the vermiform appendix, 642 Numa Rat on yaws, 840 Nunnely on avulsion of a finger, 589 ; on congenital ocular malformations, 2(51 ; on ischuria, 793 Nyctalopia, 536 Nymphae, absence of, 306 ; enlarged, 306 ; supernumerary, 307 ; triple, 306 Nymphotomy, 307 o. Oakman on pregnancy with hymen integ- rum, 42 Obermeier on sternal fissure, 283 Oberteuffer on absence of the vagina, 303 Obesity, 352 ; in childhood, 352 ; general remarks on, 355; hereditary, 356 ; re- markable instances of, 356 ; simulation of, 360 ; thyroid feeding in, 356 ; treat- ment of, 356 Obstetric anomalies, 113 O'Connell on tattooing, 750 O'Connor on cardiac injury, 621, 623 Odors associated with nervous disorders, 400 ; cadaveric, during life, 400 ; caus- ing abortion, 110 ; causing loss of smell, 875 ; of certain races, 399 ; of diseases. 401 ; of hospitals, 401 ; human, 397; influence of the emotions on, 399 ; idiosyncrasy to. 482 ; individual, 398 ; of the insane, 400 ; sexual influence of, 401 Oedmanon abortion, 110 Ogle on absence of the uvula, 256 ; on anosmia, 874, 875 ; on aphasia from snake- bite, 874 ; on longevity, 366 ; on a stick in the rectum, 647 O'Hara on injury to the spinal cord, 681 Ohmann-Dumesnil on ainhum, 830 (Fig.) ; on nose-making, 561 Oke on ischuria, 793 Olfactory lobes, absence of, 246, 403 Olier on twin pregnancy after ovariotomy, 45 Oliver on accidental extraction of the lens, 533 Ollsner on diphallic monster, 195 Olmstead on lightning-stroke, 726 O'Neill on hermaphroditism, 211 ; on nico- tin-poisoning ; on a pot on the head, 587 Operations on conjoined twins, 172 ; during pregnancy, 103 ; repeated, 707 ; self-per- INDEX. 957 formed, 131, 708, 732 ; on the young and old, 706 Opium, tolerance of, and untoward action of, 505 Opium-eating, 506 Opport on fetomancy, 214 Orbit, epithelioma of, 772 ; foreign bodies in, 531 ; gunshot injuries of, 529; inju- ries of, 528 Ord on anomaly of the Mullerian ducts, 295 ; on myxedema, 807 Orissa Sisters, 171 Or 1 off, 603 Orman, James, 724 Ormancey on anomalous growth of nails, 588 Ormerod on hyperthermy, 422 Orton on telegony, 89 Orwin on self-mutilation, 734 Osiander on antepartum crying, 128 ; on birth during sleep, 114; on protracted pregnancy, 69 ; on venesection, 709 Osier on anorexia nervosa, 414 ; on dilata- tion of the colon, 287 ; on filaria sangui- nis hominis, 820 ; on hemophilia, 815 ; on hypertrophy of the heart, 626 ; on spo- radic cretinism, 806 ; on tuberculosis, 913 ; on yellow fever, 910 Ossicles, anomalous, 263 "Ossified man," 787 Osteitis deformans, 603 Osteoarthropathy, pneumonic, 805 Osteomalacia, 600 Osteosarcoma, 772 Ostmann on postmortem birth, 127 Oswald on wolf-children, 445 Otis on arrow-wounds, 710; on rupture of the lung, 609 Otte on ovarian hernia, 310 Otto on enlarged clitoris, 308 Ottolengni on teeth-replantation, 728 Oudet on edentula, 244 Ovariotomy in aged women, 707 ; cere- monial, 755 ; in children, 79, 706 ; dur- ing pregnancy, 104 ; menstruation after, 26 Ovary, absence of the, 309 ; cysts of the, 782 ; hernia of the, 310 ; separation of the, 689 ; supernumerary, 310 Overton on idiosyncrasy to wheat flour, 492 ; on spontaneous human combustion, 427 Owen on longevity, 366 ; on maternal im- pression, 84 Owens on ovariotomy in old age, 707 Oxalic acid, tolerance of, 499 P. Packard on centipede in the nostril, 564 ; on combined fetation, 57 ; on foreign body in the appendix, 642 Paddock ou quintuplets, 150 Paget on colored saliva, 383 ; on lightning- stroke, 723 ; on osteitis deformans, 603 ; on teeth in the larynx, 582 ; on vicarious menstruation, 24 Pain, births without, 113; endurance of, 475 ; morbid desire for, 480 ; sexual enjoymeut from, 480 ; relation of shock to, 480 ; supersensitiveness to, 480 Palate, anomalies of the, 256 ; artificial, 256 Palfrey on birth during sleep, 114 Palmer on pregnancy with unruptured hymen, 42 Palmus, 855 Pamo, Gomez, on prolonged lactation, 394 Pancoast on horns, 226 ; on Millie-Christine, 179 Pancreas, anomalies of the, 291 Pantophobia, 880 Paracelsus on the dancing mania, 854, 855 Paramyoclonus multiplex, 859 Paraplegia, delivery during, 116 Parasites, human, 818 Parasitic terata, 1*9 Pare on an armless man, 265 ; on cardiac injury, 617 ; ou cranial fractures, 559 ; on a dog-boy, 162 ; on double hermaph- rodities, 165 ; ou false tongue, 566 ; on hermaphroditism, 206; on ischiopagi, 181; on knife-swallowing, 635 ; on a legless boy, 266; on maternal impres- sions, 82 ; on a monster, 164 ; on multi- ple birth, 154 ; on parasitic terata, 190; on perverted appetites in pregnancy, 80 ; on prolificity, 146 ; on quintuplets, 150 ; on supernumerary limbs, 270 ; ou teratol- ogy, 164 ; on a three-headed sheep, 166 ; on vicarious menstruation, 20 ; on worms in a fetus, 112 Pareira on arsenic, 500 Park on hypertrophy of the digits, 276 ; on rupture of the sciatic nerve, 592 Parker on foreign body in the nose, 564 ; on hiccough, 813 ; on nose-making, 562 Parosmia, 875 Parr, Thomas, 373 Parravini on Cesarean section, 130 Parrot on vicarious menstruation, 18, 19 ; on high falls, 704 Parry on protracted menstruation, 32 ; on a viable ectopic fetus, 57 Parsley, idiosyncrasy to, 491 Parsons on pregnancy after ovariotomy, 46 ; on superfetation, 48 Parsons, Walter, 329 Partridge on cryptorchids, 321 ; on elephan- tiasis of the scrotum, 801 ; on gangrene of the penis, 082 ; on rupture of the tri- ceps tendon, 593 Parturition, difficulties of, 113 ; painless, 113 ; rapid, 116 Parvin on maternal impressions, 84 ; on a "turtle man," 267; on viable ectopic fetus, 57 ; on vicarious menstruation, 27 Paschal on protracted pregnancy, 70 Pastorello on defect of the skin, 217 Pastrana, Julia, 229 Paternal impressions, 8^> Paternity, possibilities of, 157 Paterson on hernia of the stomach, 287 Patterson on anomalies of the gall-bladder, 290 ; on self-performed operations, 709 Patzki on wound of the liver, 654 Paull on amazia, 297 958 IN Paullini on anomalous urine, 383 ; on in- fantile beard, 228 ; on vicarious menstrua- tion, 24, 27 Paw on fissure of the sternum, 282 Payne on anomalous vaginal opening, 306 ; on delivery by the rectum, 120 Pea sprouting in the nose, 564 Peabody on arrow-wound, 712 Pean on splenectomy, 657 Pearl-divers, 515 Pears on absence of the ovaries, 309 Pearse on foreign body in the vagina, 694 Pearson on child-bearing after the meno- pause, 29 Pechlin on painless births, 113 ; on venesec- tion, 709 ; on vicarious menstruation, 25 Peck on delivery of ectopic fetus, 53 Pedestrians, 458 ; long-distance, 459 de Pedro, Martin, on triple monster, 167 Peebles on ischuria, 793 Peenash, 822 Peej)les on precocious menstruation, 30 Pelargus on abortion, 110 Pelvic organs, accidental extraction of the, 139 Pelvis, foreign body in the, 678 Peuada on infantile menstruation, 29 Peney on infibulation, 753 Penis, absence of, 314 ; amputation of, 680 ; self-performed, 732 ; artificial, 318 ; avul- sion of, 680, 686 ; bitten off, 680 ; double, 194 ; fracture of, 679 ; gangrene of, 682 ; gunshot wound of, 681 ; injuries to, 679, 680; large, 31(5; long-continued erection of, 683 ; luxation of, 681 ; ossification of, 316 ; regeneration of, 082 ; retraction of, 681 ; rudimentary, 314 ; torsion of, 316 ; palme, 316 Penrose on anomalies of the ureter, 294 ; on excision of the ureter, 669 "Pepin," 263 Pepper on orbital injury, 529 Pepys on the black death, 896 Percy on depraved appetite, 411 ; on ossi- fied men, 787 ; on deformity of the penis, 44 ; on polymazia, 300 ; on vitality of spermatozoa, 40 Percy and Laurent on merycism, 862 ; on nostalgia, 876 Perfect on delayed menstruation, 33 Pericardium, injury to the, 623 Periesophagitis from foreign bodies, 571 Perineum, birth through the, 121 Peritonitis in the thorax, 613 Perrin on foreign bodies in the glottis, 583 ; on injury to the bladder, 672 Pershing on acromegaly, 803 Perspiration, anomalous, 385 ; postmortem, 523 Perverted appetites, 405; in pregnant women, 80 Pessaries, long retention of, 693 Pestonji on neuropathic plica, 849 Peter on foreign body in the brain, 561 Peterman on colored saliva, 383 Peters on quinin, 509 Petersen on protracted menstruation, 33 Petrequin on gynecomazia, 395 Petrifaction, 788 Petritus on quintuplets, 150 Petrone on bloody sweat. 391 Pettigrew on the '' biped-armadillo," 823 Petty on triplets, 148 Pettyjohn on teeth-replantation, 728 Peuch on polymazia, 299 Pfau on twin birth, 142 Phares on multiple fractures, 700 Pharynx, foreign bodies in the, 570 Phenol, poisoning by, 498 Philib on adhesions of the tongue, 255 Philipeaux on fetus iu fetu, 200 Philipson on hyperthermy, 422 Philippart on precocious pregnancy, 37 Phillips on absence of the uterus, 311 ; on hermaphroditism, 311 ; on lithotomy during pregnancy, 106 Phobophobia, 880 ' Phosphorescent anomalies, 429 Phosphorus, poisoning by, 508 Physicians, longevity among, 380 Physiologic and functional anomalies, 383 Pica, 412 Picardet on urethral anomaly, 318 Picat on obesity, 355 Pick on horn of the penis, 225 Pierce on fasting, 419 Pigne on delivery by a bull-horn, 133 ; on double brain, 249 Pignot on twin parturition, 142 Pig-tail in the rectum, 645 Pike on foreign bodies in the hand, 599 Pilcher on amazia, 297 ; on removal of the breast during pregnancy, 105 Pilocarpin, untoward action of, 508 Pirn on hernia, 665 Pinard on ectopic gestation, 58 ; on post- mortem birth, 124 Pinart on twin birth, 142 Pincott ou twin birth, 143 Pineal gland, calculus in the, 792 Pinel on the effects of cold, 430 ; on male menstruation, 28 Pinkerton on avulsion of the thumb, 590 Pins, pricks of, causing death, 737 ; self- mutilation with, 7555 ; swallowed, 736 ; wanderings of, in the body, 736 Pippingskbld on conception after ovariot- omy, 46 Pisciculture, 44 Pityriasis nigra, 841 Placenta, passages of drugs through the, 98; previa, 108 Plagues, 891 ; chronologic table of, 898 ; in London, 895 Plancus on supernumerary leg, 269 Playfair on cardiac anomaly, 269 ; on post- mortem Cesarean section, 136 ; on uterine decidua, 109 Plemons, Rosa Lee, 364 Plexiform neuroma, 770 Plica polonica, 848 Pliny on Cesarean section, 128 ; on fecun- dity in the old, 38 ; on giants, 324 ; on longevity, 377 ; on menstrual supersti- tions, 17 ; on quintuplets, 150 ; on short pregnancy, 65 ; on superfetation, 46 ; on twelve children at a birth, 147 Plocquet on injury during pregnancy, 98 INDEX. 959 Plot on longevity, 377 ; on maternal im- pressions, 82 Plutarch on monsters, 163 Pneumonectomy, 608 Pneumonia in the fetus, 91 Pode on fibroma molluscum, 762 Poisoned arrows, 711 Poisonings, untoward, 496 Pollailon on avulsion of the finger, 589 ; on conception after ovariotomy, 46 ; on ovariotomy during pregnancy, 104 ; on orbital injury, 529 ; ou removal of the breast during pregnancy, 105 Poland on knife-swallowing, 635 ; on rup- ture of the ureter, 668 Pole on ascaris lumbricoides, 819 Politzer on acanthosis nigricans, 841 ; on dermoids, 205 Pollock on rupture of the lung, 609 Polydactylism, 273 Polydipsia, 404 ; in pregnancy, 80 Polymazia, 298 Polyorchids, 320 Polyphagia, 411, 632-642 Poncet on coitus, 512 Pooley on stigmata, 389 Pope on lead-poisoning, 503 Popoff on ectopia of the testicle, 688 Porak on placental absorption, 93 "Porcupine-man," 823 Porro on anomalous esophagus, 284 Portal on hair on the tongue, 256 ; on rup- ture of the spleen, 656 Posey on coloboma, 260 Pospichilli, Joseph, 467 Post on menstruation during pregnancy, 29 ; on small infant, 348 ; on vicarious men- struation,25 ; on wound of the bladder, 672 Postmortem anomalies, 522 ; births, 124 ; Cesarean section, 135 ; delivery, 123 ; growth of hair and nails, 523 ; menstrua- tion, 27 ; movements, 522 ; sweat, 391 Pot on the head, 587 Potovski on pseudoacromegaly, 805; on ovariotomy during pregnancy, 104 ; on the principal plagues, 898 Potter on suture of the liver, 652; on wound of the diaphragm, 613 Pouch iu the larynx of criminals, 585 Poulet on foreign bodies in the bladder, 677 ; in the ear, 541 ; in the esophagus, 572 ; in the rectum, 646 ; in the vagina, 694 Povall on submersion, 531 Powell on scalp-injury, 545 Powers and White on excision of the larynx, 584 Pozzi on hermaphroditism, 211 Prankard on polyorchism, 320 Precocious development, 343; impregna- tion, 34 ; menstruation, 29 Pregnancy, accidents during, 98-103 ; co- existence of, with extensive tumors of the uterus, 106 ; combined extrauterine and uterine, 54 ; in a double uterus, 311 ; extrauterine, 50 ; imaginary, 73 ; injuries during, 98 ; long, 59 ; operations during, 103 ; after ovariotomy, 45 ; short, 65 ; unconscious, 72 Preismann on odors after coitus, 399 Premature births, 65 ; burial, 519 Prenatal anomalies, 50 Prentiss on ergot, 503 ; on pilocarpin, 508; on sudden canities, 237 Preputial calculi, 791 Presentiment of death, 889 Preston on skiu-shedding, 832 Preville, Adelaide, 210 Priapism, 683 ; in leukemia, 684 ; postmor- tem, 523 ; theories of long-continued, 684 Price on rupture of the kidney, 667 Prichard on albinism, 221 Prideaux ou precocious menstruation, 31 Primperosius on retention of ectopic fetus, 62 " Princess Topaze," 343 Prochaska on cannibalism, 410 ; on vesical fusion, 295 Prognathism, 252 Progressive muscular atrophy, 859 Prolapse of the pelvic organs, 139 ; of the uterus in labor, 140 Prolificity, 144; animal, 160; climatic and racial influences on, 145 ; experiment in, 158 ; by single births, 157 ; general his- toric observations relative to, 144 ; gen- eral law and influence of war on, 145 ; legal encouragement of, 146 ; old explana- tion of, 146 ; old records of great, 147 Proudfoot on intrauterine fracture, 97 Proust on double consciousness, 886 Prowse on impalement, 650 Prowzowsky on injury during pregnancy, 101 Prudden on neuromata, 770 Pruner-Bey on the odor of negroes, 399 Prussic acid, tolerance of, 499 Pryor on a precocious boy, 346 Pseudocyesis, 73 ; case of Queen Mary, 77 Puech on multiple births, 155 ; on postmor- tem Cesarean section, 136 Pulse, suspension of the, 516 Pupils, anomalous, 259 Purcell on double uterus, 311 ; on injury during pregnancy, 99 Purdon on chromidrosis, 385 Purple on cardiac injuries, 620, 622 Purser on double gall-bladder, 290 Putnam on nosencephaly, 246 ; on pseudo- cyesis, 78 Putrefaction, retardation of, 523 Pye-Smith on aneurysm, 779 Pygmalion, a modern, 882 Pygmy people, 333 Pygopagous twins, 174 Pyle on ainhum, 829 ; on laminectomy, 661 ; on morphin-poisoning, 506 ; on rup- ture of the lung, 609 Pyloroplastv, 644 Pyrophobia, 880 Q. Quadriceps tendon, rupture of, 593 Quadruplets, 148 Queen Mary, case of, 77 Queen on brain-injury, 548 960 INDEX. Quinan on vaccination, 907 Quinin, idiosyncrasy to, 509 Quintuplets, 150 ; repeated, 150, 154 Quirke on fetal variola, 90 R. Rabies, 719 Rachitis, 601 Radica-Doddica, 171 Raggi on claustrophobia, 878 Ragozin on fetomancy, 213 Rains on premature rupture of the fetal membranes, 108 Rake on ascarides, 820 ; on circumcision, 755 Ramsbotham on combined fetation, 55 Ramsey on eventration, 292 Ramskill on unilateral sweating, 387 Randall on cardiac injury, 618 Ranney on hiccough, 813 ; on ovarian cyst, 783 Raspail on lightning-stroke, 727 Rause on precocious menstruation, 31 Raux-Tripier on protracted pregnancy, 71 Raven on retraction of the penis, 681 Rawdon on dwarf, 341 Rayer on accidental growth of hair, 235 ; on alopecia, 228 ; on canities, 236 ; on elephantiasis arabum, 798 ; on elephanti- asis of the breast, 800 ; on excessive den- tition, 244 ; on hirsuties, 232 ; on human odor, 399 ; on long hair, 234 ; on neurosis of the skin, 838 ; on nigrities, 842 ; on the "porcupine-man," 823 Rayman on male menstruation, 28 Raymond and Vulpian on sudden canities, 236 Raynaud's disease, 836 Reamy on cystotomy during pregnancy, 105 Recamier, Madame, 304 Rectum, birth by the, 120 ; foreign bodies in the, 045 Redard on skin-grafting, 729 Reed on transplantation of the ureter, 669 Reichel and Anderson on parasitic terata, 189 Reid on protracted pregnancy. 70 Reifsnyder on ovarian cyst, 783 Rein on operation during pregnancy, 105; on ovariotomy in children, 707 Reiss on postmortem birth, 125 Remy on profuse lactation, 394 Renal vessels, absence of the, 668 Renauldin on small penis, 314 Resnikoff on protracted pregnancy, 71 Reta on birth by the rectum, 120 Retention of extrauterine fetus, 62 ; of uter- ine fetus, 63 Retina, hemophilic purpura of the, 816 ; injuries to the, from lights, 537 Reutber on injury during pregnancy, 98 Reverdin on scalp-injury, 543; on skin- grafting, 731 Revolat on constipation, 794 Rey on anal operation during pregnancy, i05 a Reyes on abortion by the mouth, 52 Reyssie on exophthalmos, 527 Rhades on unconscious pregnancy, 73 Rheumatic affection of ihe testicles, (588 Rhinolith, 564 Rhinophyiua. 561, 563 Rhodiginus on double hermaphrodite, 165 ; on monster, 163, 164 ; on precocious boys, 344 Rhodius on anomalous sweat, 385 ; on horns, 222 ; on vicarious menstruation, 24 Ribes on face injuries, 585 Ribs, anomalies of the, 281 Rice, idiosyncrasy to, 491 Rice on brain injury, 550 ; on early concep- tion alter labor, 46 ; on large infant, 349 Richard on injury during pregnancy, 100 Richards on self-mutilation, 733 Richardson on aural anomaly, 2(51 ; on brain-injury, 549 ; on fasting, 419 ; on hyperidrosis, 387 ; on injury during preg- nancy, 98 ; on postmortem perspiration, 522 Ricbeborg, 340 Richelot on mottled hair, 238 Richter on postmortem birth, 126 ; on vicari- ous menstruation, 20 Rickets, 601 ; fetal, 602 Ricketts on skin-grafting, 730 Rider on foreign bodies in the eye, 532 Riders, 460 Rieken on opium, 505 Riker on anomaly of the nose, 252 Riolan on absence of the hair, 228 ; on conception with the hymen intact, 40 ; on defective nymphae, 306 ; on hermaphro- ditism, 207 Ritta-Christina, 184 Riverius on worms in the bladder, 676 Robb on double vagina, 305 Robbins on sexual desire after castration, 687 Robert on gynecomazia, 395 ; on polymazia, 302 ; on supernumerary mammae, 301 Roberts on cardiac injury, 618 ; on polypus in a pregnant womb, 106 Robertson on precocious pregnancy, 37 Robson on removal of the breast during pregnancy, 105 Rockwell on multiple births, 155 Rocquefort on longevity, 374 Rodbard on expulsion of ectopic fetus, 53 Rode on foreign body in the urethra, 678 Rodenbaugh on a bean sprouting in the bowel, 641 Rodenstein on ovarian cyst, 783 Rodet on obstetric customs, 113 Rodgers on skin-grafting, 729 Rodrigue on intrauterine fracture, 97 Rodrigues on fetus in fetu, 202 Rodsewitch on delayed menstruation, 33 Roe on conception with imperforate uterus, 41 ; on double voice, 257 Roellinger, Jacques, 698 Roger of Wendover on double monster, 184 Rogers on enlarged clitoris, 309 ; on evis- ceration, 651 ; on fetus iu fetu, 201 Rogowicz on postmortem birth, 124 Rohan, family of, 239 INDEX. 961 Rohe on cholera, 908 ; on inoculation, 905 ; on small-pox, 904 Rolfinkius on postmortem birth, 125 Romme on wounds of the liver, 653 Rongier on impregnation with hymen integ- rum, 40 Rooker on spontaneous amputation, 598 Roosa on a kiss in the ear causing deafness, 537 ; on rupture of the tympanum, 538 ; on sudden deafness, 538 Rootes on birth in the membranes, 123 Rope-walkers, 449 Rosa-Josepha Blazek, 179 Rosary (220 cm. long) swallowed, 638 Rosenberg on repeated Cesarean section, 130 Rosenbladt on vicarious menstruation, 26 Rosenthal on benzin-poisoning, 501 Ross on extrauterine gestation, 51 ; on in- jury during coitus, 692 ; on pregnancy in double uterus, 49 ; on transfixion of the abdomen, 648 ; on triplets, 148 Rosse on cbemic coloration of the hair, 241; on postmortem growth of the hair, 523 Rosset on combined fetation, 56 Rossi on anomalous vaginal opening, 306 Rossow Brothers, 343 Rostan on gangrene of the penis, 682 Rouhout on anomalies of the nails, 241 Ronsseleton " dance of the eggs," 452 Rousset on menstruation during pregnancy, 29 Routh on short pregnancy, 66 Rouxeau on vicarious menstruation, 20 Rowland on hiccough, 812 Rowlett on precocious pregnancy, 36 Roy on death from laughter, 524 ; on extra- oral dentition, 245 Rudbeck on prolificity, 146 Ruddock on lung injury, 611 Rudolph on dry births, 123 Rueff on ischiopagus, 181 ; on monster, 163 Ruelle on precocious boy, 345 Rumination in man, 862 Rundle on anomalous bullet-injury, 652 Ruuge on merycism, 863 Runners, Indian, 457 ; physiology of, 461 Running, 455 ; influence of the spleen on, 461 ; modern records of, 459 Rupture, 662 ; of the abdominal walls from coughing, 666 ; premature of the fetal membranes, 108 ; of the uterus during pregnancy, 137 Rush on fecundity in the old, 39 ; on twin- sympathy, 887 Russ on aphasia from snake-bite, 874 Russell ou amputation during pregnancy, 105 ; on anomalous position of the tes- ticles, 322 ; on aspiration during preg- nancy, 105 ; on ischuria, 794 ; on poly- orchids, 321, 420 Ruttel on precocious pregnancy, 35; on short pregnancy, 66 Ruysch on superfetation, 47 Ryan on protracted menstruation, 32 Rydygier on celiotomy during pregnancy, 104 61 s. Sabatier on foreign body in the ear, 539 Sachse on injury during pregnancy, 98 Saillant on anomalous nails, 242 St. Braun, Cesarean section ou a dwarf, 129 Saint-Foix on tickling to death, 524 St. Martin, Alexis, 630 de Saint-Moulin ou menstruation during pregnancy, 29 St. Vitus' dance, 853 "Salamanders," human, 424 Sale on a case of cut-throat, 574 Salicylic acid, untoward action of, 499 Saliva, colored, 383 Salivary calculi, 792 Salmon, Dr. W. R., 380 Salmuth on abortion by the mouth, 52 ; on elephantiasis of the breast, 800 ; on extra- uterine pregnancy, 50 ; on male menstrua- tion, 28 ; on migratory menstruation, 27 ; on vicarious menstruation, 26 Saltatoric spasm, 859 Salter ou leanness, 364 Salzer on priapism, 684 Samelson on delivery during sleep, 115 "Samson," 463, 465, 467 Samter on opium-eating, 507 Sanders on separation of the symphysis pubis, 141 Sandifort on double aorta, 286 ; on super- numerary kidney, 293 Sandow, Eugene, 467 Sands on horns, 224 ; on self-mutilation, 733 Sangalli on supernumerary penis, 198 Sanger on double vagina, 305 ; on triple ectopic gestation, 57 Sangster on dermoids, 205 Sankey on anomalous suicides, 743 Santorini on protracted pregnancy, 70 Santos, dos, Jean Baptista, 196 Sarcocele, 689 Sarcomata, 772; pigmentosum diffusnm multiplex, 772 Sargent on thoracic peritonitis, 613 Saucerotte on cardiac injuries, 617 Saulquin on absence of the tongue, 245 Saunderson, 439 Saunois on supernumerary mamma, 301 Saviard on anencephaly, 246 ; on fetus in an umbilical abscess, 122 ; on super- numerary digits, 274 Savill on epidemic exfoliative dermatitis,836 Savitzky on gynecomazia, 395 Savonarola on precocious pregnancy, 35 Saxo on giants, 325 Scalp, abnormal development of, 222 ; ele- phantiasis of, 798 ; injuries of, 542 Scalping, 747 Scanzoni on amazia, 297 Scars, exhibition of, 745 Scatologic rites, 406 Schacher on superfetation, 47 Schaeffer on hypertrophy of the breast, 760 ; on scalp-injury, 543 Schauf hausen on dwarfs, 337 Schauta on exostosis on the sacrum, 138 ; on the symphysis, 141 962 INDEX. Scbede on alopecia, 227 Scheidemautel on perverted appetite in pregnancy, 80 Schell on gunshot wound of the abdomen, 651 Schenck on absence of the liver, 290 ; on canities, 238 ; on elephantiasis of the face, 800 ; on parasitic terata, 189 ; on postmortem birth, 126 ; on superfetation, 46 ; on vicarious menstruation, 20 Scherer on supernumerary digits, 275 Schlegel on albinism, 220 Schleiser on rupture of the spermatic arteries, 689 Schmidt on precocious menstruation, 30 ; on precocious pregnancy, 35 Schmidtmuller on rupture of the esopha- gus, 628 Schmiegelow on foreign body in the ear, 542 Schneider on electric anomaly, 429 ; on paternal impression, 85 ; on protracted pregnancy, 70 Schobinger on tongue-swallowing, 565 Schoepl'er on fecundity in the old, 39 Schott on bearded women, 299 Schrader on spontaneous human combus- tion, 427 Schreiber on rupture of the uterus, 137 Sehrell on hermaphroditism, 209 Schrumpf on penis palme, 316 Schuh on abortion in twin pregnancy, 111 Schultze on delivery during sleep, 115 Schulz on naevus pilosus, 233 Schurig on birth in the membranes, 122 ; on black menstruation, 27 ; on concep- tion during sleep, 45 ; on deficiency of the funis, 109 ; on spontaneous human combustion, 427 Schutz on regeneration of the penis, 682 Schwammerdam on pisciculture, 43 Schweinfurth on pygmies, 334 Schwimmer on universal sarcomata, 772 Sciatic nerve, injuries to the, 592 Scibelli on triple bladder, 295 Scleroderma, diffuse, 826 ; neonatorum, 826 Scoliosis, 281 Scott on delivery by cow-horn, 134 ; on small infant, 348 Scottish Brothers, 184 "Scourge of St. Kilda," 817 Scrotum, anomalies of the, 321 ; avulsion of the, 686 ; elephantiasis of the, 800 ; injuries to the, 685 Scull on protracted sleep, 868 Scurvy, infantile, 817 Second-sight, 535 Secretions, anomalies of the, 383 Sedgwick on absence of the uterus, 311 ; on albinism, 221 ; on congenital alopecia, 227 ; on telegony, 89 ; on urethral anom- alies, 31b Seguin on aphasia, 873 Seiffert on dermatolysis, 218 Seignette on multiple births, 153 Self-decapitation, 577 Self-mutilation, 731 Self-performed major operations, 131, 708 Seminal flow, anomalies of the, 384 Seminal vesicles, anomalous, 323 Semple on lactation in the aged, 393 ; on protracted menstruation, 32 Senn on dermoid cysts, 204 ; on extirpation of the thyroid, 702 ; on sarcoma, 772 ; on tumor of the thyroid, 761 Sennert on viable ectopic fetus, 57 ; on vi- carious menstruation. 25 Senses, renovation of the, in old age, 378 ; substitution of the, 432 Senter on anomalous urination, 384 Sercombe on artificial palate, 256 Sermon on sudden birth, 116 Serpieri and Baliva on self-performed Ccs arean section, 132 Serres on anencephaly, 246 Seurat, 364 Seven at a birth, 152 "Seven Sutherland Sisters," 234 Severinus on abortion, 110 Sewell on transfixion of the chest, 610 Sexdigitism, 275 Sextuplets, 152 Sexualism and hair-growth, 228 Shah on evisceration, 051 Shark-bite, 721 Sharkey on hyperidrosis, 387 Shattuck on ectopia vesicae, 295 Sheep, three-headed, 166 Shive-Maon family, 231 Shock, death from, 525 Shooting, 452 Short on obesity, 358 Shortt on sudden birth, 118 Siam. early menstruation in, 29 Siamese Twins, 168 Sibois on a fall during pregnancy, 101 Sigebert on multiple birth, 153 Sight, late restoration of, 535 ; idiosyncrasy through the sense of, 487 Silex on lightning blindness, 537 Simmons on conception with imperforate vagina, 41 ; on vesical calculus, 790 Simon de Roncbard on quinin, 510 Simpson on birth through the perineum, 122 ; on fetal therapeutics, 92 ; on in- trauterine amputation, 96 ; on neuroma of the vulva. 771 ; on telegony, 88 ; on vicarious menstruation, 20 ; on worms in the uterus, 111 Sims, Marion, on artificial impregnation, 43 Sinclair on a leech in the nose, 563 ; on self-mutilation, 734 Singultus, anomalous, 811 ; causing abor- tion, 110 Sippel on supernumerary ovary, 310 "Siren," 270 Skene on vicarious menstruation, 31 Skin, abnormal elasticity of, 217 ; anoma- lous pigmentation of, 841 ; congenital defect of, 221 ; fibromata of, 7(52 ; gan- grene of, 836 : impervious, 219 ; menstru- ation from, 18 ; neuroses of, 837 Skin-diseases, anomalous. 823 Skin-grafting, 728 : methods of, 731 Skin-shedding, 832 Skinner, Robert. 338, 340 I Skinner on strychnin, 510 INDEX. 963 Skippon on discharge of the fetal bones, 53 Skoptzies, 757 Skull, extensive fractures of the, 558 ; basal fractures of the, 559 ; injuries to the, 551 Skutsch on Ccsarian section, 130 Slee on foreign body iu the nose, 560 Slee man on wolf-children, 440 Sleep, delivery during, 114 ; protracted, 867 Sleep-sickness, 872 Sleep-walking, 863 Slevogt on injuries during pregnancy, 98 Sloane on giants, 327 ; on lactation in the aged, 393 Slocum on sternal fissure, 283 Slusser on birth in the membranes, 123 Small-pox, 903 ; fetal, 90 Smart on arrow-wounds, 712 Smell, idiosyncrasy through the sense of, 482 ; loss of the sense of, 874 ; supersensi- tiveness of, 398, 875 Smellie on superfetation, 48 Smetius on obesity, 358 Smith on armless monsters, 265 ; on bulimia, 403 ; on double penis, 198 ; on intrauter- ine fractures, 97 ; on large infants, 349 ; on a precocious boy, 344 ; on precocious impregnation, 38 ; on rupture of the uterus, 137 ; on sudden birth, 118 ; on superfetation, 48 Smith and Norwell on sexdigitism, 275 Sniyly on anomalous coloration of the hair, 240 ; on foreign body in the eye, 533 Snake-bites, 715 ; causing abortion, 110 ; aphasia from, 874 "Snake-boy," 835 Snakes swallowed, 636 Sneddon on gynecomazia, 396 ; on super- numerary mammae, 301 Sneezing, anomalous, 813; causing abor- tion, 110 ; in coitus, 511 Snell on foreign body in the eye, 532, 533 Snow on postmortem changes, 522 Snow-blindness, 537 Snyder on knife-blade in the chest, 614 Soiingen on abortion, 110 Solly on a case of cut-throat, 576 Somnambulism, 863; birth in, 116 Sonnenschein on phosphorus, 508 Sonnini on anomalous mons veneris, 308 Sorrow causing death, 524 Sourrouille on atresia of the mouth, 254 Souvray, Therese, 339 Spach," Israel, on extrauterine pregnancy, 50 Spaeth on injuries in coitus, 691, 692; on premature fetus, (58 Spallanzani on artificial impregnation, 43 Sparkman on early conception after labor, 46 Speech, loss of, 872 Spelling-book in the groin, 659 Spencer, Herbert, on ceremonial mutila- tions, 745 ; on telegony, 86, 88 Speranza on human odors, 400 Sperling on triplets. 148 Spermatic vessels, injuries of the, 689 Spermatophobia. 880 Spermatozoa, vitality of, 40 Speth on hypertrophy of the breast, 760 Sphaceloderma, 836 Spider-bite, 713 Spiegelberg on fibroid blocking the pelvis, 107 Spinal canal, anomalies of the, 280 Spinal cord, injuries of the, 661 Spindler on vicarious menstruation, 24 Spine, curvatures of, 281 ; fracture of, lower, 659 ; upper, 578 ; operations ou, 660 Spizharny on gastric fistula, 631 Spleen, anomalies of, 290 ; injuries of, 656 ; influence of, ou running, 461 ; laceration of, in pregnaucy, 103; large and small, (557 ; operations on, 657 ; rupture of, 656 ; during labor, 141 Splenectomy, 056 ; in malaria. 657 Spontaneous human combustion, 426 Squire on anomalous color of the hair, 240 ; on postmortem section, 136 Stahl on protracted pregnancy, 72 Stalkartt on injuries to the testicles, 685 Stallcup on precocious pregnancy, 37 Stalpart on delivery by a cannon-ball, 134 Stanley on intrauterine fracture, 97 Stapedius on postmortem births, 126 Staples on injury during pregnancy, 102 ; on pregnancy with stricture of the vagina, 42 Starkey on injuries of the vagina, 691 Starr on megalocephaly, 805 Staton on reunion of the hand, 588 Stature, anomalies of, 324 Steinam on paternal impression, 85 Steinhausen on ichthyosis, 823 Stelzner on cardiac injury, 622 Stengel on retention of the fetus, 64 Stepanoff on vicarious menstruation, 24 Stephens on horns, 226 Sternum, fissure of the, 282 Stevenson on hiccough, 812 Stewart on boxing the ears, 537 ; on fish in the pharynx, 568 ; on lightning-stroke, 724 Stigmata, 25, 388 Stings of insects, 713 Stoakley on precocious pregnancy, 37 Stockard on fibrocyst of the uterus, 781 Stoll on cardiac injury, 622 Stolz on repeated Cesarean section, 130 Stoker, Mannetta, 340 Stoker on quintuplets, 151 Stokes on displacement of the heart, 626 Stomach, anomalies of, 286 ; digestion of, 628 ; extirpation of, (544 ; hernia of, 286, 287 ; rupture of, 629 ; wounds of, 630 Stone-in-the-bladder, 788 Stone on avulsion of the finger, 589 ; on ovarian cyst, 783; on precocious boy, 345 ; on vaginal septa, 305 Stones in the rectum, 646. 648 Storck on painless birth, 113 Storer on retention of the fetus, 64 ; on vicarious menstruation, 26 Storrs on fracture of the femur, 594 Storry on ovariotomy during pregnancy, 104 Strabismus, 2(50 Strand on death from grief, 524 Strasberger on protracted menstruation, 33 Strength, extraordinary, 463 ; fraudulent, 964 INDEX. 470 ; in the hands, 470 ; in the jaws, 468 ; officially recorded feats of, 470 Stricture of the ureter, 669 ; of the urethra, 080 "Strongmen." 463 Strong on dry birth, 123 " Strong women," 408 Struma, 761 Struthers on double stomach, 280 Strychnin, idiosyncrasy to, and tolerance of, 510 Studley on fracture of the penis, 141 Studsgaard on foreign body in the rectum, 646, 647 Sturgis on syphilis, 913 Stute on absence of the funis, 109 Subclavian artery, -wound of, 627 Submersion, recovery after, 513 Succi, 420 Suckling on fear-psychoses, 877, 878 Suicides, anomalous, 742 Sulikowski on fetus in fetu, 201 Sullivan on anomalous effect of coitus, 511 Sulphuric acid, tolerance of, 499 Sulzberger on abortion, 110 Superfetation, 46 ; with different colored children, 48 Surgical anomalies of the extremities, 588 ; of the head and neck, 527 ; of the genito- urinary system, 667; of the thorax and abdomen, 606 Suspended animation, 513 ; pulse, 516 Sutton on monstrosity, 187 Swallowing foreign bodies, 637 ; live ani- mals, 636 ; swords, 633 ; the tongue, 565 Swain on brain-injury, 549 Swan on multiple birth, 155 Swann, Anna, 332, 3,49 Swayne on postmortem birth, 126 Sweat, anomalous, 385 ; cadaveric, 391 ; unilateral, 387 Sweating sickness, 896 ; mortality of, 897 van Swieten on bloody sweat, 390 ; on male menstruation, 28 ; on precocious menstruation, 30 ; on vicarious menstrua- tion, 19 Swimming, 461 Swingler on operation on a monster, 172 Sworder on lactation in infants, 392 Sword swallowing, 633 Sycyanko on lightning-stroke, 726 Sykes on cretinism, 805 Sym on albinism. 221 Symes on hiccough, 811 Symonds on skin-grafting, 730 Symphysiotomy, 141 Svmphvsis pubis, separation of, during labor, 140 Syphiliophobia, 879 Syphilis, 912 ; acquired in tattooing, 751 ; from a flea bite, 714 ; from a human bite, 719; haemorrhagica neonatorum, 816 Szigethy on foreign bodies in the vagina, 694 T. Tactile sense, perversion of the, 875 Tagert on brain injury, 557 Tails, human, 277 Tait on excision of the liver, 653 ; on pre- mature birth, (57 ; on rupture of the spleen, 656 ; on surgery of the lung, 608 ; ou uterine myoma, 781 ; on viable ectopic fetus, 57 ; on vicarious menstruation, 26 Takacs on unilateral sweat, 388 Talcott on protracted pregnancy, 70 Talicotian method, 561 Talipes, 276 Tamburini on acromegaly, 803 Tanner, Doctor, 420 Tanner on unconscious pregnancy, 72 Tansley on a diamond in the ear, 541 Tapeworms, 818 Tarantism, 854 Tarchanoff on music, 486 Tardieu on digitalis, 502 ; on extraction of the uterus, 139; on intestinal injury, 643 Tarcnta on fecundity in the old, 39 Tarnier ou postmortem Cesarean section, 136 ; on premature births, 68 ; on pro- tracted pregnancy, 71 ; on vicarious men- struation, 2(5 Tarrare, 411 " Tarred and feathered " persons, 743 Tartar emetic, untoward action of, 499 Taruffi on diphallic monster, 198 ; on tel- egony, 89 Tasker on unconscious preguancy, 72 Tatevosoff on hiccough, 813 Tattooing, 749 ; syphilis from, 751 ; tuber- culosis from, 751 Tauri-Mauri Indians. 457 Taussig on quinin, 510 Taylor on diphallic terata, 195 ; on foreign . body in the eye, 532 ; on hanging, 519 ; on human combustion, 426 ; on injuries to the vagina, 691 ; on nostalgia, 876 ; on protracted preguancy, 70 ; on short preg- nancy, 65; on sudden birth, 119; on suspended animation, 513 ; on venesec- tion, 709 Teale on hyperthermy, 422 Tears, anomalies of the, 384 Tecontjeff on varnishing the skin, 743 Tedford on separation of the ovary, 689 Teeth, absence of, 243 ; anomalies of, 242 ; at birth, 242 ; in the bronchus, 616 ; extraoral, 244 : knocking out, 747 ; re- plantation of, 728 ; supernumerary, 244 ; swallowed, 639 Telegony, 86 Temperature, anomalies of, 421 Temple on snake-bite. 717 Tenia, 818 Terata, classification of, 167 ; double her- maphroditic, 165 ; among the lower ani- mals, 166 ; major, 161 ; minor, 213 Teratogenesis, 166 Teratology, early, 164 ; scientific, 165 Teratoscopy, 213 Terrier on ovariotomy in age, 707 ; on sple- nectomy, 657 INDEX. 965 Terrilon on foreign body in the bladder, 677 ; on ligature of the liver, 654 Terry on elephantiasis of the hand, 798 Testa on postmortem menstruation, 27 Testicles, anomalies of, 319 ; anomalous po- sition of, 322 ; atrophy of, 687 ; avulsion of, 686 ; death from a blow on, 525 ; ectopia of, 688 ; injuries of, 685 ; inver- sion of, 323 ; operations on anomalous, 322 ; retraction of, 688 ; rheumatic affec- tion of, 688 Testut and Marcondes on anomalous lung, 285 Tetanus neonatorum, 817 Teufard on vicarious menstruation, 20 Thalassophobia, 877 Thanatophobia, 879 Thatcher on delivery by a cow-horn, 134 Thebault on sudden birth, 120 Thevenot on giants, 325 ; on postmortem births, 124 Thibaut de Chauvalon on fecundity in the old, 39 Thiernesse on combined fetation, 57 Thiersch on self-mutilation, 732; on skin- grafting, 731 Thigh, mamma on the, 301 Thilenius on twin birth, 142 Thimble in the nose, 565 Thin people, 363 Thirst, excessive, 404 ; lack of, 405 Thirteen children at a birth, 154 Thomas, Edith, 437 Thomas on a case of cut-throat, 577 ; on fetal dentition, 242 ; on fetal therapeutics, 92 Thomka on anomalies of the ossicles, 263 Thompson on bee-stings, 714 ; on cardiac injury, 618 ; on vesical calculi, 790 Thomson on achondroplasia, 002 ; on der- moid cyst, 202 ; on mycosis fungoides, 850 ; on thoracic defects, 284 Thoracic duct, wounds of the, 657 Thorax, defects of, 284 ; foreign bodies in, 613 ; injuries of, 606 ; transfixion of, 610 ; peritonitis in, 613 Thorburu on fetal therapeutics, 92 ; ou in- jury to the cervical vertebrae, 580 ; on laminectomy, 661 Thoresby on prolificity, 157 Thorington on the ocular instillation of atropine causing epileptic convulsions, 853 Thormeau on protracted pregnancy, 70 Thornton on canities, 238 ; on postmortem birth, 124 Three-headed monster, 167 Thudicum on brain-injury, 549 Thumb, supernumerary, 275 Thurman on alopecia, 227 Thurston on placenta pra?via, 108 Thyroid gland, extirpation of the, 762 ; tumors of the, 761 Thyroidectomy, 762 Thyroid-feeding in obesity, 356 Tichomiroff on absence of the lung, 285 Tickling to death, 524 Tidd on protracted pregnancy, 70 Tietze on plexiform neuro-fibroma, 771 Tiffany on injury during pregnancy, 100, 103; on operations during pregnancy, 104, 105 ; on sarcoma, 777 " Tigretier," 854 Tilanus on hemihypertrophy, 350 Tilesius on lightning-stroke, 726 Tillaux on cardiac injury, 621 Til let on heat, 425 Tinea nodosa, 849 Tinnitus aurium, objective, 538 Tissot on somnambulism, 864 Titorier on rupture of the intestines, 645 Tizzoni on splenectomy, 657 Tocci Brothers, 186 Toes, supernumerary, 273 Toft, Mary, 163 Tolberg on conception with hymen integ- rum, 41 Tolerance of drugs, -497 Tolifree on death from the wind of a can- non-ball, 526 "Tom Thumb," 342 Tomes on edentula, 243 Tomlinson on maggots in the nose, 564 Tommassini on constipation, 794 Tompsett on absence of the kidney, 293, on foreign body in the rectum, 646 Tongue, abnormal mobility of, 255 ; anky- losis of, 255 ; artificial, 566 ; bifid, 255 ; congenital absence of, 254 ; foreign body in, 566 ; hair on, 256 ; hemiatrophy of, 860; hypertrophy of, 566; injuries to, 565 ; large, 256 ; restitution of, 565; speech without a, 254, 566 ; supernumer- ary tongue, 255 Tongue-sucking, 565 Tongue-swallowing, 565 Tool-box in a convict's rectum, 647 Tooth in the larynx, 581, 582 ; in the nose, 244 (see Teeth) Tooth-brush swallowed, 640 ; -handle in the bladder, 677 Topham, Thomas, 465 Torreau on anomalies of the ossicles, 263 "Totemism," 494 Touch, idiosyncrasy through the sense of, 488 ; perversion of the sense of, 875 Tousey on foreign body in the arm, 600 Townsend on bloodless labor, 123 ; on vis- ceral hemorrhages in the new-born, 817 Tozzetti on ovarian cyst, 782 Trachea, foreign body in the, 580 ; wounds of the, 575 Tracheotomy tube in the bronchus, 615 Trance, 867 ; delivery during a, 114 Transfixion of the abdomen, 648 ; of the brain, 545 ; of the thorax, 610 Transposition of the viscera, 291 Traube on digitalis, 502 Travers on wound of the stomach, 632 Trazegines, family of, 154 Trelat on hemihypertrophy, 350 Tremaine on arrow-wounds, 712 Treves on the "elephant-man," 827 Triceps tendon, rupture of the, 593 ( Trichinosis, 820 Tricomi on ligature of the liver, 654 ; on splenectomy, 657 Trioen on inj ury to the crystalline lens, 533 966 INDEX. Tripe on priapism, 684 Triple dentition, 243 Triple ectopic section, 57 Triple monsters, 167 Triplets, 1 18 ; repeated, 146 Troisfontaines on gangrene of the penis, (582 Trompert on injury to the vagina, 690 Tubby on suppression of the digits, 273 Tuberculosis, 913 ; from tattooing, 751 Tucker on supernumerary legs. 269 Tuffier on pneumonectomy, 608 Tufnell on multiple fractures, 702 Tuke on protracted sleep, 808 ; on somnam- bulism, 865 Tulpius on anomalies of the nails, 241 ; on deficient urethra, 317 ; on obesity, 352 ; on perverted appetite of pregnancy, 80 Tumors, 759 ; coexisting with pregnancy, 106 Tupper on worms in the bladder, 676 Turnbull on ascarides in the ear, 820 "Turtle-man," 84, 267 "Turtle-woman," 2(57 Tweedie on conception with imperforate os uteri, 41 Twelve children at a birth, 154 Twiggs on tapeworm. 818 Twin pregnancy, abortion in, 110 Twins, 148 ; borne by aged women, 40 ; borne by a child-mother, 38 ; delivered by Cesarean section, 129 ; of different colors, 48 ; interval between the birth of, 142 ; morbid sympathy of, 887 Twitchell on sudden birth, 119 Two-headed animals, 166 "Two-headed Nightingale" (Millie-Chris- tine), 179 Tyler on exophthalmos, 527 Tympanum, anomalies of, 263 ; perforation of, 539 ; by ascarides, 820 ; rupture of, 537 Tynberg on a monster, 180 Typhus fever, 910 Tyson on multiple ureter, 294 u. Umbilical calculi, 792 Umbilical cord, anomalies of, 109 ; knots in, 109 Umbilical hernia, 662 Underbill on pseudocyesis, 78 Untoward action of drugs, 496 Ureter, anomalies of, 294 ; catheterization of, 670 ; operations on, 669 ; penetration of, 670 ; rupture of, 6(58, 669 ; stricture of, 669 ; transplantation of, 669 Ureterocystoneostomy, 669 Urethra, anomalies of, 317; calculus in, 791 ; duplication of. 317 ; foreign bodies in. 676 ; menstruation from male, 27 ; passage of excrement through, 675 ; rup- ture of, 079 ; slitting of, 754 ; stricture of, 680 Urination, anomalous, 383 Urine, retention and suppression of, 792 Urster, Barbara, 229 Usher on short pregnancy, 66 Uterus, absence of, 311 ; accidental extrac- tion of, 139 ; anomalous positions of, 313 ; bipartite, duplex, etc.. 311 ; double, 311 ; fibrocyst of, 781 ; foreign body in, 095 ; hernia of, 313 ; prolapse of! in labor, 140 ; rupture of, in pregnancy, 137 : tumors of, 780 ; successful removal of, without inter- rupting pregnancy, 106 Uvula, anomalies of, 256 V. Vaccination, 906 " Vagabond's disease," 941 Vagina, absence of, 303 ; anomalous open- ings of, 305; double, 304 : excrement from, 675 ; foreign bodies in, 692 ; injuries of, 689 ; sloughing of parietes of, 691 ; spontaneous rupture of, 138 ; transverse septa of, 305 Vale on twin births, 143 Valentini on abortion, 110; on conception during sleep, 45 ; on diphallic terata, 195 Valerian von Meister on regeneration of the liver. 655 Valerius Maximus on postmortem birth, 125 Vallentini on living cyclopia, 258 Vallisneri on anomalous urine, 383 ; on birth by the rectum, 121 ; on double uterus, 311 Valsalli on sextuplets, 152 Van Bibber on birth in the membranes, 123 ; on superfetation, 48 Van Buren on supernumerary liver, 290 Van Buren and Keyes on diphallic monster, 196 ; on elephantiasis of scrotum, 802 Van Cuyck on anomalous esophagus, 284 Van der Veer on precocious menstruation, 31 Van Dnyse on macrostoma, 253 Van Helmont on pygmies, 333 Van Owen on longevity, 375 Van Wy on dropsy, 786 Vanderpool on fracture of the odontoid pro- cess, 578 Vanderveer on intrauterine fracture, 97 Vanini on telegony, 89 Vanmeter on skin-grafting, 729 Vanzetti on preputial calculi, 791 Varicella in the fetus, 91 Varicose veins, 778 Variola, 903 ; in the fetus, 90 Variot on lactation in infants, 392 Varnishing the skin, 743 Vassilet, Fedor, 156 Veazie on fracture of the penis, 679 Veit on multiple births, 148 Velasquez of Tarentum on protracted men- struation, 33 Velpeau on diphallic monster, 196 ; on fetus in fetu, 201 ; on polyphagia, 638 Venesections, extensive, 709 Venette on polyorchism, 320 Ventriloquists, 453 ; in China, 454 Vepan on quinin, 509 Verdile on pregnancy with hymen integ- rum, 42 INDEX. 967 Verduc on injury during pregnancy, 98 ; on vicarious menstruation, 25 Verhucghe on avulsion of the eye, 527 Vermiform appendix, foreign body in the, 642 Verneuil on double monster, 317 Verondeu ou postmortem Cesarean section, 137 Verrier on traumatism in pregnancy, 101 Vertebrae, anomalies of the, 277 ; fracture of the lower, 659 ; of the upper, 578 ; transposition of the, 277 Vesalius on male menstruation, 28 Vesey on amputation during pregnancy, 105 Veslingius on postmortem birth, 126 Vespre on rupture of the uterus, 137 Vesti on abortion, 110 Vicarious menstruation, 18 ; in the male, 28 Vicat on bearded women, 228 Vicq d'Azir on absence of the vagina, 303 Victor on ascarides, 819 Vidal on fetal variola, 90 ; on horns, 224 Vieussens on hypertrophied liver, 655 Villemin on premature birth, 66, 67 Villerme on anomalous coloration of the hair, 240 ; on hirsuties, 23,3 Vincent on death from shock, 52(5 Vinuedge on multiple fractures, 702 Virchow on chondromata, 767 ; on hermaph- roditism, 210 ; on human tails, 278 ; on megalocephaly, 805; on microcephaly, 248 ; on neuro-fibroma, 770 Virey on a dwarf, 341 Viscera, inversion of the, 166 ; transposition of the, 291 Vite on cardiac injury, 619 Vocal bauds, web of the, 256 Vogel on avulsion of the finger, 589 Voice, double, 257 Voight on longevity, 374 ; on supernumer- ary digits, 274 ; on triple uterus, 313 Voigte ou horns, 224 Vomiting producing exophthalmos, 527; causing rupture of the esophagus, 028 ; of urine, 384 ; voluntary, 630 Von During on sclerodactylia annularis ain- humoides, 83,2 Von Langenbeck on phenol, 498 Von Mayr on prolificity, 145 Von Quast on tumor of the pregnant uterus, 107 Vos on presentiment of death, 890 Vosberg on vesical calculi, 790 Voss on foreign body in the ear, 542 Vulpius on splenectomy, 656 Vulva, deficient, 303 ; neuroma of the, 771 w. Wadham on aphasia, 873 Wagner on prolapse of the uterus, 140 ; on sudden birth, 117 Wagstaffe on horns, 22(5 Wainwright on injury during pregnancy, 102 Wakefulness, 863 Walford on longevity, 365 ; on multiple birth, 153, 155 ; on prolificity, 157 ; on spontaneous human combustion, 428 Walker on precocious pregnancy, 37 Wall on precocious menstruation, 30 Wallace on fecundity in the old, 39 ; on quadruple amputation, 597 ; on rupture of the abdominal parietes from coughing, 666 Waller, David, 492 Wallick, statistics of fetal pneumonia, 91 Walsh on arsenic, 500 Walter on postmortem Cesarean section, 137 Walters on accidental extraction of the pel- vic organs, 139 Walther on injury during pregnancy, 98 ; on retention of" the ectopic fetus, 63 Walton on urethral calculi, 791 Ward on dermoid cysts, 205 ; on rupture of the kidney, 668 Waring on rhinolith, 564 Warner on precocious menstruation, 30 ; on precocious pregnancy, 34; on super- numerary auricle, 261 Warren, Charles, 473 Warren on aneurysm, 779 ; on anomalous growth of bones, 605 ; on enchondroma, 768 ; on fracture of the spine, 659 ; on horns, 227 ; on hypertrophy of the breast, 760 ; on large infants, 348 ; on multiple births, 155; on " noli-me-tangere," 772; on orbital injury, 531 ; on tumors of the thyroid, 761 Warrington on self-mutilation, 735 Wart-grafting, 730 Washington on leg-injury, 593 Water-closet, birth in a, 120 Watering on multiple birth, 153 Watkins on death from shock, 525 ; on human combustion, 426 ; on retention of ectopic fetus, 63 Watson on fetal variola, 90 ; on foreign body in the orbit, 531 ; on rupture of the ure- thra, 679 ; on stricture of the ureter, 669 Webb, Captain, 461 Webb on aneurysm, 779 ; on maternal im- pression, 83 Webber on epilepsy, 852 Weber on anomalous seminal vesicles, 323 Wedders, Thomas, 253 Wegelin on postmortem birth, 124 Wehrle, Felix, 217 " Weichselzopf," 848 Weil on dermoid cyst, 204 Weill on delivery during sleep, 115 Weinlechner on intrauterine amputation, 94 Weismann on telegony, 86 Welch on hyperthermy, 423 Wells on dipygus, 194 ; on ovariotomy in age, 707 Wendt on fetus in fetu, 201 Wenyou on foreign body in the orbit, 530 Werder on ectopic fetus, 62 Werner on the funis, 109 West on multiple fractures, 702 ; on spora- dic cretinism, 807 Westergaard on multiple births, 147 968 INDEX. Westmoreland on multiple fractures, 701 Westphal on unusual birth, 120 Wctmore on injury during pregnancy, 100 Whaley on dipygus, 194 Wharton on foreign bodies in the brain, 501 ; on triple amputation, 597 Wheat flour, idiosyncrasy to, 492 Whinery ou combined fetation, ~>6 ; on rup- ture of the uterus, 137 White on chromidrosis, 386 ; on discharge of the fetal bones, 53 ; on fish in the pharynx, 5(58 ; on foreign body in the foot, 600 ; on foreign body in the intestines, 641 ; on laminectomy, 661 ; on syphilis, 913 ; on tapeworm, 818; on vicarious menstruation, 25 Whitehead on protracted menstruation, 32 ; on wound of the liver, 653 Whitelaw on ischuria, 793 Whiteside on foreign body in bladder, 677 Whitney on ectopic gestation, 54 Wierski, 329 Wight on superfetation, 49 Wilcox on double vagina, 305 Wildberg on twin birth, 142 '" Wild-boys," manufacture of, 448 " Wild-man," 232 Wilks on lightning-stroke, 725 Will on avulsion of the arm, 591 Willard on hiccough, 812 ; on infantile spinal paralysis, 604 Willett on gangrene of the penis, 682 Williams on alopecia, 227 ; on foreign body in the eye, 532 ; on obesity, 353 ; on pre- cocious pregnancy, 3.7 ; on rupture of the esophagus, (528 ; on tattooing, 752 ; on wound of the spleen, 656 Willoughby on birth in the membranes, 122 ; on postmortem births, 125 ; on sud- den birth, 116 Wilson on abortion in twin pregnancy, 111 ; on bloody sweat, 391 ; on brain-injury, 549 ; on . chromidrosis, 386 ; on ectopic gestation, 58 ; ou epistaxis, 534 ; on ec- topic fetus, 53 ; on gastrotomy, (538 ; on hair, 234 ; on horns, 223 ; on ischuria, 793 ; on precocious pregnancy, 37 ; on rudimentary penis, 315 ; on rupture of tympanum, 537 ; on sudden birth, 119 Wiltshire ou gynecomazia, 396 ; on rupture of the vagina, 138 Winckel's disease, 816 Winn on coitus, 511 Winslow on parasitic terata, 191 Winterbotham on foreign body in ear, 541 Winthier on merycism, 8(52 Woakes on "ear sneezing," 815 Wolf-children, 444 Wolff on antepartum crying, 128 Wolffius on precocious pregnancy, 35 Wolfius on postmortem birth, 126 Wblfler on tumors of the thyroid, 761 Wood on croton oil, 504 ; on ergotism, 502 ; on opium, 506 ; on premature rupture of fetal membranes, 108 ; on strychnin, 510 Woodbury on transfixion of the abdomen, 649 Woodman on oxalic acid, 499 ; on poly- mazia, 302 Woodruff on precocious menstruation, 31 Woods on precocious boys, 346 Woodson on inversion of the uterus, 140 ; on twins in the secundines, 123 Worbe on hermaphroditism, 208 Wordsworth on absence of the eyes, 257 ; on foreign bodies in the orbit, 531 Worms, 8i8 ; in the bladder, 676 ; in the ear, 538 ; in the fetus, 111, 112; in the heart, 24 ; in the nose, 563, 821; in the uterus, 111 Wrench on simulated symptoms, 583 Wright on epistaxis, 535 ; on rupture of the heart, (525 Wrisberg on birth in the membranes, 122 Wroe on horns, 222 Wnlf on obesity, 353 Wunderlich on hyperthermy, 422 Wunschheim on rupture of the stomach, 629 Wygodzky on coiling of the funis, 96 Wyman on terata, 166 Wynter on longevity, 379 X. Xeroderma pigmentosum, 842 Y. Yale on pregnancy with unruptured hymen, 42 Yarrow on poisonous snakes, 715 Yavorski on morphin, 506 Yaws, 839 Yellow fever, 910 Yellowlees on somnambulism, 866 Yonge on chromidrosis, 386 Youmans on telegony, 88 Young on fetus in fetu, 200, on injury to the pericardium, 624 ; on superfetation, 48 ; on transposition of the viscera, 291 Ysabeau on late dentition, 243 "Yung-ti" sheep, 261 Z. Zacchias on conception with hymen intact, 40 ; on protracted pregnancy, 68 Zacutus Lusitanus on chromidrosis, 3,85 ; on horns, 222 ; on a leech in the nose, 563 ; on male menstruation, 28 ; on pri- apism, 683 ; on torsion of the penis, 316 ; on vicarious menstruation, 25, 26 Zarete, Lucia, 343 Zeidler on wound of the liver, 653 Zesas on gastrostomy, 644 Zeuner on pedestrianism, 459 Ziemssen on naevus pilosus, 233 Zillner on wound of the aorta, 626 Zoophobia, 880 Zuboldie on delivery by a cattle-horn, 133 Zuccarelli on splenectomy, 657 Zuhmeister on foreign body in uterus, 695 Zweifel on repeated Cesarean section, 130 ; on symphysiotomy, 141 «." 8: © P3 I 8 H PUBLISHED BY W. g. gaunder^, 925 Walnut $b>eet, aP^iladel^ia. MR. SAUNDERS, in presenting to the profession the fol- lowing list of publications, begs to state that the aim has been to make them worthy of the confidence of medical book-buyers by the high standard of authorship and by the excellence of typography, paper, printing, and binding. The works indicated in the Index (see next page) with an asterisk (*) are sold by subscription {not by booksellers\ usually through travelling solicitors, but they can be ob- tained direct from the office of publication (charges of ship- ment prepaid) by remitting the quoted prices. Full descrip- tive circulars of such works will be sent to any address upon application. All the other books advertised in this catalogue are commonly for sale by booksellers in all parts of the United States; but any book will be sent by the publisher to any address (post-paid) on receipt of the price herein given. CONTENTS. Anatomy. page Haynes, Manual of Anatomy.........24 Nancrede, Anatomy and Manual of Dissection . 16 Nancrede, Essentials of Anatomy........26 Bacteriology. Ball, Essentials of Bacteriology.........26 Frothingham, Laboratory Guide........20 McFarland, Text-Book of Pathogenic Bacteria . 13 Botany. Bastin, Laboratory Exercises in Botany.....20 Chemistry and Physics. Brockway, Essentials of Physics........26 Wolff, Essentials of Chemistry.........26 Children. *An American Text-Book of Dis'eases of Children 8 Griffith, Care of the Baby............21 Powell, Essentials of Diseases of Children ... 26 Clinical Charts, Diet, and Diet Lists. Hart, Diet in Sickness and in Health......22 Keen, Operation Blank.............19 Laine, Temperature Chart............16 Meigs, Feeding in Early Infancy........14 Starr, Diets for Infants and Children......22 Thomas, Detachable Diet Lists, etc........22 Diagnosis. Cohen and Eshner, Essentials of Diagnosis ... 26 MacDonald, Surgical Diagnosis and Treatment. 27 ♦Vierordt and Stuart, Medical Diagnosis .... 12 Dictionaries, *Keating and Hamilton, New Pronouncing Dic- tionary of Medicine.............12 Morten, Nurses' Dictionary of Medical Terms . 22 Saunders' Pocket Medical "Lexicon.......17 Saunders' Pocket Medical Formulary......17 Ear. Gleason, Essentials of Diseases of the Ear Electricity. Stewart and Lawrance, Essentials of Medical Electricity.................. Embryology. Heisler, Text-Book of Embryology....... 26 26 Eye, Nose, and Throat. Cor win, Essentials of the Physical Diagnosis of the Thorax.................. *De Schweinitz, Diseases of the Eye....... Jackson and Gleason, Essentials of Diseases of Eye, Nose, and Throat............ Kyle, Manual of Diseases of Nose and Throat. . Genito-urinary. Hyde, Syphilis and the Venereal Diseases . . . Martin, Essentials of Minor Surgery, Bandaging, and Venereal Diseases............ Gynecology. *An American Text-Book of Gynecology .... Cragin, Essentials of Gynecology........ Garrigues, Diseases of Women......... Long, Syllabus of Gynecology.......... Histology. Clarkson, Text-Book of Histology........ Life Insurance. Keating, How to Examine for Life Insurance . . Materia Medica and Therapeutics. *An American Text-Book of Applied Therapeu- tics ..................... Butler, Text-Book of Materia Medica, Therapeu- tics, and Pharmacology........... Cerna, Notes on the Newer Remedies...... Griffin, Manual of Materia Medica and Therapeu^ tics...................... Morris, Essentials of Materia Medica, etc. . . . 2 15 27 Stevens, Manual of Therapeutics Thornton, Dose-Book and Prescription-Writing. *Warren, Surgical Pathology and Therapeutics . Medical Jurisprudence. Chapman, Medical Jurisprudence and Toxi- cology ...........,-.•••:' Semple, Essentials of Legal Medicine, etc. . . . Medicine. *An American Text-Book of Practice..... Gould and Pyle, Anomalies and Curiosities of Medicine................... Lockwood, Manual of the Practice of Medicine 24 Morris, Essentials of the Practice of Medicine . 26 Saunders' American Year-Book of Medicine and Surgery...................28 Stevens, Manual of the Practice of Medicine . . 16 Nervous Diseases and Insanity. Burr, Manual of Nervous Diseases.......24 Shaw,Essentials of Nervous Diseases and Insanity 26 Nursing. Griffith, Care of the Baby............21 Hampton, Nursing: its Principles and Practice 21 Stoney, Practical Points in Private Nursing ... 10 Obstetrics. *An American Text-Book of Obstetrics.....5 Ashton, Essentials of Obstetrics.........26 Boisliniere, Obstetric Accidents.........20 Dorland, Manual of Obstetrics.........24 Jewett, Outlines of Obstetrics..........18 Norris, Syllabus of Obstetrical Lectures.....19 Pathology. Semple, Essentials of Pathology and Morbid Anatomy..................26 *Senn, Pathology and Surgical Treatment of Tumors................... 11 Stengel, Manual of Pathology..........24 ♦Warren, Surgical Pathology and Therapeutics . 11 Pharmacy. Say re, Essentials of Pharmacy 26 Physiology. *An American Text-Book of Physiology .... 3 Hare, Essentials of Physiology.........26 Raymond, Manual of Physiology........24 Skiagraphy. Rowland, Archives of Clinical Skiagraphy . . . 15 Skin. Pictorial Atlas of Skin Diseases.........16 Stelwagon, Essentials of Diseases of the Skin . . 26 Surgery. *An American Text-Book of Surgery...... 6 Beck, Surgical Asepsis.............\ 24 DaCosta, Manual of Surgery..........\ 24 Keen, Operation Blank............. 19 MacDonald, Surgical Diagnosis and Treatment . 27 Martin, Essentials of Surgery..........26 Martin, Essentials of Minor Surgerv, etc. . . ! 26 Saunders' American Year-Book of Medicine and Surgery...................28 *Senn, Pathology and Surgical Treatment of Tumors............. u Senn, Syllabus of Surgery..... ......ig *Warren, Surgical Pathology and Therapeutics '. 11 Urine. Wolff, Essentials of Examination of Urine ... 26 Miscellaneous. *Gross, Autobiography of............13 Saunders' New Aid Series of Manuals .... 23, 24 Saunders' Question Compends .... 25, 26 Thresh, Water and Water Supplies.....' .15 CA TALOGUE OF MEDICAL WORKS. 3 For Sale by Subscription. AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by William H. Howell, Ph. D., M. D., Professor of Physiology in the Johns Hopkins University, Baltimore, Md. One handsome octavo volume of 1052 pages, fully illustrated. Prices: Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. This work is the most notable attempt yet made in America to combine in one volume the entire subject of Human Physiology by well-known teachers who have given especial study to that part of the subject upon which they write. The completed work represents the present status of the science of Physiology, par- ticularly from the standpoint of the student of medicine and of the medical practitioner. American teachers of physiology have not been altogether satisfied with the text-books at their disposal. The defects of most of the older books are that they have not kept pace with the rapid changes in modern physiology, while few if any of the newer books have been uniformly satisfactory in their treatment of all parts of this many-sided science. Indeed, the literature of experimental physiology is so great that it would seem to be almost impossible for any one teacher to keep thoroughly informed on all topics. The collaboration of several teachers in the preparation of an elementary text- book of physiology is unusual, the almost invariable rule heretofore having been for a single author to write the entire book. One of the advantages to be derived from this collaboration method is that the more limited literature necessary for consultation by each author has enabled him to base his elementary account upon a comprehensive knowledge of the subject assigned to him; another, and perhaps the most important, advantage, is that the student gains the point of view of a number of teachers. In a measure he reaps the same benefit as would be obtained by following courses of instruction under different teachers. The different stand- points assumed, and the differences in emphasis laid upon the various lines of pro- cedure, chemical, physical, and anatomical, should give the student a better insight into the methods of the science as it exists to-day. The work will also be found useful to many medical practitioners who may wish to keep in touch with the development of modern physiology. The main divisions of the subject-matter are as follows: General Physiology of Muscle and Nerve—Secretion—Chemistry of Digestion and Nutrition—Movements of the Alimentary Canal, Bladder, and Ureter—Blood and Lymph—Circulation— Respiration—Animal Heat—Central Nervous System—Special Senses—Special Muscular Mechanisms—Reproduction—Chemistry of the Animal Body. CONTRIBUTORS: HENRY P. BOWDITCH, M. D., Professor of Physiology, Harvard Medical School. JOHN G. CURTIS, M. D., Professor of Physiology, Columbia University, N. Y. (College of Physicians and Surgeons). HENRY H. DONALDSON, Ph.D., Head-Professor of Neurology, University of Chicago. W. H. HOWELL, Ph. D., M. D.( Professor of Physiology, Johns Hopkins University. PREDERIC S. LEE, Ph. D., Adjunct Prof, of Physiology, Columbia University, N. Y. (College of Physicians and Surgeons). WARREN P. LOMBARD, M. D., Professor of Physiology, University of Michigan. GRAHAM LUSK, Ph.D., Professor of Physiology, Yale Medical School. W. T. PORTER, M. D., Assistant Professor of Physiology, Harvard Medical School. EDWARD T. REICHERT, M. D.( Professor of Physiology, University of Pennsylvania. HENRY SEWALL, Ph. D., M. D., Professor of Physiology, Medical Department, Uni- versity of Denver. 4 W. B. SAUNDERS' ILLUSTRATED For Sale by Subscription. AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU- TICS. For the Use of Practitioners and Students. Edited by James C. Wilson, M. D., Professor of the Practice of Medicine and of Clinical Medicine in the Jefferson Medical College. One handsome octavo volume of 1326 pages. Illustrated. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. The arrangement of this volume has been based, so far as possible, upon mod- ern pathologic doctrines, beginning with the intoxications and following with infections, diseases due to internal parasites, diseases of undetermined origin, and finally the disorders of the several bodily systems—digestive, respiratory, circu- latory, renal, nervous, and cutaneous. It was thought proper to include also a consideration of the disorders of pregnancy. The list of contributors comprises the names of many who have acquired dis- tinction as practitioners and teachers of practice, of clinical medicine, and of the specialties. CONTRIBUTORS: Dr. I. E. Atkinson, Baltimore, Md. Sanger Brown, Chicago, 111. John B. Chapin, Philadelphia, Pa. William C. Dabney, Charlottesville, Va. John Chalmers DaCosta, Phila., Pa. I. N. Danforth, Chicago, 111. John L. Dawson, Jr., Charleston, S. C. F. X. Dercum, Philadelphia, Pa. George Dock, Ann Arbor, Mich. Robert T. Edes, Jamaica Plain, Mass. Augustus A. Eshner, Philadelphia, Pa. J. T. Eskridge, Denver, Col. F. Forchheimer, Cincinnati, O. Carl Frese, Philadelphia, Pa. Edwin E. Graham, Philadelphia, Pa. John Guiteras, Philadelphia, Pa. Frederick P. Henry, Philadelphia, Pa. Guy Hinsdale, Philadelphia, Pa. Orville Horwitz, Philadelphia, Pa. W. W. Johnston, Washington, D. C. Ernest Laplace, Philadelphia, Pa. A. Laveran, Paris, France. Dr. James Hendrie Lloyd, Phila., Pa. John Noland Mackenzie, Bait., Md. J. W. McLaughlin, Austin, Texas. A. Lawrence Mason, Boston, Mass. Charles K. Mills, Philadelphia, Pa. John K. Mitchell, Philadelphia, Pa. W. P. Northrup, New York City. William Osier, Baltimore, Md. Frederick A. Packard, Phila., Pa. Theophilus Parvin, Philadelphia, Pa. Beaven Rake, London, England. E. O. Shakespeare, Philadelphia, Pa. Wharton Sinkler, Philadelphia, Pa. Louis Starr, Philadelphia, Pa. Henry W. Stelwagon, Phila., Pa. James Stewart, Montreal, Canada. Charles G. Stockton, Buffalo, N. Y. James Tyson, Philadelphia, Pa. Victor C. Vaughan, Ann Arbor, Mich. James T. Whittaker, Cincinnati, O. J. C. Wilson, Philadelphia, Pa. The articles, with two exceptions, are the contributions of American writers. Written from the standpoint of the practitioner, the aim of the work is to facili- tate the application of knowledge to the prevention, the cure, and the alleviation of disease. The endeavor throughout has been to conform to the title of the book—Applied Therapeutics—to indicate the course of treatment to be pursued at the bedside, rather than to name a list of drugs that have been used at one time or another. While the scientific superiority and the practical desirability of the metric system of weights and measures is admitted, it has not been deemed best to discard entirely the older system of figures, so that both sets have been given where occasion demanded. CATALOGUE OF MEDICAL WORKS. 5 For Sale by Subscription. AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by Rich- ard C. Norris, M. D.; Art Editor, Robert L. Dickinson, M. D. One handsome octavo volume of over iooo pages, with nearly 900 colored and half-tone illustrations. Prices : Cloth, $7.00 ; Sheep or Half-Morocco, $8.00. The advent of each successive volume of the series of the American Text- Books has been signalized by the most flattering comment from both the Press and the Profession. The high consideration received by these text-books, and their attainment to an authoritative position in current medical literature, have been matters of deep international interest, which finds its fullest expression in the demand for these publications from all parts of the civilized world. In the preparation of the "American Text-Book of Obstetrics " the editor has called to his aid proficient collaborators whose professional prominence entitles them to recognition, and whose disquisitions exemplify Practical Obstetrics. While these writers were each assigned special themes for discussion, the correla- tion of the subject-matter is, nevertheless, such as ensures logical connection in treatment, the deductions of which thoroughly represent the latest advances in the science, and which elucidate the best modern methods of procedure. The more conspicuous feature of the treatise is its wealth of illustrative matter. The production of the illustrations had been in progress for several years, under the personal supervision of Robert L. Dickinson, M. D., to whose artistic judg- ment and professional experience is due the most sumptuously illustrated work of the period. By means of the photographic art, combined with the skill of the artist and draughtsman, conventional illustration is superseded by rational methods of delineation. Furthermore, the volume is a revelation as to the possibilities that may be reached in mechanical execution, through the unsparing hand of its publisher. CONTRIBUTORS: Dr. James C. Cameron. Edward P. Davis. Robert L. Dickinson. Charles Warrington Earle. James H. Etheridge. Barton Cooke Hirst. Henry J. Garrigues. Charles Jewett. Dr. Howard A. Kelly. Richard C. Norris. Chauncey D. Palmer. Theophilus Parvin. George A. Piersol. Edward Reynolds. Henry Schwarz. " At first glance we are overwhelmed by the magnitude of this work in several respects, viz.: First by the size of the volume, then by the array of eminent teachers in this department who have taken part in its production, then by the profuseness and character of the illustrations, and last, but not least, the conciseness and clearness with which the text is rendered. This is an entirely new composition, embodying the highest knowledge of the art as it stands to-day by authors who occupy the front rank in their specialty, and there are many of them. We cannot turn over these pages without being struck by the superb illustrations which adorn so many of them. We are confident that this most practical work will find instant appreciation by practitioners as well as students."— New York Medical Times. Permit me to say that your American Text-Book of Obstetrics is the most magnificent medical work that I have ever seen. I congratulate you and thank you for this superb work, which alone is sufficient to place you first in the ranks of medical publishers. With profound respect I am sincerely yours, Alex. J. C. Skene. 6 IV. B. SAUNDERS" ILLUSTRATED For Sale by Subscription. AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil- liam W. Keen, M. D., LL.D., and J. William White, M. D., Ph. D. Forming one handsome royal-octavo volume of 1250 pages (10x7 inches), with 500 wood-cuts in text, and 37 colored and half-tone plates, many of them engraved from original photographs and drawings furnished by the authors. Prices : Cloth, $7.00 ; Sheep or Half-Morocco, $8.00 net. SECOND EDITION, REVISED AND ENLARGED. The want of a text-book which could be used by the practitioner and at the same time be recommended to the medical student has been deeply felt, especially by teachers of surgery; hence, when it was sug- gested to a number of these that it would be well to unite in preparing a text-book of this description, great unanimity of opinion was found to exist, and the gentlemen below named gladly consented to join in its production. Especial prominence has been given to Surg- ical Bacteriology, a feature which is believed to be unique in a surgical text-book in the English language. Asepsis and Antisepsis have received particular attention. The text is brought well up to date in such important branches as cere- bral, spinal, intestinal, and pelvic surgery, the most important and newest operations in these departments being described and illustrated. The text of the entire book has been sub- mitted to all the authors for their mutual criti- cism and revision—an idea in book-making that is entirely new and original. The book as a whole, therefore, expresses on all the im- portant surgical topics of the day the consensus of opinion of the eminent surgeons who have joined in its preparation. One of the most attractive features of the book is its illustrations. Very many of them are original and faithful reproductions of photographs taken directly from patients or from specimens, and the modern improvements in the art of engraving have enabled the publisher to produce illustrations which it is believed are superior to lihose in any similar work. Specimen Illustration {largely reduced). CONTRIBUTORS: Dr. Charles H. Burnett, Philadelphia. Phineas S. Conner, Cincinnati. Frederic S. Dennis, New York. William W. Keen, Philadelphia. Charles B. Nancrede, Ann Arbor, Mich. Roswell Park, Buffalo, N. Y. Lewis S. Pilcher, Brooklyn, N. Y. Dr. Nicholas Senn, Chicago. Francis J. Shepherd, Montreal, Canada. Lewis A. Stimson, New York. William Thomson, Philadelphia. J. Collins Warren, Boston. J. William White, Philadelphia. " If this text-book is a fair reflex of the present position of American surgery, we must admit it is of a very high order of merit, and that English surgeons will have to look very carefully to their laurels if they are to preserve a position in the van of surgical practice."—London Lancet. " The soundness of the teachings contained in this work needs no stronger guarantee than is afforded by the names of its authors."—Medical News, Philadelphia. CATALOGUE OF MEDICAL WORKS. 7 For Sale by Subscription. AN AMERICAN TEXT-BOOK ON THE THEORY AND PRACTICE OF MEDICINE. By American Teachers. Edited by William Pepper, M. D., LL.D., Provost and Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania. Complete in two handsome royal-octavo volumes of about iooo pages each, with illustrations to elucidate the text wherever necessary. Price per Volume: Cloth, $5.00 net; Sheep or Half-Morocco, $6.00 net. VOLUME I. CONTAINS Hygiene.—Fevers (Ephemeral, Simple Con- tinued, Typhus, Typhoid, Epidemic Cerebro- spinal Meningitis, and Relapsing).—Scarlatina, Measles, Rotheln, Variola, Varioloid, Vaccinia, Varicella, Mumps, Whooping-cough, Anthrax, Hydrophobia, Trichinosis, Actinomycosis, Glan- ders, and Tetanus. — Tuberculosis, Scrofula, Syphilis, Diphtheria, Erysipelas, Malaria, Chol- era, and Yellow Fever.—Nervous, Muscular, and Mental Diseases. VOLUME II. CONTAINS: Urine (Chemistry and Microscopy).—Kidney and Lungs.—Air-passages (Larynx and Bronchi) and Pleura. — Pharynx, CEsophagus, Stomach and Intestines (including Intestinal Parasites), Heart, Aorta, Arteries and Veins.—Peritoneum, Liver, and Pancreas.—Diathetic Diseases (Rheu- matism, Rheumatoid Arthritis, Gout, Lithsemia, and Diabetes).— Blood and Spleen.—Inflamma- tion, Embolism, Thrombosis, Fever, and Bacte- riology. The articles are not written as though addressed to students in lectures, but are exhaustive descriptions of diseases, with the newest facts as regards Causation, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large number of approved formulae. The recent advances made in the study of the bacterial origin of various diseases are fully described, as well as the bearing of the know- ledge so gained upon prevention and cure. The subjects of Bacteriology as a whole and of Immunity are fully considered in a separate section. Methods of diagnosis are given the most minute and careful attention, thus enabling the reader to learn the very latest methods of investigation without con- sulting works specially devoted to the subject. CONTRIBUTORS Dr. J. S. Billings, Philadelphia. Francis Delafield, New York. Reginald H. Fitz, Boston. James W. Holland, Philadelphia. Henry M. Lyman, Chicago. William Osier, Baltimore. Dr. William Pepper, Philadelphia. W. Gilman Thompson, New York. W. H. Welch, Baltimore. James T. Whittaker, Cincinnati. James C. Wilson, Philadelphia. Horatio C. Wood, Philadelphia. " We reviewed the first volume of this work, and said: ' It is undoubtedly one of the best text- books on the practice of medicine which we possess.' A consideration of the second and las) volume leads us to modify that verdict and to say that the completed work is, in our opinion, tht BEST of its kind it has ever been our fortune to see. It is complete, thorough, accurate, and clear. It is well written, well arranged, well printed, well illustrated, and well bound. It is a model of what the modern text-book should be."—New York Medical Journal. s " A library upon modern medical art. The work must promote the wider diffusion of sound knowledge."—American Lancet. " A trusty counsellor for the practitioner or senior student, on wh:ch he may implicitly rely."— Edinburgh Medical Journal. 8 IV. B. SAUNDERS' ILLUSTRATED For Sale by Subscription. AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL- DREN. By American Teachers. Edited by Louis Starr, M. D., assisted by Thompson S. Westcott, M. D. In one handsome royal-8vo vol- ume of 1190 pages, profusely illustrated with wood-cuts, half-tone and colored plates. Prices: Cloth, $7.00 net; Sheep or Half-Morocco, $8.00 net. The plan of this work embraces a series of original articles written by some sixty well-known paediatrists, representing collectively the teachings of the most prominent medical schools and colleges of America. The work is intended to be a practical book, suitable for constant and handy reference by the practitioner and the advanced student. One decided innovation is the large number of authors, nearly every article being contributed by a specialist in the line on which he writes. This, while entailing considerable labor upon the editors, has resulted in the publication of a work thoroughly new and abreast of the times. Especial attention has been given to the consideration of the latest accepted teaching upon the etiology, symptoms, pathology, diagnosis, and treatment of the disorders of children, with the introduction of many special formulae and thera- peutic procedures. Special chapters embrace at unusual length the Diseases of the Eye, Ear, Nose and Throat, and the Skin ; while the introductory chapters cover fully the important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of Food. Trache- otomy, Intubation, Circumcision, and such minor surgical procedures coming within the province of the medical practitioner, are carefully considered. CONTRIBUTORS: Dr. S. S. Adams, Washington. John Ashhurst, Jr., Philadelphia. A. D. Blackader, Montreal, Canada. Dillon Brown, New York. Edward M. Buckingham, Boston. Charles W. Burr, Philadelphia. W. E. Casselberry, Chicago. Henry Dwight Chapin, New York. W. S. Christopher, Chicago. Archibald Church, Chicago. Floyd M. Crandall, New York. Andrew F. Currier, New York. Roland G. Curtin, Philadelphia. J. M. DaCosta, Philadelphia. I. N. Danforth, Chicago. Edward P. Davis, Philadelphia. John B. Deaver, Philadelphia. G. E. de Schweinitz, Philadelphia. John Doming, New York. Charles Warrington Earle, Chicago. Wm. A. Edwards, San Diego, Cal. F. Forchheimer, Cincinnati. J. Henry Fruitnight, New York. Landon Carter Gray, New York. J. P. Crozer Griffith, Philadelphia. W. A. Hardaway, St. Louis. M. P. Hatfield, Chicago. Barton Cooke Hirst, Philadelphia. H. Illoway, Cincinnati. Henry Jackson, Boston. Charles G. Jennings, Detroit. Henry Koplik, New York. Dr. Thomas S. Latimer, Baltimore. Albert R. Leeds, Hoboken, N. J. J. Hendrie Lloyd, Philadelphia. George Roe Lockwood, New York. Henry M. Lyman, Chicago. Francis T. Miles, Baltimore. Charles K. Mills, Philadelphia. John H. Musser, Philadelphia. Thomas R. Neilson, Philadelphia. W. P. Northrup, New York. William Osier, Baltimore. Frederick A. Packard, Philadelphia. William Pepper, Philadelphia. Frederick Peterson, New York. W. T. Plant, Syracuse, New York. William M. Powell, Atlantic City. B. Alexander Randall, Philadelphia. Edward O. Shakespeare, Philadelphia. F. C. Shattuck, Boston. J. Lewis Smith, New York. Louis Starr, Philadelphia. M. Allen Starr, New York. J. Madison Taylor, Philadelphia. Charles W. Townsend, Boston. James Tyson, Philadelphia. W. S. Thayer, Baltimore. Victor C. Vaughan, Ann Arbor, Mich, Thompson S. Westcott, Philadelphia. Henry R. Wharton, Philadelphia. J. William White, Philadelphia. J. C. Wilson, Philadelphia. CATALOGUE OF MEDICAL WORKS. For Sale by Subscription. A.N AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL AND SURGICAL, for the use of Students and Practitioners. Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume, with 360 illustrations in text and 37 colored and half-tone plates. Prices: Cloth, $6.00 net; Sheep or Half-Morocco, $7.00 net. In this volume all anatomical descriptions, excepting those essential to a clear understanding of the text, have been omitted, the illustrations being largely depended upon to eluci- 'date the anatomy of the parts. This work, which is thoroughly practical in its teachings, is intended, as its title implies, to be a working text-book for physicians and students. A clear line of treatment has been laid down in every case, and although no attempt has been made to discuss mooted points, still the most important of these have been noted and explained. The ope- rations recommended are fully illustrated, so that the reader, having a pic- ture of the procedure de- scribed in the text under his eye, cannot fail to grasp the idea. All ex- traneous matter and dis- cussions have been care- fully excluded, the attempt being made to allow no unnecessary details to cumber the text. The subject-matter is brought up to date at every point, and the work is as nearly as possible the combined opinions of the ten specialists who figure as the authors. The work is well illustrated throughout with wood-cuts, half-tone and colored plates, mostly selected from the authors' private collections. Specimen Illustration. CONTRIBUTORS: Dr. Henry T. Byford. John M. Baldy. Edwin Cragin. J. H. Etheridge. William Goodell. Dr. Howard A. Kelly. Florian Krug. E. E. Montgomery. William R. Pryor. George M. Tuttle. " The most notable contribution to gynecological literature since 1887, .... and the most com- plete exponent of gynecology which we have. No subject seems to have been neglected, .... and the gynecologist and surgeon and the general practitioner, who has any desire to practise diseases of women, will find it of practical value. In the matter of illustrations and plates the book sur- passes anything we have seen."—Boston Medical and Swgical Journal. io W. B. SAUNDERS' ILLUSTRATED PRACTICAL POINTS IN NURSING. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely illustrated with 73 engravings in the text, and 9 colored and half-tone plates. Cloth. Price, $1.75 net. In this volume the author explains, in popular language and in the shortest possible form, the entire range of private nursing as distinguished from hospital nursing, and the nurse is instructed how best to meet the various emergencies of medical and surgical cases when distant from medical or surgical aid or when thrown on her own resources. An especially valuable feature of the work will be found in the directions to the nurse how to improvise everything ordinarily needed in the sick-room, where the embarrassment of the nurse, Owing to the want of proper appliances, is fre- quently extreme. The work has been logically divided into the following sections: I. The Nurse : her responsibilities, qualifications, equipment, etc. II. The Sick-Room : its selection, preparation, and management. III. The Patient: duties of the nurse in medical, surgical, obstetric, and gyne- cologic cases. IV. Nursing in Accidents and Emergencies. V. Nursing in Special Medical Cases. VI. Nursing of the New-born and Sick Children. VII. Physiology and Descriptive Anatomy. The last section, while sketched very briefly, will be ample for the purposes of the nurse. The Appendix contains much information in compact form that will be found of great value to the nurse, including Rules for Feeding the Sick; Recipes for Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for Com- puting the Date of Labor ; List of Abbreviations ; Dose-List; and a full and com- plete Glossary of Medical Terms and Nursing Treatment. Finally, the work, being based on a series of lectures delivered at the Carney Training-School for Nurses, will serve as a text-book for student-nurses and a useful teaching book for those occupying positions as teachers in training-schools; it will also be of value to the "home" nurse who wishes to comprehend some- thing of the purposes of the different methods adopted in nursing treatment. " The author's style is most agreeable, and she handles her subject in a way that clearly shows her familiarity with it."—New York Polyclinic, Aug. 15, 1896. " There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one."—Therapeutic Gazette, Aug. 15, 1896. " This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise and how to prepare everything ordinarily needed in the illness of her patient."—American Journal of Obstetrics and Diseases of Women and Children, Aug., 1896. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit."—Ohio Medical Journal, Aug., 1896. " We know of no more serviceable book for nurses than this one; it is thoroughly practical in every sense of the word. Even the home nurse may profit by its reading."—Medical Summary, Aug., 1896. " This is an excellent work, which covers its special line judiciously and clearly."—Canadian Medical Review, Aug., 1896. CATALOGUE OF MEDICAL WORKS. n For Sale by Subscription. PATHOLOGY AND SURGICAL TREATMENT OF TUMORS. By N. Senn, M. D., Ph. D., LL. D., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic; Attending Surgeon to Presbyterian Hospital; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. 710 pages, 515 engravings, including full-page colored plates. Prices: Cloth, $6.00 net; Half-Morocco, $7.00 net. Books specially devoted to this subject are few, and in our text-books and systems of surgery this part of surgical pathology is usually condensed to a degree incompatible with its scientific and clinical importance. The author spent many years in collecting the material for this work, and has taken great pains to present it in a manner that should prove useful as a text-book for the student, a work of reference for the busy practitioner, and a reliable, safe guide for the surgeon. The more difficult operations are fully described and illustrated. More than one hundred of the illustrations are original, while the remainder were selected from books and medical journals not readily accessible to the student and the general practitioner. " The appearance of such a work is most opportune. ... In design and execution the work is such as will appeal to every student who appreciates the logical examination of facts and the prac- tical exemplification of well-digested clinical observation."—Medical Record, New York. " The most exhaustive of any recent book in English on this subject. It is well illustrated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, .... and the author has given a notable and lasting contribution to surgery."—Journal of American Medical Association, Chicago. SURGICAL PATHOLOGY AND THERAPEUTICS. By John Collins Warren, M. D., LL. D., Professor of Surgery, Medical Depart- ment Harvard University; Surgeon to the Massachusetts General Hospital, etc. A handsome octavo volume of 832 pages, with 136 relief and litho- graphic illustrations, 33 of which are printed in colors, and all of which were drawn by William J. Kaula from original specimens. Prices: Cloth, $6.00 net; Half-Morocco, $7.00 net. " The volume is for the bedside, the amphitheatre, and the ward. It deals with things not as we see them through the microscope alone, but as the practitioner sees their effect in his patients ; not only as they appear in and affect culture- media, but also as they influence the human body; and, following up the demon- strations of the nature of diseases, the author points out their logical treatment" {New York Medical Journal}. " Indeed, the volume may be termed a modern medical classic, for such is the position to which it has already risen " {Medical 'A°-e, Detroit), " and is the handsomest specimen of bookmaking * * * that has ever been issued from the American medical press'' {American Journal oj the Medical Sciences, Philadelphia). Without Exception, the Illustrations are the Best ever Seen in a "Work of this Kind. " A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. * * * Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section."—Annals of Surgery, Philadelphia. 12 IV. B. SAUNDERS' ILLUSTRATED For Sale by Subscription. A NEW PRONOUNCING DICTIONARY OF MEDICINE, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila- delphia ; Vice-President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors; Editor " Cyclopaedia of the Diseases of Children," etc. ; and Henry Hamilton, Author of a "A New Translation of Virgil's yEneid into English Rhyme;" Co-Author of "Saunders' Medical Lexicon," etc.; with the Collaboration of J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D. With an Appendix, containing Important Tables of Bacilli, Micrococci, Leucomai'nes, Ptomaines ; Drugs and Materials used in Antiseptic Surgery ; Poisons and their Antidotes; Weights and Measures; Thermometric Scales; New Official and Unofficial Drugs, etc. One volume of over 800 pages. Second Revised Edition. Prices : Cloth, $5.00 ; Sheep or Half-Morocco, $6.00 net; Half-Russia, $6.50 net, with Denison's Patent Ready-Reference Index ; without Patent Index, Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net. " I am much pleased with Keating's Dictionary, and shall take pleasure in recommending it to my classes." Henry M. Lyman, M. D., Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III. " I am convinced that it will be a very valuable adjunct to my study-table, convenient in size and sufficiently full for ordinary use." C. A. Lindsley, M. D., Professor of Theory and Practice of Medicine, Medical Depl. Yale University ; Secretary Connecticut State Board of Health, New Haven, Conn. MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the Second Enlarged German Edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Third and Revised Edition. In one handsome royal-octavo volume of 700 pages, 178 fine wood-cuts in text, many of which are in colors. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net; Half-Russia, $5.50 net. In this work, as in no other hitherto published, are given full and accurate explanations of the phenomena observed at the bedside. It is distinctly a clinical work by a master teacher, characterized by thoroughness, fulness, and accuracy. It is a mine of information upon the points that are so often passed over without explanation. Especial attention has been given to the germ-theory as a factor in* the origin of disease. This valuable work is now published in German, English, Russian, and Italian. The issue of a third American edition within two years indicates the favor with which it has been received by the profession. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. All the chapters are full, and leave little to be desired by the reader. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. Not- withstanding a few minor errors in translating, which are of small importance to the accuracy of the rest of the volume, the reviewer would repeat that the book is one of the best—probably,, the best—which has fallen into his hands. An excellent and comprehensive index of nearly one hundred pages closes the volume."—University Medical Magazine, Philadelphia. CATALOGUE OF MEDICAL WORKS. 13 For Sale by Subscription. AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Professor of Surgery in the Jefferson Medical College of Philadelphia, with Reminiscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surgery and of Clinical Surgery in the Jefferson Medical College, and A. Haller Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr. Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes, each con- taining over 400 pages, demy 8vo, extra cloth, gilt tops, with fine Frontis- piece engraved on steel. Price, $5.00 net. This autobiography, which was continued by the late eminent surgeon until within three months before his death, contains a full and accurate history of his early struggles, trials, and subsequent successes, told in a singularly interesting and charming manner, and embraces short and graphic pen-portraits of many of the most distinguished men—surgeons, physicians, divines, lawyers, statesmen, scientists, etc.—with whom he was brought in contact in America and in Europe; the whole forming a retrospect of more than three-quarters of a century. TEXT-BOOK UPON THE PATHOGENIC BACTERIA. Spe- cially written for Students of Medicine. By Joseph McFarland, M. D., Professor of Pathology and Bacteriology in the Medico-Chirurgical College of Philadelphia, etc. 359 pages, finely illustrated. Cloth. Price, $2.50 net. The book presents a concise account of the technical procedures necessary in the study of Bacteriology. It describes the life-history of pathogenic bacteria, and the pathological lesions following invasions. The work is intended to be a text-book for the medical student and for the practitioner who has had no recent laboratory training in this department of med- ical science. The instructions given as to needed apparatus, cultures, stainings, microscopic examinations, etc. are ample for the student's needs, and will afford to the physician much information that will interest and profit him relative to a subject which modern science shows to go far in explaining the etiology of many diseased conditions. The illustrations have been gathered from standard sources, and comprise the best and most complete aggregation extant. " It is excellently adapted for the medical students and practitioners for whom it is avowedly written. . . . The descriptions given are accurate and readable, and the book should prove useful to those for whom it is written."—London Lancet, Aug. 29, 1896. "The author has succeeded admirably in presenting the essential details of bacteriological technics, together with a judiciously chosen summary of our present knowledge of pathogenic bac- teria. . '. . The work, we think, should have a wide circulation among English-speaking students of medicine."—N Y. Medical Journal, April 4, 1896. " The book will be found of considerable use by medical men who have not had a special bacteriological training, and who desire to understand this important branch of medical science."— Edinburgh Medical Journal, July, 1896. " We cordially recommend the book, believing it to be one of the most useful of recent publica- tions."— Philadelphia Polyclinic, June 6, 1896. " The author has rendered a great service to the profession in bringing out this work at this opportune time."— The American Therapist, Aug., 1896. 14 W. B. SAUNDERS' ILLUSTRATED DISEASES OF THE EYE. A Hand-Book of Ophthalmic Practice. By G. E. de Schweinitz, M. D., Professor of Ophthalmology in the Jeffer- son Medical College, Philadelphia, etc. A handsome royal-octavo volume of 679 pages, with 256 fine illustrations, many of which are original, and 2 chromo-lithographic plates. Prices: Cloth, $4.00 net; Sheep or Half- Morocco, $5.00 net. The object of this work is to present to the student, and to the practitioner who is beginning work in the fields of ophthal- mology, a plain description of the optical defects and diseases of the eye. To this end special attention has been paid to the clinical side of the question; and the method of examination, the symptoma- tology leading to a diagnosis, and the treatment of the various ocular defects have been brought into prominence. SECOND EDITION, REVISED AND GREATLY ENLARGED. The entire book has been thoroughly specimen illustration. revised. In addition to this general re- vision, special paragraphs on the following new matter have been introduced: Filamentous Keratitis, Blood-staining of the Cornea, Essential Phthisis Bulbi, Foreign Bodies in the Lens, Circinate Retinitis, Symmetrical Changes at the Macula Lutea in Infancy, Hyaline Bodies in the Papilla, Monocular Diplopia, Subconjunctival Injections of Germicides, Infiltra- tion-Anaesthesia, and Sterilization of Collyria. Brief mention of Ophthalmia Nodosa, Electric Ophthalmia, and Angioid Streaks in the Retina also finds place. An Appendix has been added, containing a full description of the method of deter- mining the corneal astigmatism with the ophthalmometer of Javal and Schiotz, and the rotations of the eyes with the tropometer of Stevens. The chapter on Operations has been enlarged and rewritten. "A clearly written, comprehensive manual. . . . One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science."—British Medical Journal. " The work is characterized by a lucidity of expression which leaves the reader in no doubt as to the meaning of the language employed. ... We know of no work in which these diseases are dealt with more satisfactorily, and indications for treatment more clearly given, and in harmony with the practice of the most advanced ophthalmologists."—Maritime Medical News. " It is hardly too much to say that for the student and practitioner beginning the study of Ophthalmology, it is the best single volume at present published."—Medical News. " The latest and one of the best books on Ophthalmology. The book is thoroughly up to date, and is certainly a work which not only commends itself to the student, but is a ready reference for the busy practitioner."—International Medical Magazine. FEEDING IN EARLY INFANCY. By Arthur V. Meigs, M. D. Bound in limp cloth, flush edges. Price, 25 cents net. Synopsis : Analyses of Milk—Importance of the Subject of Feeding in Early Infancy—Proportion of Casein and Sugar in Human Milk—Time to Begin Arti- ficial Feeding of Infants—Amount of Food to be Administered at Each Feeding__ Intervals between Feedings— Increase in Amount of Food at Different Periods of Infant Development—Unsuitableness of Condensed Milk as a Substitute for Moth- er's Milk—Objections to Sterilization or "Pasteurization" of Milk—Advances made in the Method of Artificial Feeding of Infants. CATALOGUE OF MEDICAL WORKS. 15 A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC- TICAL. For the Use of Students. By Arthur Clarkson, M. B., C. M., Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in the Yorkshire College, Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174 beautifully colored original illustrations. Price, strongly bound in Cloth, $6.00 net. The purpose of the writer in this work has been to furnish the student of His- tology, in one volume, with both the descriptive and the practical part of the science. The first two chapters are devoted to the consideration of the general methods of Histology; subsequently, in each chapter, the structure of the tissue or organ is first systematically described, the student is then taken tutorially over the specimens illustrating it, and, finally, an appendix affords a short note of the methods of preparation. In the descriptive portion of the work the writer has avoided, as much as possible, the discussion of disputed points and contending views of only historical value. In the practical part also the same principle has been followed—only the well-known and well-tried methods are given; and, throughout, the object has been, while placing before the reader all that is necessary for his equipment as an histologist, to avoid withdrawing his mind from the salient facts of the science by the introduction of a number of comparatively unimportant ones, of main interest to the specialist. ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland, B. A., Camb., late Scholar of Downing College, Cambridge, and Shuter Scholar of St. Bartholomew's Hospital, London; .Special Commissioner to "British Medical Journal" for the Investigation of the Applications of the New Photography to Medicine and Surgery. A series of collotype illustra- tions, with descriptive text, illustrating the applications of the New Photog- raphy to Medicine and Surgery. Price, per Part, $1.00. Parts I. and II. now ready. The object of this publication is to put on record in permanent form some of the most striking applications of the new photography to the needs of Medicine and Surgery. The progress of this new art has been so rapid that, although Prof. Rontgen's discovery is only a thing of yesterday, it has already taken its place among the approved and accepted aids to diagnosis. WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc, M. B., D. P. H., Lecturer on Public Health, King's College, London; Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus- trated. Handsomely bound in Cloth, with gold side and back stamps. Price, #2.25 net. This work will furnish any one interested in public health the information requisite for forming an opinion as to whether any supply or proposed supply is sufficiently wholesome and abundant, and whether the cost can be considered reasonable. The work does not pretend to be a treatise on Engineering, yet it contains sufficient detail to enable any one who has studied it to consider intelligently any scheme which may be submitted for supplying a community with water. 16 W. B. SAUNDERS' ILLUSTRATED THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPH- ILITIC AFFECTIONS (American Edition). Translation from the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Physician to, and Physician to the department for Diseases of the Skin at, the Middle- sex Hospital, London. Photo-lithochromes from the famous models of der- matological and syphilitic cases in the Museum of the Saint-Louis Hospital, Paris, with explanatory wood-cuts and text. In 12 Parts, at $3.00 per Part. Parts 1 to 4 now ready. " The plates are beautifully executed."—Jonathan Hutchinson, M. D. (London Hospital). " I strongly recommend this Atlas. The plates are exceedingly well executed, and will be of great value to all studying dermatology."—Stephen Mackenzie, M. D. (London Hospital). " The plates in this Atlas are remarkably accurate and artistic reproductions of typical ex- amples of skin disease. The work will be of great value to the practitioner and student."— William Anderson, M. D. (St. Thomas Hospital). ESSENTIALS OF ANATOMY AND MANUAL OF PRACTICAL DISSECTION, containing "Hints on Dissection." By Charles B. Nancrede, M. D., Professor of Surgery and Clinical Surgery in the Uni- versity of Michigan, Ann Arbor; Corresponding Member of the Royal Academy of Medicine, Rome, Italy; late Surgeon Jefferson Medical Col- lege, etc. Fourth and revised edition. Post 8vo, over 500 pages, with handsome full-page lithographic plates in colors, and over 200 illustrations. Price: Extra Cloth (or Oilcloth for the dissection-room), $2.00 net. No pains nor expense has been spared to make this work the most exhaustive yet concise Student's Manual of Anatomy and Dissection ever published, either in America or in Europe. The colored plates are designed to aid the student in dissecting the muscles, arteries, veins, and nerves. The wood-cuts have all been specially drawn and engraved, and an Appendix added containing 60 illustrations representing the structure of the entire human skeleton, the whole being based on the eleventh edition of Gray's Anatomy. A MANUAL OF PRACTICE OF MEDICINE. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the University of Pennsyl- vania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. Specially intended for students preparing for graduation and hospital examinations. Post 8vo, 512 pages. Illustrated. Price, $2.50. FOURTH EDITION, REVISED AND ENLARGED. Contributions to the science of medicine have poured in so rapidly during the last quarter of a century that it is well-nigh impossible for the student, with the limited time at his disposal, to master elaborate treatises or to cull from them that knowledge which is absolutely essential. From an extended experience in teach- ing, the author has been enabled, by classification, to group allied symptoms, and by the elimination of theories and redundant explanations to bring within a com- paratively small compass a complete outline of the practice of medicine. TEMPERATURE CHART. Prepared by D. T. Laine, M. D. Size 8x 13^ inches. Price, per pad of 25 charts, 50 cents net. A conveniently arranged chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. CATALOGUE OF MEDICAL WORKS. 17 MANUAL OF MATERIA MEDICA AND THERAPEUTICS. By A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the Uni- versity of Pennsylvania, and Demonstrator of Pathology in the Woman's Medical College of Philadelphia. 435 pages. Price, Cloth, $2.25. This wholly new volume, which is based on the 1890 edition of the Pharma- copoeia, comprehends the following sections: Physiological Action of Drugs; Drugs ; Remedial Measures other than Drugs; Applied Therapeutics; Incom- patibility in Prescriptions ; Table of Doses; Index of Drugs; and Index of Dis- eases ; the treatment being elucidated by more than two hundred formulae. NOTES ON THE NEWER REMEDIES: their Therapeutic Appli- cations and Modes of Administration. By David Cerna, M.D., Ph.D., Demonstrator of and Lecturer on Experimental Therapeutics in the Univer- sity of Pennsylvania. Post 8vo, 253 pages. Price, $1.25. SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED. The work takes up in alphabetical order all the newer remedies, giving their physical properties, solubility, therapeutic applications, administration, and chem- ical formula. SAUNDERS' POCKET MEDICAL FORMULARY. By William M. Powell, M. D., Attending Physician to the Mercer House for Invalid Women at Atlantic City. Containing 1750 Formulae, selected from several hundred of the best-known authorities. Forming a handsome and convenient pocket companion of nearly 300 printed pages, with blank leaves for additions; with an Appendix containing Posological Table, Formulae and Doses for Hypodermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Dis- eases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Third edition, revised and greatly enlarged. Handsomely bound in morocco, with side index, wallet, and flap. Price, $1.75 net. " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is very useful, and as the name of the author of each prescription is given is unusually reliable."—New York Medical Record. SAUNDERS' POCKET MEDICAL LEXICON; or, Dictionary of Terms and Words used in Medicine and Surgery. By John M. Keating, M. D., Editor of "Cyclopaedia of Diseases of Children," etc.; Author of the "New Pronouncing Dictionary of Medicine," and Henry Hamilton, Author of "A New Translation of Virgil's ^Eneid into English Verse;" Co-Author of a "New Pronouncing Dictionary of Medicine." A new and revised edition. 321x10, 282 pages. Prices: Cloth, 75 cents; Leather Tucks, $1.00. " Remarkably accurate in terminology, accentuation, and definition."—Journal of American Medical Association. " Brief, yet complete .... it contains the very latest nomenclature in even the newest depart- ments of medicine."—Medical Record. 18 W. B. SAUNDERS' ILLUSTRATED DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D., Pro- fessor of Obstetrics in the New York Post-Graduate Medical School and Hos- pital ; Gynaecologist to St. Mark's Hospital, and to the German Dispensary, etc., New York City. One octavo volume of nearly 700 pages, illustrated by 300 wood-cuts and colored plates. Prices: Cloth, S4.00 net; Sheep, $5.00 net. A practical work on gynaecology for the use of students and practitioners, written in a terse and concise manner. The importance of a thorough knowledge of the anatomy of the female pelvic organs has been fully recognized by the author, and considerable space has been devoted to the subject. The chapters on Operations and on Treatment are thoroughly modern, and are based upon the large hospital and private practice of the author. The text is elucidated by a large number of illustrations and colored plates, many of them being original, and forming a complete atlas for studying embryology and the anatomy of the Jemale genitalia, besides exemplifying, whenever needed, morbid conditions, instruments, apparatus, and operations. EXCERPT OF CONTENTS. Development of the Female Genitals.—Anatomy of the Female Pelvic Organs.—Physiology.— Puberty.—Menstruation and Ovulation.—Copulation.—Fecundation.—The Climacteric.—Etiology in General.—Examinations in General.—Treatment in General.—Abnormal Menstruation and Me- trorrhagia.—Leucorrhea.—Diseases of the Vulva.—Diseases of the Perineum.—Diseases of the Vagina.—Diseases of the Uterus.—Diseases of the Fallopian Tubes.—Diseases of the Ovaries.— Diseases of the Pelvis.—Sterility. The reception accorded to this work has been most flattering. In the short period -which has elapsed since its issue, it has been adopted and recommended as a text-book by more than 60 of the Medical Schools and Universities of the United States and Canada. " One of the best text-books for students and practitioners which has been published in the English language; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners, to whom experienced consultants may not be available, will find in this book invaluable counsel and help." Thad. A. Reamy, M. D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio; Gynecologist to the Good Samaritan and to the Cincinnati Hospitals. OUTLINES OF OBSTETRICS: A Syllabus of Lectures Delivered at Long Island College Hospital. By Charles Jewett, A. M., M. D., Professor of Obstetrics and Pediatrics in the College, and Obstetrician to the Hospital. Edited by Harold F. Jewett, M. D. Post 8vo, 264 pages. Price, $2.00. This book treats only of the general facts and principles of obstetrics: these are stated in concise terms and in a systematic and natural order of sequence, theoretical discussion being as far as possible avoided; the subject is thus pre- sented in a form most easily grasped and remembered by the student. Special attention has been devoted to practical questions of diagnosis and treatment, and in general particular prominence is given to facts which the student most needs to know. The condensed form of statement and the orderly arrangement of topics adapt it to the wants of the busy practitioner as a means of refreshing his know- ledge of the subject and as a handy manual for daily reference. CATALOGUE OF MEDICAL WORKS. *9 SYLLABUS OF OBSTETRICAL LECTURES in the Medical Department, University of Pennsylvania. By Richard C. Norris, A. M., M. D., Demonstrator of Obstetrics in the University of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown 8vo. Price, Cloth, interleaved for notes, $2.00 net. " This work is so far superior to others on the same subject that we take pleasure in calling attention briefly to its excellent features. It covers the subject thoroughly, and will prove invaluable both to the student and the practitioner. The author has introduced a number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject-matter is clear, forcible, and modern. We are especially pleased with the portion devoted to the practical duties of the accoucheur, care of the child, etc. The paragraphs on antiseptics are admirable; there is no doubtful tone in the directions given. No details are regarded as unimportant; no minor matters omitted. We venture to say that even the old practitioner will find useful hints in this direction which he cannot afford to despise."—Medical Record. A SYLLABUS OF GYNECOLOGY, arranged in conformity with " An American Text-Book of Gynecology." By J. W. Long, M. D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Price, Cloth (interleaved), #1.00 net. Based upon the teaching and methods laid down in the larger work, this will not only be useful as a supplementary volume, but to those who do not already possess the Text-Book it will also have an independent value as an aid to the prac- titioner in gynecological work, and to the student as a guide in the lecture-room, as the subject is presented in a manner systematic, succinct, and practical. A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR- GERY, arranged in conformity with "An American Text-Book of Surgery." By Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago, and in the Chicago Polyclinic. Price, $2.00. This excellent work of its eminent author, himself one of the contributors to "An American Text-Book of Surgery," will prove of exceptional value to the advanced student who has adopted that work as his text-book. It is not only the syllabus of an unrivalled course of surgical practice, but it is also an epitome of, or supplement to the larger work. AN OPERATION BLANK, with Lists of Instruments, etc. re- quired in Various Operations. Prepared by W. W. Keen, M. D., LL.D., Professor of Principles of Surgery in the Jefferson Medical College, Philadelphia. Price per pad, containing Blanks for fifty operations, 50 cents net. SECOND EDITION, REVISED FORM. A convenient blank (suitable for all operations), giving complete instructions regarding necessary preparation of patient, etc., with a full list of dressings and medicines to be employed. On the back of each blank is a list of instruments used__viz. general instruments, etc., required for all operations; and special in- struments for surgery of the brain and spine, mouth and throat, abdomen, rectum, male and female genito-urinary organs, the bones, etc. The whole forming a neat pad arranged for hanging on the wall of a surgeon's office or in the hospital operating-room. 20 W. B. SAUNDERS' ILLUSTRATED LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin. M. A., Professor of Materia Medica and Botany in the Philadelphia Col- lege of Pharmacy. Octavo volume of 536 pages, with 87 plates. Price, Cloth, $2.50. This work is intended for the beginner and the advanced student, and it fully covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers, bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross and microscopical structure of plants, and to those used in medicine. The illus- trations fully elucidate the text, and the complete index facilitates reference. LABORATORY GUIDE FOR THE BACTERIOLOGIST. By Langdon Frothingham, M. D. V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Price- Cloth, 75 cents. The technical methods involved in bacteria-culture, methods of staining, and microscopical study are fully described and arranged as simply and concisely as possible. The book is especially intended for use in laboratory work. OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA- TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of Ob- stetrics in the St. Louis Medical College. 381 pages, handsomely illustrated. Price, $2.00 net. " For the use of the practitioner who, when away from home, has not the opportunity of consulting a library or of calling a friend in consultation. He then, being thrown upon his own resources, will find this book of benefit in guiding and assisting him in emergencies." CATALOGUE OF MEDICAL WORKS. 21 HOW TO EXAMINE FOR LIFE INSURANCE. By John M. Keating, M. D., Fellow .of the College of Physicians and Surgeons of Phila- delphia ; Vice-President of the American Paediatric Society; Ex-President of the Association of Life Insurance Medical Directors. Royal 8vo, 211 pages, with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections; also, numerous cuts to elucidate the text. Price, in Cloth, $2.00 net. " This is by far the most useful book which has yet appeared on insurance examination, a sub- ject of growing interest and importance. Not the least valuable portion of the volume is Part II., which consists of instructions issued to their examining physicians by twenty-four representative companies of this country. As the proofs of these instructions were corrected by the directors of the companies, they form the latest instructions obtainable. If for these alone the book should be at the right hand of every physician interested in this special branch of medical science."—The Medical News, Philadelphia. THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D., Clmi- cal Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. 392 pages, with 67 illustrations in the text, and 5 plates, nmo. Price, $1.50. A reliable guide not only for mothers, but also for medical students and prac- titioners whose opportunities for observing children have been limited. " The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read with benefit not only by mothers, but by medical students and by any prac- titioners who have not had large opportunities for observing children."—American Journal of Obstetrics, July, 1895. " The best book for the use of the young mother with which we are acquainted. . . . There are very few general practitioners who could not read the book through with advantage."—Archives of Pediatrics, Aug., 1895. " No better book of its kind has come under our notice for some time. Although intended primarily for mothers and nurses, it will well repay perusal by medical students."—Birmingham Medical Review, Oct., 1895. " This is one of the best works of its kind that has been presented to the people for many a •day."—Maryland Medical Journal, Aug. 13, 1895. NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel Adams Hampton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital; Superintendent of Nurses, and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md.; late Superin- tendent of Nurses, Illinois Training School for Nurses, Chicago, 111. In one very handsome i2mo volume of 484 pages, profusely illustrated. Price, Cloth, $2.00 net. This original work on the important subject of nursing is at once compre- hensive and systematic. It is written in a clear, accurate, and readable style, suit- able alike to the student and the lay reader. Such a work has long been a deside- ratum with those intrusted with the management of hospitals and the instruction of nurses in training-schools. It is also of especial value to the graduate nurse who desires to acquire a practical working knowledge of the care of the sick and the hygiene of the sick-room. 22 W. B. SAUNDERS' ILLUSTRATED CATALOGUE. NURSE'S DICTIONARY of Medical Terms and Nursing Treat- ment, containing Definitions of the Principal Medical and Nursing Terms and Abbreviations; of the Instruments, Drugs, Diseases, Accidents, Treat- ments, Physiological Names, Operations, Foods, Appliances, etc. encountered in the ward or in the sick-room. Compiled for the use of nurses. By Honnor Morten, Author of "How to Become a Nurse," "Sketches of Hospital Life," etc. i6mo, 140 pages. Price, Cloth, $1.00. This little volume is intended merely as a small reference-book which can be consulted at the bedside or in the ward. It gives sufficient explanation to the nurse to enable her to comprehend a case until she has leisure to look up larger and fuller works on the subject. DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women; with an Introduction by Sir Henry Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price, Cloth, $1.50. Useful to those who have to nurse, feed, and prescribe for the sick. ... In each case the accepted causation of the disease and the reasons for the special diet prescribed are briefly described. Medical men will find the dietaries and recipes practically useful, and likely to save them trouble in directing the dietetic treatment of patients. " We recommend it cordially to the attention of all practitioners; . . . . both to them and to their patients it may be of the greatest service."—Medical Journal, New York. DIETS FOR INFANTS AND CHILDREN IN HEALTH AND IN DISEASE. By Louis Starr, M. D., Editor of "An American Text- Book of the Diseases of Children." 230 blanks (pocket-book size), per- forated and neatly bound in flexible morocco.. Price, $1.25 net. The first series of blanks are prepared for the first seven months of infant life; each blank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulce for the prepara- tion of diluents and foods are appended. DIET LISTS AND SICK-ROOM DIETARY. By Jerome B. Thomas, M. D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home; Assistant Visiting Physician to the Kings County Hospital; Assistant Bacteriologist, Brooklyn Health Department. Price, $1.50. Send for sample sheet. There is here offered, in portable form, as an efficient aid to the better practice of Therapeutics, a collection of detachable Diet Lists and a Sick-room Dietary. It meets a want, for the busy practitioner has but little time to write out Systems oj Diet appropriate to his patients, or to describe the preparation of their food. Compiled from the most modern works on dietetics, the Dietary offers a variety of easily-digested foods. " A convenience that will be appreciated by the physician."—Medical Journal, New York. " The work is an excellent one, and ought to be welcomed by physician, patient, and nurse- alike.''—Indian Lancet, Calcutta. Practical, Exhaustive, Authoritative. SAUNDERS' NEW AID SERIES OF MANUALS. FOR STUDENTS AND PRACTITIONERS. Mr. Saunders is pleased to announce the successful issue of several volumes of his NEW AID SERIES OF MANUALS, which have received the most flattering commendations from Students and Practitioners and the Press. As publisher of the Standard Series of Question Compends, and through intimate relations with leading members of the medical profession, Mr. Saunders has been enabled to study progressively the essential desiderata in practical "self-helps " for students and physicians. This study has manifested that, while the published "Question Compends" earn the highest appreciation of students, whom they serve in reviewing their studies preparatory to examination, there is special need of thoroughly reliable handbooks on the leading branches of Medicine and Surgery, each subject being compactly and authoritatively written, and exhaustive in detail, without the intro- duction of cases and foreign subject-matter which so largely expand ordinary text- books. The Saunders Aid Series will not merely be condensations from present literature, but will be ably written by well-known authors and practitioners, most of them being teachers in representative American Colleges. This new series, therefore, will form an admirable col- lection of advanced lectures, which will be invaluable aids to students in reading and in comprehending the contents of " recommended " works. Each Manual will further be distinguished by the beauty of the new type; by the quality of the paper and printing; by the copious use of illustrations; by the attractive binding in cloth; and by the extremely low price at which they will be sold. 23 Saunders' New Aid Series of Manuals. VOLUMES PUBLISHED. PHYSIOLOGY, by Joseph Howard Raymond, A.M., M.D., Professor of Physi- ology and Hygiene and Lecturer on Gynecology in the Long Island College Hos- pital ; Director of Physiology in the Hoagland Laboratory; formerly Lecturer on Physiology and Hygiene in the Brooklyn Normal School for Physical Education; Ex-Vice-President of the American Public Health Association; Ex-Health Commis- sioner, City of Brooklyn, etc. Illustrated. $1.25 net SURGERY, General and Operative, by John Chalmers DaCosta, M. D., Demon- strator of Surgery, Jefferson Medical College, Philadelphia; Chief Assistant Sur- geon, Jefferson Medical College Hospital; Surgical Registrar, Philadelphia Hospital, etc. 188 illustrations and 13 plates. (Double number.) $2.50 net DOSE-BOOK AND MANUAL OF PRESCRIPTION-WRITING, by E. Q. Thornton, M. D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Price, cloth, $1.25 net. SURGICAL ASEPSIS, by Carl Beck, M. D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Price, cloth, $1.25 net. MEDICAL JURISPRUDENCE, by Henry C. Chapman, M. D., Professor of Insti- tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia; Member of the College of Physicians of Philadelphia, of the Acade- my of Natural Sciences, of the American Philosophical Society, and of the Zoologi- cal Society of Philadelphia. Illustrated. $1.50 net. SYPHILIS AND THE VENEREAL DISEASES, by James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases, in Rush Medical College, Chicago. Profusely Illustrated. (Double number.) $2.50 net. PRACTICE OF MEDICINE, by George Roe Lockwood, M. D., Professor of Practice in the Woman's Medical College of the New York Infirmary; Instructor of Physical Diagnosis of the Medical Department of Columbia College; Attending Physician to the Colored Hospital; Pathologist to the French Hospital; Member of the New York Academy of Medicine, of the Pathological Society, of the Clinical Society, etc. Illustrated. (Double number.) $2.50 net. MANUAL OF ANATOMY, by Irving S. Haynes, M. D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Department of the New York University, etc. Beautifully Illustrated. (Double number.) Price, $2.50 net. MANUAL OF OBSTETRICS, by W. A. Newman Dorland, M. D., Asst. Demon- strator of Obstetrics, University of Pennsylvania; Chief of Gynecological Dispen- sary, Pennsylvania Hospital; Member of Philadelphia Obstetrical Society, etc. Profusely illustrated. (Double number.) Price, §2.50 net. VOLUMES IN PREPARATION. MATERIA MEDICA, by Henry A. Griffin, A. B., M.D., Assistant Physician to the Roosevelt Hospital, Out-patient Department, New York City. NOSE AND THROAT, by D. Braden Kyle, M. D, Chief Laryngologist of the St. Agnes Hospital, Philadelphia; Bacteriologist of the Orthopaedic Hospital and Infirmary for Nervous Diseases; Instructor in Clinical Microscopy and Assistant Demonstrator of Pathology in the Jefferson Medical College, etc. NERVOUS DISEASES, by Charles W. Burr, M. D., Clinical Professor of Nervous Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopaedic Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph Hospital, etc. MANUAL OF PATHOLOGY, by Alfred Stengel, M. D., Instructor in Clinical Medicine, Medical Department University of Pennsylvania etc. *** There will be published in the same series, at close intervals, carefully-prepared works on the subjects of Children, Gynecology, Hygiene, etc., by prominent specialists. 2 SAUNDERS' QUESTION COMPENDS. Arranged in Question and Answer Form. THE LATEST, CHEAPEST, AND BEST ILLUSTRATED SERIES OP COMPENDS EVER ISSUED. Now the Standard Authorities in Medical Literature with Students and Practitioners in every City of the United States and Canada. THE REASON WHY They are the advance guard of "Student's Helps"—that DO HELP; they are the leaders in their special line, well and authoritatively written by able men, who, as teachers in the large col- leges, know exactly what is wanted by a student preparing for his examinations. The judgment exercised in the selection of authors is fully demonstrated by their professional elevation. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of them have become Pro- fessors and Lecturers in their respective colleges. Each book is of convenient size (5x7 inches), containing on an average 250 pages, profusely illustrated, and elegantly printed in clear, readable type, on fine paper. The entire series, numbering twenty-three volumes, has been kept thoroughly revised and enlarged when necessary, many of them being in their fourth and fifth editions. TO SUM UP. Although there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of them approach the " Blue Series of Question Compends;" and the claim is made for the following points of excellence: I. Professional distinction and reputation of authors. 2. Conciseness, clearness, and soundness of treatment. 3. Size of type and quality of paper and binding. V* Any of these Compends will be mailed on receipt of price (see over for List). 25 26 W. B. SAUNDERS ILLUSTRATED Saunders' Question-Compend Series. —i <«» — #saP Price, Cloth, $1.00 per copy, except when otherwise noted. i. ESSENTIALS OF PHYSIOLOGY. 3d edition. Illustrated. Revised and enlarged. By H. A. Hare, M. D. (Price, #1.00 net.) 2. ESSENTIALS OF SURGERY. 5th edition, with an Appendix on Antiseptic Surgery. 90 illustrations. By Edward Martin, M. D. 3. ESSENTIALS OF ANATOMY. 5th edition, with an Appendix. 180 illustrations. By Charles B. Nancrede, M. D. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 4th edition, revised, with an Appendix. By Lawrence Wolff, M. D. 5. ESSENTIALS OF OBSTETRICS. 3d edition, revised and enlarged. 75 illustrations. By W. Easterly Ashton, M. D. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. 6th thousand. 46 illustrations. By C. E. Armand Semple, M. D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION-WRITING. 4th edition. By Henry Morris, M. D. 8, 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M. D. An Appendix on Urine Examination. Illustrated. By Lawrence Wolff, M. D. 3d edition, enlarged by some 300 Essential Formulae, selected from eminent authorities, by Wm. M. Powell, M. D. (Double number, price $2.00.) 10. ESSENTIALS OF GYNECOLOGY. 3d edition, revised. With 62 illustrations. By Edwin B. Cragin, M. D. ii. ESSENTIALS OF DISEASES OF THE SKIN. 3d edition, revised and enlarged. 71 letter-press cuts and 15 half-tone illustrations. By Henry W. Stelwagon, M. D. (Price, $1.00 net.) 12. ESSENTIALS OF MINOR SURGERY, BANDAGING, AND VENEREAL DISEASES. 2d edition, revised and enlarged. 78 illustrations. By Edward Martin, M. D. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 130 illustrations. By C. E. Armand Semple, M. D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 124 illustrations. 2d edition, revised. By Edward Jackson, M. D., and E. Baldwin Gleason, M. D. 15. ESSENTIALS OF DISEASES OF CHILDREN. 2d edition. By William M. Powell, M. D. 16. ESSENTIALS OF EXAMINATION OF URINE. Colored " Vogel Scale," and numerous illustrations. By Lawrence Wolff, M. D. (Price, 75 cents.) 17. ESSENTIALS OF DIAGNOSIS. By S. Solis-Cohen, M. D., and A. A. Eshner, M.D. 55 illustrations, some in colors. (Price, $1.50 net.) 18. ESSENTIALS OF PRACTICE OF PHARMACY. By L. E. Sayre. 2d edition, revised and enlarged. 20. ESSENTIALS OF BACTERIOLOGY. 2d edition. 81 illustrations. By M V Ball, M. D. 21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. 48 illustrations. 2d edition, revised. By John C. Shaw, M. D. 22. ESSENTIALS OF MEDICAL PHYSICS. 155 illustrations. 2d edition, revised By Fred J. Brockway, M. D. (Price, $1.00 net.) 23. ESSENTIALS OF MEDICAL ELECTRICITY. 65 illustrations. By David D. Stewart, M. D., and EdWard S. Lawrance, M. D. 24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M. D. 89 illustrations. CATALOGUE OF MEDICAL WORKS. JUST PUBLISHED. A TEXT-BOOK OF MATERIA MEDICA, THERAPEUTICS, AND PHARMACOLOGY. By George F. Butler, Ph. G., M. D., Professor of Materia Medica and of Clinical Medicine in the College of Physicians and Surgeons, Chicago ; Professor of Materia Medica and Thera- peutics, Northwestern University, Woman's Medical School, etc. 8vo, 858 pages. Illustrated. Prices: Cloth, $4.00 net; Sheep or Half-Morocco, 55.00 net. A clear, concise, and practical text-book, adapted for permanent reference no less than for the requirements of the class-room. The arrangement (embodying the synthetic classification of drugs based upon therapeutic affinities) is believed to be at once the most philosophical and rational, as well as that best calculated to engage the interest of those to whom the academic study of the subject is wont to offer no little perplexity. Special attention has been given to the Pharmaceutical section, which is exceptionally lucid and complete. In giving the Latin accent and quantity of medicinal nomenclature {Foster), the design has been to correct a prevalent disregard of proper pronunciation. FORTHCOMING PUBLICATIONS. ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THO- RAX. By Arthur M. Corwin, A. M., M. D., Demonstrator of Physical Diagnosis in the Rush Medical College, Chicago; Attending Physician to the Central Free Dispensary, Department of Rhinology, Laryngology, and Diseases of the Chest. Nearly ready. ANOMALIES AND CURIOSITIES OF MEDICINE. By George M. Gould, M. D., and Walter L. Pyle, M. D. Profusely illustrated with wood-cuts, half-tones, and colored plates. Large 8vo volume. In preparation. An encyclopedic collection of bizarre cases and of the most striking instances of deviations from the normal in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, conveniently grouped in the text, and indexed for ready reference. SURGICAL DIAGNOSIS AND TREATMENT. By J. W. Mac- Donald, M. D., Graduate of Medicine of the University of Edinburgh; Licentiate of the Royal College of Surgeons of Edinburgh; Professor of the Practice of Surgery and of Clinical Surgery in Minneapolis College of Physicians and Surgeons; Surgeon to Wisconsin Central Railway, etc. TEXT-BOOK OF EMBRYOLOGY. By John C. Heisler, M. D., Pro- sector to the Professor of Anatomy, Medical Department of the University of Pennsylvania. A MANUAL OF ORTHOPEDIC SURGERY. By James E. Moore, M. D., Professor of Orthopedia and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. A^J> « NOW READY—VOLUME FOR 1896. SAUNDERS' American Year-Book of Medicine and Surgery COLLECTED AND ARRANGED BY EMINENT AMERICAN SPECIALISTS AND TEACHERS, 85 UNDER THE EDITORIAL. CHARGE OF § GEORGE M. GOULD, M.D. to C Notwithstanding the rapid multiplication of medical and surgical works, ^ still these publications fail to meet fully the requirements of the general physician, > inasmuch as he feels the need of something more than mere text-books of well- ^ known principles of medical science. Mr. Saunders has long been impressed with % this fact, which is confirmed by the unanimity of expression from the profession ^ at large, as indicated by advices from his large corps of canvassers. g This deficiency would best be met by current journalistic literature, but © most practitioners have scant access to this almost unlimited source of informa- ^ tion, and the busy practiser has but little time to search out in periodicals the S» many interesting cases, whose study would doubtless be of inestimable value in his *g practice. Therefore, a work which places before the physician in convenient form .S an epitomization of this literature by persons competent to pronounce upon |* The Value of a Discovery or of a Method of Treatment cannot but command his highest appreciation. It is this critical and judicial function that will be assumed by the Editorial staff of the " American Year-Book of Medicine and Surgery." It is the special purpose of the Editor, whose experience peculiarly qualifies him for the preparation of this work, not only to review the contributions to American journals, but also the methods and discoveries reported in the leading medical journals of Europe, thus enlarging the survey and making the work characteristically international. These reviews will not simply be a series of undigested abstracts indiscriminately run together, nor will they be retro- spective of "news" one or two years old, but the treatment presented will be synthetic and dogmatic, and will include only what is new. Moreover, through expert condensation by experienced writers, these discussions will be Comprised in a Single Volume of about 1200 Pages. The work will be replete with original and selected illustrations skilfully reproduced, for the most part, in Mr. Saunders' own studios established for the purpose, thus ensuring accuracy in delineation, affording efficient aids to a right comprehension of the text, and adding to the attractiveness of the volume. Prices: Cloth, $6.50 net; Half Morocco, $7.50 net. W. B. SAUNDERS, Publisher, 925 Walnut Street, Philadelphia* : .. / >*if ■ ■iv?• * '■'v|^;vi:; ;-;iJ- •'•' •" '*v!i.-.'-:i.,'..' «*.' •, '-*. .i'vv»J ">M&:V ■ *••''£ C" .::.'.g^>v;::;; • »/.,V»V. v.'. .• ..