THE BOSTON 
MEDICAL AND SURGICAL JOURNAL. 
VOL. XCIL —THURSDAY, JANUARY 14, 1875. — NO. 2. 
THE TRUE NECK OF THE FEMUR: ITS STRUCTURE AND 
PATHOLOGY.1 - 
- r "y . 
BY HENRY J. BIGELOW, M. D. U 
PAT,,0,00V. 
IMPACTED FRACTURES.,- T.. 
0 
POSTERIOR IMPACTED FRACTURE OF THE RASE OF THE cTAviX.2 
The posterior impacted fracture of the base of the cervix often occurs 
in old people. 1 have met with it also in middle life, and do not hesi- 
tate to express the belief that it is the most common of the fractures of 
the neck of the thigh bone. That it has not been so considered may be 
explained by the following considerations: — 
1. It has been generally recognized only of late years. 
2. The injury may be a comparatively slight one. 
o. Its signs are in some cases a shortening and eversion hardly per- 
ceptible. 
4. When it unites, there may be no lameness to attract subsequent 
attention. 
5. When it proves fatal before union, the impaction may have been 
disengaged by manipulation or otherwise, during life or after death,— 
especially by macerating the specimen for preservation. 
6. On the other hand, unimpacted fracture of the small part of the 
neck, usually supposed to be most common, is marked by prominent 
symptoms : it entails great and persistent lameness, inviting attention 
and examination after death, however remote, and the specimen when 
obtained is unmistakable. 
The displacement varies greatly in degree. One wall only—the 
posterior one — is impacted at the intertrochanteric line, where the bone 
is a mere shell, driving the true neck, or the remains of it, farther be- 
neath the trochanters, and Sometimes detaching the latter. The firm 
anterior wall resists impaction, but bends at the line of fracture as a 
hinge. If this hinge were vertical, the shaft would be only everted ; 
while if it were transverse, the neck would be ouly beut and the leg 
shortened. Hut as the hinge stands at an angle of about 45°, shorten- 
O O 7 
1 Concluded from 5. 
2 7, 8, and 9. 30 
The True Neck of the Femur: 
Jan. 14, 
ing and eversion are nearly equal Impaction, when slight, is detected 
by a difficulty of inverting the foot rather than by actual eversion ; and 
the shortening may seem doubtful. 
It is needless to say that the rotated trochanter still sweeps through 
an arc of which the head of the femur is the centre, and that there is 
no crepitation. Shortening and eversion, however inconsiderable, point 
directly to this lesion. A large number both of cases and of specimens 
are referrible to this type, — impaction behind, with a hinge in front, 
each at its respective intertrochanteric iine. In some of these speci- 
mens the neck is bent down nearly to a right angle with the shaft. 
The remaining varieties of fracture of the femoral neck are suscepti- 
ble of classification, and deserve, for the purpose of comparison, to be 
mentioned in this connection. 
IMPACTED FRACTURE OF THE HEAD OF THE FEMUR.1 
The impacted fracture of the head of the femur is rare, and I do not 
believe it possible to distinguish it from that just described, even if it 
wrere desirable to do so. In three cases I have known, there was the 
same shortening and eversion, and the same comparative ability to move 
the limb. A woman who has just died of the injury was able to get 
into and out of bed with but little assistance, and the trochanter, when 
rotated, swept through its arc. There was no union. The small ex- 
tremity of the cervix was rather “ rebated ” than impacted with the 
head of the femur, and the fracture was “ within the capsular liga- 
ment.” 2 
The firmness of the fragments in such a case is chiefly due to the 
dense central cone of spongy tissue which projects from the head of the 
bone and impacts itself in the friable cavity of the cervix. If the cylin- 
der of the cervical portion is simultaneously impacted into the head of 
the femur, around the base of the cone, immobility is doubly insured. 
I have elsewhere expressed the opinion that these conditions are es- 
sential to the very exceptional occurrence of bony union of the small 
part of the cervix. In default of anchylosis, the neck is doubtless ab- 
sorbed, presenting, after a time, the familiar conditions of an old “ un- 
united fracture.” So that permanent lameness may result from a fract- 
ure which, by simulating impaction of the base, promises, at first, bony 
union, with comparatively little deformity. 
IMPACTED FRACTURE OF THE WHOLE OF THE CERVIX WITH 
INVERSION.3 
The very rare impacted fracture of the neck with inversion, instead 
1 Fig. 10. 
2 See extracts from the Proceedings of the Society for Medical Improvement, this Joubnal, 
No. 1, 1875, p. 20. 
3 Figs. 11 and 12. 1875.; 
Its Structure and Pathology. 
31 
of eversion which is the rule, occurs when the neck in front slips off 
its hinge into the cavity of the shaft. This is hardly possible, as I have 
elsewhere shown, unless the whole posterior intertrochanteric mass, in- 
cluding the trochanters, is fairly detached. 
UNIMPACTED FRACTURES. 
FRACTURE OF THE SMALL PART OF THE CERVIX OF THE FEMUR. 
The fracture of the small part of the cervix of the femur, which has 
been usually described as the most common fracture of elderly people, 
and erroneously as deriving importance from being within the capsular 
ligament, is a loose fracture, with no interlocking to maintain the im- 
mobility of the small extremities, even were they disposed to bony 
union. Familiarly characterized by increased motion, great pain and 
disability, much shortening, marked eversion, and the rotation of the 
shaft upon its axis instead of through an arc, it is not likely to be mis- 
taken even at first sight. But its relations to the capsular ligament are 
probably uncertain, owing to differences in the size and insertions of the 
latter. 
COMMINUTED FRACTURE OF THE TROCHANTERS AND SHAFT. 
Lastly, when the trochanteric portion of the femur is comminuted, the 
detached neck and head of the bone may be very variously placed in 
bony union, both as to angle and as to the part which becomes subse- 
quently attached to the shaft. 
In completing the list of injuries to be borne in mind while exam- 
ining a hip with reference to impacted fracture, we may enumerate dis- 
location, sprain, crack, the rare separation of the epiphyses, and the 
fracture of the acetabulum into the pelvis. 
TREATMENT. 
A few words of a practical character may be added here. Apart 
from dislocation, the main object of examination is to decide, with refer- 
ence to treatment, whether a fracture is loose or impacted. I have 
demonstrated here and elsewhere the following points, illustrating the 
difficulty of further diagnosis : — 
1. The common impacted fracture of the base of the neck and the 
rare one of the head may be indistinguishable from each other. 2. A 
fracture seemingly impacted and promising bony union may yet result 
in ligamentous union with corresponding lameness. 3. In loose fract- 
ures with great shortening, it may be sometimes difficult to distinguish 
a fracture of the small part of the neck, which does not promise bony 
union, from that of the trochanters, which does. 
But while an accurate diagnosis of such cases is sometimes absolutely 
impossible, no embarrassment need be felt in the treatment of these 
injuries. Their treatment is simple. 32 
The True Neck of the Femur, Etc. 
[Jan. 14, 
If to extend a limb means to draw it down, impacted fracture and 
whatever resembles it should never be extended ; but only steadied by 
weight or splint. On the other hand, a loose fracture with decided 
shortening should be first drawn down to something like its normal length. 
Or, more briefly, treatment consists in immobility, with the previous ex- 
tension of a loose fracture. 
A careful review of these injuries thus leads back to a practical rule 
already usually adopted. But it leads further, and demonstrates con- 
clusively that prolonged and active flexion and rotation of the hip, in 
search of positive signs, is more than superfluous. Without amesthe- 
sia it entails needless suffering, and with or without it, by loosening 
impaction or lacerating tissues, it may be disastrous. 
The question of dislocation settled, a very brief and gentle examina- 
tion is alone admissible ; chiefly to determine (1) the degree of short- 
ening, (2) whether the shaft rotates through an arc or on its axis. 
The most useless and damaging examination is that by quick and per- 
sistent rotation, and by flexion of the thigh as far as a right angle. 
The prognosis, if the patient lives, is favorable for bony union, except 
in the case of loose fracture of the small part of the cervix, which, if not 
readily distinguished, had better be disturbed as little as possible. 
Familiarity with the posterior impacted fracture of the base of the 
neck will remove the most frequent source of doubt in the diagnosis of 
injuries of this region ; anil the sooner the old classification “ intra and 
extra capsular fracture ” is abandoned, the better it will be for science, 
for diagnosis, and for treatment. In the interest of the patient and of 
treatment the question should be, “ Is the fracture loose or impacted?” 
and science is often compelled to rest satisfied when this is settled. 
EXPLANATION OF FIGURES. 
Fig. 7. Front view of right femur showing the fractured cervix bending like a hinge at the 
anterior intertrochanteric line, to allow the posterior impaction. The head of the bone leans 
more distinctly from the observer than the perspective indicates. 
Fig. 8. Rear view of same, showing the cervix impacted beneath the posterior inter- 
trochanteric line. The head of the bone leans towards the observer. 
Fig. 9. Horizontal section of the same, showing the anterior hinge and the posterior impac- 
tion. The dotted line shows the normal position of the head. The patient who furnished 
the specimen from which these figures were taken was seventy-two years of age. It will be 
seen that the prolongation of the true neck has disappeared by senile atrophy, leaving only 
a few radiating lamellae. The specimen is of exceptional interest as showing this form of 
impaction with little comminution or other injury of the bone. 
Fig. 10. Impacted fracture of the head of the femur. The patient who furnished this 
specimen died of pneumonia in two weeks. 
Figs. 11 and 12. Impacted fracture of the base with inversion. The anterior view (Fig. 
11) shows the neck slipped otf its thick hinge, into the cavity of the shaft. To allow this, 
the whole trochanteric mass must have been detached, as seen in the rear view. (Fig. 12.) 
Fig. 13. (See first half of this paper.) Diagram of a section of the head of the femur 
of a sheep, showing a deep trochanteric fossa. If this fossa were filled with spongy tissue 
(as seen beneath the dotted line), the posterior neck would be partially concealed, as in the 
human femur. The analog}', whether true or not, is too striking to be overlooked. A 1875.] 
A Cane of Immediate Transfusion. 
33 
deeper fossa exists in certain animals, especially South African ruminants, of which I ex- 
amined sections in the Hunterian Museum in 1868. In this specimen the tendon inserted at 
the bottom of the fossa is prolonged into the spongy tissue by radiating lamellae which 
intersect concentric arches as represented in the diagram, and resist traction to great ad- 
vantage. 
In examining a number of preparations lately made by my friend Dr. Dwight, I am 
satisfied that the tendency of what I have called the true neck is to attach itself below, 
where it becomes thin, as a tangent to the inside of the cylinder of the shaft; and also that 
it may be tolerably well pronounced in a subject six or eight years of age. 
A CASK OF IMMEDIATE TRANSFUSION. 
BY .JAMBS R. CHADWICK, M. D., OF BOSTON. 
Mrs. M. N., thirty-two years of age, entered the Massachusetts Gen- 
eral II ospital on May 27th, 1874, eleven weeks after the delivery of her 
second child. The labor had been short, but attended by profuse haem- 
orrhage ; this haemorrhage had recurred frequently until two weeks be- 
fore her entrance to the hospital, when it ceased. The convalescence 
had been satisfactory in other respects, so that she was able to be out at 
the end of the third week. The repeated losses of blood, however, soon 
began to undermine her health, previously robust, until she was com- 
pletely blanched, had a persistent headache, and frequent attacks of 
syncope; she was in this condition on entering the hospital. Bowels 
constipated, pulse 108, urine dark-colored. 
May 28th. Iron, eggs, broth, and two ounces of sherry three times 
daily were ordered. Dr. F. Minot, in whose ward the patient lay, 
invited me to perform transfusion, if I thought advisable. On learning 
her history, I declined to operate until the ordinary methods of treat- 
ment had been tried and found inefficient, not deeming the case a favor- 
able one for transfusion. 
On June 2d she was failing, had had nausea and vomiting all night. 
June 3d. Less vomiting. Dr. Minot notified me that she was sinking. 
In view of this I agreed to operate on the following morning. At 6 
o’clock p. m. I took these notes of her condition : Great emaciation, 
sallow waxy complexion, extreme prostration ; pulse 118, respiration 
30, temperature, 102.8°. A loud souffie with the first sound of the 
heart was considered to be anaemic. No bruit du diable over the jugu- 
lar veins. Areas of hepatic and splenic dullness were not enlarged. A 
drop of blood from her finger was seen to be very deficient in color; 
under the microscope, the number of both red and white corpuscles was 
found to be greatly diminished when compared directly with healthy 
blood. Urine normal, no albumen by nitric acid test; urophaein in- 
creased, uroxanthin normal. With microscope no casts, but very few 
and doubtful disintegrated blood corpuscles. 
June 4th. Operation, with the assistance of Drs. Minot, Ellis, Lyman, 34 
A Case of Immediate Transfusion.. 
[Jan. 14, 
C. P. Putnam and J. J. Putnam, of Boston, E. J. Forster of Charlestown, 
L. Wheeler of Worcester, and a number of house-officers and students. 
Dr. J. J. Putnam furnished the blood. Aveling’s instrument for imme- 
diate transfusion was used. Dr. Putnam, having seated himself upon a 
stool beside the bed, extended his left arm by the side of the patient’s 
right arm. A fold of skin over the median basilic vein of the patient 
was then raised and a transverse incision made : the wound gaped so as 
to expose the vein to view. The anterior wall of the latter was raised 
by the forceps, and a Y-shaped cut made with the scissors. The affer- 
ent nozzle was next taken from the basin, with the fore-finger closely 
applied to its external end to prevent the escape of the warm water; it 
was inserted into the vessel without difficulty, and intrusted to an assist- 
ant. A direct longitudinal incision was then made into Dr. Putnam’s 
median cephalic vein, but the attempt to introduce the efferent nozzle 
failed, despite persistent efforts, owing, I believe, to the bifurcation of 
the vessel just below the opening. Dr. C. P. Putnam now offered his 
arm, and a similar cut was made directly into the left radial vein ; the 
nozzle, however, could not be inserted until a slight transverse incision 
had been made in the integument. The afferent nozzle had by this time 
become filled with blood, so that it had to be withdrawn from the 
patient’s vein, cleared of the clots, refilled with water and reinserted. 
The rubber tube, likewise filled with warm water, was then affixed to the 
nozzles, and the process of transfusion inaugurated by the injection o 
the syringeful of water into the vein, and prosecuted by the repeated 
filling and emptying of the bulb. 
According to the printed directions, sold with the instrument by 
Messrs. Krohne and Sesemann, of London, the bulb should hold two 
drachms ; on this assumption I based my calculation as to the amount 
of blood transfused, but a recent measurement of my bulb reveals its 
capacity to be precisely four drachms, a discrepancy of most vital im- 
portance, and one which, in my opinion, contributed largely to bring 
about the fatal result hereinafter recorded. 
The following notes were taken during the operation : — 
After sixth evacuation of bulb, pulse 118, some nausea, patient com- 
plains of heart-beat and backache. More color in lips and cheeks. 
After eleventh, pulse fuller, now 108. 
After thirteenth, pulse fuller, now 104 ; bulb empties less freely. 
After nineteenth, pulse 104. 
After twentieth, bulb does not fill readily. 
After twenty-second, operation terminated. 
Some retching after withdrawal of nozzle. 
During the operation, Dr. Ellis applied the stethoscope to the chest 
several times, but failed to detect any change in the character of the 
respiration or of the heart-sounds. The anemic souffle was unaffected. 1875.] 
A Case of Immediate Transfusion. 
35 
Some difficulty was experienced in stanching the flow of blood from 
the incised vein. .Before I left, the patient expressed herself as feeling 
much better and stronger than before the operation; she was free 
from headache or backache. 
For the subsequent notes I am indebted to Mr. W. F. Whitney, 
medical house-officer of the hospital. 
10 a. m. Severe rigor, lasting nearly an hour. Extra blankets, 
brandy, heater to feet, and sulphate of morphia, one fifth of a grain sub- 
cutaneously, afforded relief. Brandy punch (3j.) was ordered to be 
given every hour. 
10.30 a. m. Temperature 106.3°. 
11 a. m. Temperature 106.4°. 
11.30 a. m. All oozing from wound has ceased. Pulse 134; tern- 
perature 105.3°. 
12 m. Has been vomiting constantly for the last hour. The bandage 
about the wound is found to have become loosened and at least four or 
five ounces of blood to have escaped into the bed. A ligature is put 
around the vein. Some vomiting. 
1 r. m. Temperature 104.2°. 
3.30 p. m. Vomiting ceased at 8 p. m. Patient is now delirious. 
4.30 p. m. Comatose ; temperature 103°. 
June 5. 8 a. m. Comatose during night; now conscious, recognizing 
husband. Stimulants. Failed during the day, and died at 7.30 P. M. 
Autopsy by Dr. Fitz, twenty-six hours after death ; the following are 
his notes: — 
Skin very pale. A watery blood is pressed from the proximal portion 
of the incised vein. Right hand moderately oedematous. 
Acute Internal Pachymeningitis. — Inner surface of the dura mater 
on both sides shows patches of a thin, delicate, translucent false mem- 
brane, very readily detached and containing numerous minute luumor- 
rhagic spots. 
Increased Fluid in Pericardium. — About two ounces of clear yellow 
fluid in pericardium. 
Anaemia.—The heart, in common with all the other organs of the 
body* except the spleen, is extremely anaemic. The valves and cavities 
are healthy; no thrombi in the latter, nor are any found in the pulmon- 
ary arteries after careful search. 
Spotted Fatty Degeneration of the Heart.— Almost the entire inner 
surface of the left ventricle is spotted with minute yellowish-white 
opaque points. A section through the walls reveals a similar appear- 
ance, but the spots are more thickly clustered and extend into the sub- 
stance for at least two thirds of its thickness. The right ventricle is in 
a like condition but to a considerably less extent. The microscope 
shows these spots to be due to fatty degeneration. 36 
A Case of Immediate Transfusion. 
Jan. 14, 
(Edema of Lungs. — Lungs extensively oedematous. Kidneys pale. 
Tubules of cortex indistinctly separated. About one third of right kid- 
ney is atrophied ; the surface is depressed, granular, dirty red, and 
tough. The veins leading from this part are filled with a firm, decolor- 
ized, adherent thrombus, similar to that found in one of the uterine 
veins, both being unmistakably of long standing. 
Retrogression of Uterus. — Uterus of normal size. Walls cut with 
greater ease than usual; surface of section opaque. The membrane 
lining the cavity presents a tripe-like aspect from the intersection of 
slightly elevated red ridges. 
The urine taken from the bladder at the autopsy was analyzed by 
Professor Wood with the following result: Color slightly smoky. Re- 
action slightly acid. Specific gravity, 1012.° Much sediment. Uro- 
phafin diminished. Uroxanthin increased. Urea, chlorides, and uric acid 
diminished. Sulphates, earthy and alkaline phosphates normal. Albu- 
men about one per cent. Sediment is chiefly bladder epithelium. Con- 
siderable pus. Few renal epithelial cells. A few brown, coarsely granular, 
and hyaline casts. One blood corpuscle seen in six specimens. The 
casts were chiefly large, but some were of medium and small size. 
Haematin was present, as shown by brown coagulum of albumen on heat- 
ing, and also by brown precipitate with sodic tungstate. 
Remarks. — Neither the train of symptoms presented by this patient, 
nor the pathological changes found post mortem give a clew to any seri- 
ous malady other than universal fatty degeneration. The atrophy of one 
kidney w7as clearly connected with the thrombosis of the renal and 
uterine veins, and may unquestionably be referred to the early days of 
childbed ; there was no indication that the functions of the kidneys were 
impaired. At the autopsy, the most careful search throughout the 
whole vascular system failed to discover any clot that could awaken 
a suspicion of embolism such as might be caused by coagulation of blood 
in transit through the tube. No froth or air-bubbles were found in the 
© 
vessels. 
The fatty degeneration of all the internal organs, and especially of the 
heart, was the direct result of imperfect nutrition, due to the frequent 
losses of blood. The diminution in the volume of the circulation, which 
is the first effect of a ha3morrhage, is soon corrected by the osmotic ex- 
traction of serum from all the tissues of the body, but a corresponding 
deterioration in the quality of the blood results. This poverty of the 
blood, nature can rectify, if she is given time. Multiply the large losses 
of blood at short intervals, howrever, and she succumbs in the effort to 
make good the extraordinary waste ; not oidy does nutriment fail, but 
the circulating medium, by means of which it is distributed throughout 
the economy, is wanting. No wonder, then, that the system is poorly 
nourished, and soon becomes too far reduced to carry on the functions ot 1875.] 
A Case of Immediate Transfusion. 
37 
life. This dependence of fatty degeneration upon frequent losses of 
blood has been recently pointed out by Gusserow,1 Ponfick,2 Perl,° and 
others. Ponfick describes the identical spotted fatty heart—of normal 
size and sound valves— found at our autopsy, as occurring particularly 
in women who have lost much blood in childbed. According to him, it 
is associated with a marked reduction in the number of the red blood 
corpuscles and in tbe amount of fibrine. Dropsy is almost constant. 
Perl succeeded in developing this fatty degeneration of the heart in dogs, 
by bleeding them a few times to a great extent. When small amounts 
of blood were abstracted quite frequently, no such result was obtained. 
The direct practical bearing of these remarks becomes apparent 
when we realize that the introduction of blood into the vascular system, 
when it is already filled to about its natural capacity, is quite a different 
matter from infusing blood when the vessels are empty and collapsed. 
In the former case, the vascular tension is increased far beyond the 
normal ; the cavities of the heart are obliged to dilate far beyond their 
natural limits, and must then contract with more than their habitual 
force in order to propel tbe augmented volume of the circulation 
through the comparatively narrow channels. In short, a severe task is 
imposed upon the heart, for which, in such instances as the present, 
it is incapacitated by disease. By transfusion we seek to better the 
quality of the blood, but this end may generally be compassed by other 
means, so that we have no right to employ transfusion, with its attend- 
ant risks, until the other remedies have failed. 
The fatal termination in this case was certainly inevitable, but was 
in all probability hastened by the shock of the operation and the subse- 
quent haemorrhage, with the attendant mental perturbations, but more 
particularly by the direct strain to which the heart was subjected by 
increasing tbe volume of the circulation. 
These views had not taken so definite a shape in my mind before the 
operation ; yet for these very reasons I had designed to restrict the 
amount transfused to six ounces. In this I was foiled by the erroneous 
statement of the description bought with my instrument. I transfused 
eleven ounces instead of six as I supposed, an error — as may be in- 
ferred from what has gone before—most prejudicial to the chances of 
the patient. Recent reflection has convinced me that transfusion is at- 
tended by great risk in chronic cases associated with fatty degeneration 
of the heart, and that this state of the heart is to be suspected in all 
patients who have been subject to repeated losses of blood. If we de- 
cide to employ transfusion, in spite of this unfavorable element, the 
danger must be as far as possible averted by the introduction of a very 
small amount of blood at one time, and repeating the process later it 
1 Archiv fiir Gynaekologie, 1871, page 218. 
2 Berliner Ivlinische Wochenschrift, 1873, No. 1. 
8 Virchow’s Archiv, 1874, page 39. 38 
A Case of Immediate Transfusion. 
[Jan. 14, 
required; or the poor blood of the patient must he allowed to escape 
from one arm, while the healthy blood is being injected into the other. 
Acting upon these convictions I have advised against the operation 
in several consultations to which I have been summoned during the 
past summer. On one occasion I was persuaded to go sixty miles to 
transfuse lamb’s blood into the veins of a consumptive. I went after 
repeated solicitations and a distinct disavowal—on my part — of any 
belief in the curative agency of transfusion in such diseases. On ex- 
amining the patient I found, in addition to extensive disease of both 
lungs, very labored action of the heart, and obtained the history of 
much pain and distress in the cardiac region, and a number of fainting 
turns during the previous month ; the patient was likewise greatly ema- 
ciated. I represented to the man the peculiar danger which would at- 
tend the transfusion of blood into his veins, and finally persuaded him to 
renounce the project. A month later, however, a more daring surgeon 
from New York, a German, successfully transfused six ounces of lamb’s 
blood into the patient. My prognostications of the exceptional risk 
were fully verified by the unusual symptoms subsequent to the opera- 
tion. There were “sharp pains throughout the back, chest, and limbs” 
immediately after the operation ; on the next day, again “ acute pains 
in the back ; ” on the following morning, “ two fainting spells in quick 
succession,” and a pulse.of 130; on the fourth morning, “ palpitation of 
the heart ” for half an hour, and again in the afternoon lasting two 
hours. Since that date no untoward symptoms have occurred, but the 
patient has recently published a card in the local journals announcing 
that his condition has not been improved by the operation, and warning 
others from trying the experiment. 
Aveling’s instrument worked well. The slight obstacle to the empty- 
ing of the bulb after the thirteenth evacuation I attributed at the time 
to a tilting upwards of the external end of the afferent nozzle in the 
hands of my assistant, whereby the oblique internal opening was forced 
against the wall of the vein and thus closed as by a valve. To this 
view I still hold. The tardy filling of the bulb after the twentieth 
evacuation may fairly be set down to the anaemic condition produced 
in the blood-donor after the loss of eleven ounces of blood. The diffi- 
culty of obtaining a steady flow from an incised vessel was, I am told, 
often experienced in the days of frequent blood-letting. I can quite 
understand, however, that these explanations may not seem satisfactory 
to those who look with disfavor upon immediate transfusion. 
In conclusion let me ask whether the fact that eleven ounces of 
blood were infused without sensibly modifying the anaemic souffle, 
taken in connection with the fatty degeneration of the heart, does not 
throw a little discredit upon the-; theory that this souffle is due to the 
impoverished condition of the blood ? May not further investigations 
demonstrate that it is symptomatic of a fatty heart ? 1875.] 
Recent Program in Medical Chemistry. 
39 
RECENT PROGRESS IN MEDICAL CHEMISTRY.1 
BY E. 8. WOOD, M. D. 
Phosphorus. — On account of tlie powerful attraction whicli phospho- 
rus has for oxygen, when the former is in a state of minute subdivision, 
as is frequently the case in substances suspected to contain it as a 
poison, and on account of the fact that that property of phosphorus 
which is chiefly relied upon in Mitscherlich’s test (its phosphorescence) 
can be prevented by the presence of many substances, such as turpen- 
tine, the generally accepted antidote, it is extremely desirable to have 
a good method by which phosphorus can be effectually isolated from 
organic mixtures without danger of becoming oxidized during the pro- 
cess. In addition to the method of I). A. Van Bastelaer,2 L. Dusart 
contributes another3 which has the advantage of enabling us to preserve 
for any desired length of time the phosphorus in the form of a stable 
compound ; with this compound one of the characteristic reactions of 
phosphorus can be obtained, and its non-oxidation is insured. This 
process depends first, upon the ready solubility of phosphorus in a mix- 
ture of equal parts of bisulphide of carbon, ether and alcohol ; secondly, 
upon the easy formation of a compound of sulphur and phosphorus, 
which is oxidized much less easily than free phosphorus ; and thirdly, 
upon the precipitation of the sulphide of phosphorus thus formed by 
metallic copper, a compound resulting which can be preserved for an 
indefinite period, and which, when subjected to the action of nascent 
hydrogen, disengages pliosplioretted hydrogen, an inflammable gas 
which burns with a green flame. 
The process is as follows: To the liquids to be examined is added 
the mixture of alcohol, ether, and bisulphide of carbon, in which one 
half per cent, of sulphur has been previously dissolved, in successive 
portions. This solution is added until itf forms an emulsion with the 
organic liquids. The solids to be examined are finely divided, covered 
with the solution, and repeatedly shaken. After twenty-four hours’ 
contact, the bisulphide of carbon solution is removed, and the residues 
treated in the same manner a second and a third time. The mixed 
bisulphide solutions are filtered rapidly into a retort, and metallic cop- 
per freshly reduced by hydrogen is added. Sufficient copper has been 
added when the last portions remain brilliant after warming a few 
minutes on a water-bath. This liquid, after standing twenty-four 
hours, should be distilled over a water-bath. After the distillation, 
there remains in the retort a little water, fatty matters which float on 
the surface of the water, a certain amount of extractive matter, and 
1 Concluded from page 12. 
2 See this Journal, January 1, 1874. 
8 Journal de Chimie Medicate, September, 1874. 40 
Recent Progress in Medical Chemistry. 
[Jan. 14, 
the compound of copper with the sulphur and phosphorus. These col- 
lected on a filter should be washed with alcohol and then with ether ; 
this process removes the fat and leaves the copper compound as a black, 
brilliant substance which undergoes no perceptible alteration when ex- 
posed to the air. When this substance is placed in a Marsh’s apparatus 
in which hydrogen is being generated, phosphoretted hydrogen is given 
off, which burns with a green flame. Sulphuretted hydrogen is also 
formed, and must be separated by passing the mixed gases through a 
tube filled with pumice-stone saturated with a strong alkaline hydrate. 
By this method, the phosphorus was detected in the paste made by 
mixing the ends of two matches with sixty grammes of bread, fatty 
matters, and like substances. 
The following question arose in France in consequence of a report off 
chemical experts who, finding in the organs of a cadaver, after death 
under suspicious circumstances, free phosphoric acid and an excess 
of crystals of triple phosphate, stated as their opinion that the probable 
cause of death was phosphorus poisoning: “ In the absence of the 
slightest trace of free phosphorus in the suspected matters, and also in 
the absence of all characteristic post-mortem appearances, such as fatty 
degeneration of the liver, can experts conclude that phosphorus poison- 
ing has taken place, because they have observed an abnormal amount of 
phosphoric acid and ammonio-magnesian phosphate in the substances 
submitted to chemical analysis? ” This question was referred to a com- 
mission consisting of MM. Gaillard, Grassi, Roucher, and Jules Lefort, 
who reported as follows: 1 “ The proportion of phosphoric acid found 
in the suspected matters submitted to chemical analysis is no convincing 
proof that poisoning bv phosphorus has taken place.” And, further, 
that “ neither the presence nor the quantity of phosphoric acid and crys- 
tals of ammonio-magnesian phosphate in the suspected matters can be 
considered as proofs of poisoning by phosphorus.” 
Analogy between Phosphorut, Arsenic, and Antimony. — Dr. Ch. Rou- 
cher refers 2 to a case of mild arsenic poisoning reported by Dr. Gaillard 
which has several points of interest. Fowler’s solution was prescribed for 
a patient, twenty-two years of age, for an obstinate eczema. Fifteen 
drops were ordered morning and night for fifteen days, fifteen drops three 
times a day for the next fifteen days, and after that twenty drops three 
times a day. This corresponds to about one quarter of a grain of white 
arsenic for the first fifteen days, one third of a grain for the second fifteen 
days, and one half a grain daily after the first month. The result was 
that the first doses were tolerably well borne, there being only slight dis- 
turbance of the stomach. The forty-five drops daily caused vomiting and 
more intense pain in the stomach. The sixty drops daily could not be 
1 Journal de Pharmacie et de Chimie, July and August, 1874. 
2 Annales d’Hygi&ne, October, 1874. 1375.] 
Recent Progress in Medical Chemistry. 
41 
borne, and as the skin disease was not cured, the patient gave up the treat- 
ment. A short time afterwards, however, the eczema disappeared. The 
arsenic caused some pain in the limbs with symptoms of paralysis. After 
omitting the Fowler’s solution, the paraplegia increased instead of dimin- 
ished. This being attributed by I)r. Gaillard (who first saw the patient 
five weeks after the omission of the Fowler's solution) to the continued 
presence of arsenic in the system, an examination of the urine was made 
and arsenic detected. Its elimination by the kidneys continued for six 
and one half weeks after discontinuing the medicine. Seven and one 
half weeks after its omission, no arsenic could be detected in the urine. 
After this period the paralysis rapidly disappeared. 
This case is remarkable, first, for the tolerance of such large doses by 
one unaccustomed to its use ; and, secondly, for the slowness of the 
elimination of the poison. Different authors give the time for the 
elimination of arsenic as from twelve days to a month, and many con- 
sider that the opinion can be given that, if arsenic is detected in the 
organs, it must have been ingested within a month before death. The 
above case, however, shows that it may require about fifty days for its 
complete elimination. Whether the elimination after chronic poisoning 
is slower than after acute remains to be decided. 
In connection with this case the author cites experiments with tartar 
emetic, and shows that the action upon the digestive organs, upon 
nutrition, and upon the nervous system are the same for both arsenic 
and antimony. In several cases of phosphorus poisoning reported bv 
Andante, M. Roucher finds similar symptoms produced as in chronic 
arsenic and antimony poisoning, and he is led to believe that the analogy 
which marks the chemical properties of these three closely allied ele- 
ments will be found to exist in regard to their physiological action also. 
On the Physiological Test for Poisons. — MM. Albertoni and Lus- 
sana 1 find that the extractive matters obtained from the various animal 
fluids and tissues produce death in animals when injected subcutane- 
ously or into the veins. The symptoms produced by such injections are 
first an increase and then a diminution in the frequency of the pulse, 
soon a lowering of the temperature, slow respiration, diarrhoea, and cer- 
tain convulsive and paralytic phenomena, most frequently paraplegia. 
Ordinary extract of meat, like Liebig’s extract, has precisely the same 
effect; also the substances extracted in the ordinary way from the or- 
gans of two sisters who died under suspicious circumstances proved fatal 
to animals when injected subcutaneously, the symptoms which were 
produced being the same as those caused by the extract of meat. They 
conclude, therefore, that it is impossible to affirm that certain organs 
contain a substance foreign to the organism and capable of producing 
death, because the extract from those organs has been found to cause 
the death of an animal when injected subcutaneously. 
1 Aunales d’llygiene, July, 1874. 42 
Recent Literature. 
[Jan. 14, 
MAREY ON ANIMAL MECHANISM.1 
Of late years several works have appeared treating of a greater or less part 
of this subject of Animal Mechanism. Though referring only to the human 
skeleton, the work of Meyer stands far in advance of all others. The views 
are correct, and, though hard reading, the book is intelligible. Haughton’s 
Animal Mechanics is for the most part incomprehensible to those of us who 
are not advanced mathematicians, but the looseness of the work in the parts we 
can understand enables us to bear our exclusion from the rest with philosophy. 
In Pettigrew’s Animal Locomotion 2 similar defects are to be observed, with the 
difference that as the author conceals liis ideas in mazes of words instead of 
labyrinths of figures, it is more easily criticised. With these works in our 
mind, we have looked forward with much interest to the work now before us. 
In certain respects we are much disappointed ; in others as much pleased. The 
work is divided into three books: the first treats of Forces and Organs, the 
second of Functions: Terrestrial Locomotion, and the third of Aerial Loco- 
motion. As may be inferred from the title, the first book embraces a pretty 
extensive field. We think it a mistake to devote so much space to the correla- 
tion of forces and such general principles, for the space does not admit of their 
receiving justice, and a superficial discussion is unprofitable. The whole of the 
first book is open to a similar criticism, as it treats of a great number of topics 
not essential to the plan of the work. Animal heat and electricity might, we 
think, be dispensed with. The discussion of the evolution theory is interesting 
and able. The author shows very well how the shape of the bones depends 
upon the arrangement of the muscles, vessels, etc., though we have doubts if 
the rule be absolutely true that “ there is not a single depression or projection 
in the skeleton the cause of which cannot be found in an external force, which 
has acted on the bony matter either to indent it or to draw it forward.” There 
is a good deal about the muscular system that is inaccurate, and a little that we 
think is quite wrong. The author follows Borelli with a blind confidence that 
accounts for some of these defects. He quotes this author’s comparison of a 
primitive muscular fibre with a chain composed of minute circular elastic rings, 
and speaks of the laws governing the manner in which it will recover itself 
after being stretched, apparently thinking this a parallel case to contraction 
from a state of repose. The author gives it as a law that “ the work done by 
a muscle will be in proportion to its length and its tranverse section ; that is to 
say, to its volume or to its weight.” To make this true, it is of course, neces- 
sary to assume that the “ substance of the muscles, that is to say, of red flesh, 
presents the same density in the different parts of the animal frame ; ” but he 
states this not as an assumption but as an acknowledged fact. We are unable 
to say this is not true, but we should like to have some proof of its truth before 
accepting it. Considering the great difference of coarseness of fibre in different 
parts of the body, and the different kinds of work required by different muscles, 
1 Animal Mechanism: A Treatise on Terrestrial and Aerial Locomotion. By E. J. Marey, 
Professor at the College of France. (International Scientific Series.) New York : D. Apple- 
ton & Co. 1874. Pp. 283. 
2 See this Journal, May 14, 1874. 1875.] 
Recent Literature. 
43 
we should think it very improbable that an ounce of muscle represented always 
the same potential force. Some muscles, like those of the orbit, are incessantly 
employed during the waking hours in moving a light unresisting body hither 
and thither; some, like the muscles of the back, must be kept for a great part 
of the time in partial contraction ; and again others have usually but little to 
do, and are occasionally called upon for a violent effort. It is hard to believe 
that the power of all these is the same. Ranvier a year ago showed that there 
were marked differences both in structure and manner of contracting between 
the red and the white muscles of the rabbit, and it is not impossible that anal- 
ogous distinctions can be drawn between different muscles of animals in which 
all are red. It is surely a serious error to speak of the rectus abdominis as a 
long muscle. By way of putting all our fault-finding together, we must say 
here that the translator appears to be quite ignorant of anatomy, for he makes 
utter nonsense of two passages (pp. 75 and 88) by translating the French for 
fibula (perone) into “ perinaeum.” 
Leaving general principles, the author turns to the discussion of the phe- 
nomena of locomotion on land, as shown by man and the horse; and through 
air, as shown by insects and birds. We shall limit our discussion to the 
movements of man. We regret that the mechanism by which movements are 
effected is not more considered, the author giving us merely the results but 
not all the steps by which the results are obtained. Thus, while showing the 
length of contact of each foot with the ground in walking, the rise and oscilla- 
tion of the pubes, etc., he says little of the muscular action by which this is 
accomplished. He ignores entirely the bending of the knee. But in spite of 
these defects, it is impossible to praise too highly the ingenuity displayed in 
contriving apparatus to record the results, and the accuracy with which it is 
accomplished. The following is a short summary of the movements in walk- 
ing. One foot is always on the ground, the one which has completed a step 
reaching the ground just before the other leaves it. The raising of the latter 
of course causes the former to bear all the weight, and to make the pressure 
necessary to start the body. The pressure is not equal throughout, but in- 
creases gradually during the greater part of the step and rapidly toward its 
end, at which moment the forward movement of the body is most rapid. The 
pubes (and consequently the head) is highest at the middle of the step ; for 
then the supporting leg is nearly straight. At the same moment the pelvis is 
thrown towards the side of the supporting leg, so that the foot may be nearly 
under the median line of the body. The variations in the step in running, go- 
ing up and down stairs, and in the galloping of children are freely discussed. 
Most ingenious modifications of this apparatus are made for the horse; and 
that for birds is especially complicated. 
If the scientific part were equal to the mechanical, the work would be 
perfect. T. D., Jr. 44 
The Roxbury Society for Medical Improvement. 
[Jan. 14, 
PROCEEDINGS OF THE ROXBURY SOCIETY FOR MEDICAL 
IMPROVEMENT. 
[reported for the journal.] 
A special meeting of the society was held on the evening of November 
24, 1874, at the house of Dr. F. W. Goss. 
Dr. R. T. Edes occupied the chair. 
Veratrum Viride. — Dr. P. O’M. Edson presented the regular paper for 
the evening, on the uses of veratrum viride, illustrating the same by reports of 
cases. 
The first case was one of croup, in which the symptoms were severe, with 
high fever and all the indications of a grave case, and one in which exudation 
was to be expected ; but the symptoms abated soon after the exhibition of the 
veratrum viride. No membrane was thrown off, and there was no muco-puru- 
lent expectoration. It was believed that the case ended by resolution before 
exudation had time to take place, a result due, probably, to the prompt action 
of the drug. In this case he gave a two-ounce mixture containing half a 
drachm of Norwood’s tincture ; and of this he ordered a teaspoouful every 
two hours. The age of the patient was four and a half years. 
The second case was that of a stout, plethoric young man, with clonic 
spasms; his face was injected, his eyes were bright, and his carotids throbbing, 
lie had been similarly affected before, and on former occasions the convul- 
sions had continued for some time after the use of emetics and other treat- 
ment. As a result of these former seizures he had been left weak and de- 
pressed for several days afterwards. But on this occasion Dr. Edson gave 
him at once half a drachm of the tincture with the effect of reducing the pulse 
in one hour from one hundred to seventy. In two hours he was perfectly 
rational and went to sleep ; and in two days he was well. 
The third case was one of acute mania from the excessive use of alcoholic 
stimulants. There was furious delirium. Fifteen drops of the tincture of 
veratrum were given, to be repeated in an hour; but the patient slept and 
there was no further trouble. 
Dr. Edson then spoke of the good effect of the veratrum viride in meningitis 
of children; it is safer than other depressants, as its effect can easily be 
checked by the exhibition of opium and stimulants, thus differing from aconite 
and antimony. It is a sedative, reducing the action of the heart and causing 
general relaxation, and its best results are obtained from small doses often 
repeated. 
In answer to questions Dr. Edson said that he had never given the drug to 
a child under two and a half years old. In one case he gave on one occasion 
two drops every two hours, for twelve hours, with no bad effect. One drop 
would be a dose for a child one year old. The effect should be carefully 
watched, the patient being visited often while the drug is being adminis- 
tered. Veratrum is indicated in cases of rapid pulse due to too great power 
of the heart, but not in the rapid pulse of debility. 
Group.— I)r. Edes asked if any member had ever seen a non-membranous 
case of croup prove fatal.