TRANSACTIONS 
I 
r 
OF THE 
Nternational Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
BY 
JOHN B. HAMILTON, M. D., 
Secretary-general. 
VOLUME III. 
WASHINGTON, D. C., U. S. A. 
1887. PUBLISHED BY AUTHORITY OF THE EXECUTIVE COMMITTEE. 
PUBLICATION COMMITTEE: 
JOHN B. HAMILTON, M. D., 
Secretary- General. 
A. Y. P. GARNETT, M. D., 
Chairman Local Committee of Arrangements. 
C. II. A. KLEINSCHMIDT, M.D., 
Librarian American Medical Association. 
WM. F. FELL & CO.. 
Electrotypers and Printers, 
PHILADELPHIA. PA. ERRATA.-VOLUME III. 
Page 2. For H. G. Beyer. Surg. U. S. " Army" read Navy. 
Page 101. Third paragraph, first line, for " Resorcin-Cocaostäbchen " read Resorcin-Cacaostäbchen. 
Page 136. For Professor " Rabb-Rückhard " read Rabl-Riickhard. 
Page 160. French title, for " Defformité " read Difformité. 
Page 175. French title, for " Sétro " read Rétro. 
Page 181. For " Demonstrater " read Demonstrator. 
Page 311. French title, for "Fundamentales" read Fondamentales. 
Page 335. French title, for " Méthods " read Méthodes. 
Page 536. End of line commencing " Brown-Séquard," for " on '' read ou. 
Page 558. Tenth paragraph, first line, for "livré " read livres. 
Page 695. Last line, for " permis " read parmi. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
OFFICERS. 
President: DR. TRAILL GREEN, Easton, Pa. 
VICE-PRESIDENTS. 
Dr. Justus Andeer, Munich, Germany. 
Dr. Dujardin Beaumetz, Paris, France. 
Dr. Dudley W. Buxton, London, England. 
Dr. J. M. G. Carter, Waukegan, Ill. 
Dr. Thomas Edmonston Charles, Rome, Italy. 
Dr. Hiram Corson, Pennsylvania. 
Dr. J. G. S. Coghill, Ventnor, Isle of Wight, 
England. 
Dr. Hy. M. Field, Dartmouth, N. H. 
Dr. Thos. A. Fraser, e. r. c. p., Edinburgh, 
Scotland. 
Dr. A. Frické, Philadelphia, Pa. 
Dr. Sidney H. C. Martin, London, England. 
Dr. Richard W. Mott. 
Dr. Wm. Murrell, London, England. 
Dr. Chas. D. F. Phillips, London, England. 
Dr. Ralph Stockman, Edinburgh, Scotland. 
Dr. Chas. Webber, Rome, Italy. 
Dr. F. Dronke, Berlin, Germany. 
Dr. Alfred S. Gubb, London, England. 
SECRETARIES. 
Dr. L. Lewin, Berlin, Germany. 
Dr. Frank Woodbury, Philadelphia, Pa. 
COUNCIL. 
Dr. A. E. Adams, Danbury, Conn. 
Dr. W. E. Casselberry, Chicago, Ill. 
Dr. J. H. Etheridge, Chicago, Ill. 
Dr. E. P. Fraser, Portland, Ore. 
Dr. Wm. B. Hazard, St. Louis, Mo. 
Dr. W. F. Kinsman, Lancaster, Ohio. 
Dr. J. W. H. Lovejoy, Washington, D. C. 
Dr. J. F. B. Payne, Galveston, Texas. 
Dr. Charles Rice, New York (Bellevue Hospital) 
Dr. F. E. Stewart, Wilmington, Del. 
Dr. A. B. Tadlock, Knoxville, Tenn. 
Dr. J. B. Vanvelsor, Yankton, Dak. 
Dr. De W. C. Wade, Holly, Mich. 
Dr. Robt. D. Webb, Livingston, Ala. 
Dr. Theo. A. Weed, Cleveland, Ohio. 2 
NINTH INTERNATIONAL MEDICAL CONGRE««. 
FIRST DAY. 
The Section in Therapeutics and Materia Medica met at the Columbian University, 
Corner of II and 15th Sts., on Monday, September 5th, at 3 P. M. Among those 
in attendance were President Traill Green, M.D., of Easton, Penna. ; Vice-Presidents 
Justus Andeer, M.D., of Munich, Germany; J. M. G. Carter, M.D., of Waukegan, 
Ill.; Thomas Edmonston Charles, M.D., Rome, Italy; J. G. S. Coghill, M. I)., 
Ventnor, Isle of Wight, England; A. Frické, M.D., of Philadelphia, Pa.; Wm. Mur- 
rell, M.D., London, England; Chas. D. F. Phillips, M.D., London, Eng.; Ralph Stock - 
man, M.D., Edinburgh, Scotland; Secretaries Drs. L. Lewin, Berlin, Germany; 
Alfred S. Gubb, London, England ; and Frank Woodbury, Philadelphia, Pa. 
Among those in attendance upon the Session were : Drs. J. Gnezda, Berlin ; F. E. 
Stewart, Wilmington, Del. ; De Witt C. Wade, Holly, Michigan ; J. Z. Gerhart, 
Harrisburg, Pa.; Gasper Griswold, New York; J. N. Upshur, Richmond, Va.; 
John E. Brackett, Washington, D. C.; Hugh Hamilton, Harrisburg, Pa.; Wm. 
Ward, Washington, D. C. ; A. S. Hull, Chambersburg, Pa. ; H. G. Beyer, Surg. 
U. S. Army; J. Solis Cohen, Philadelphia, and others. 
Vice-President Dr. Phillips, of London, took the chair during the delivery of the 
Address of the President of the Section. 
HISTORY OF THE PROGRESS OF MATERIA MEDICA IN THE 
UNITED STATES. 
HISTOIRE DU PROGRÈS DE LA MATIERE MEDICALE DANS LES ÉTATS-UNIS. 
GESCHICHTE DES FORTSCHRITTES DER MATERIA MEDICA IN DEN VEREINIGTEN 
STAATEN. 
opening address. 
TRAILL GREEN, M.D., LL. D. 
President of the Section. 
Gentlemen of the Section of Materia Medica and Therapeutics of the 
Ninth International Medical Congress :- 
Coming together after the very cordial welcome to this City which has been 
given to the Congress, we can enter cheerfully upon the work which we have under- 
taken to do by appointment of the Congress, as cultivators of the science of 
Materia Medica and Therapeutics. We are not strangers, as Mr. Bayard said this 
morning, but of the brotherhood of science, always and in every land united by a 
common bond. It is proper that we should hold in high esteem this department of SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
3 
our professional studies, and consider how large and important is the place which it 
occupies. Those who are engaged in the practice of other departments of our pro- 
fession are dependent, in a very large degree, upon the student of Materia Medica, 
who investigates the properties of medicines and makes known the results of his 
studies. The surgeon, the practitioner of medicine, the obstetrician, all are depend- 
ent upon him who pursues the study of Materia Medica. 
We believe that our associates in the profession do not fail to appreciate the aid 
which they receive from us. The active practitioners of the profession learn much 
of the application and properties of medicines, but there remains beyond what they 
learn, which can be acquired by special experiments only on the lower animals, the 
study of the physiological action of remedies; and this the busy practitioner cannot 
find time for. We believe that the assent of the profession will be given to the truth 
of this statement. It is a noble service which we render to the other departments 
of medicine; let us give it most heartily. 
It is interesting to observe that at a very early period in the history of this 
country, when the colonies were seeking to establish a government in the presence of 
a savage people, and while laboring to supply their physical wants, arrangements 
were made for giving instruction in Materia Medica. 
As our history of the study of Materia Medica illustrates the statement made as 
to its importance in the profession, I will devote to this subject the brief time allotted 
to me in the midst of pressing work of the Section. In November, 1765, Dr. John 
Morgan commenced a course of lectures on Materia Medica, in Philadelphia. He 
graduated M. D., at Edinburgh, in 1763, and was a member of the R. C. P., Edin- 
burgh, and F. R. S., London. It was announced that the lectures would be given 
three times a week and would last between three and four months. Dr. Morgan was 
eminently qualified to give instruction in Materia Medica. Writing to Dr. Cullen, 
he remarked, "lam now preparing for America, to see whether, after fourteen 
years' devotion to medicine, I can get my living without turning apothecary or prac- 
titioner of surgery. My scheme of instituting lectures you will hereafter know 
more of." 
These lectures were designed for young men who were engaged in the study of 
medicine. The Medical School of the College of Philadelphia sanctioned the lec- 
tures, and in 1766 Dr. Morgan gave a course of lectures on the Theory and Practice 
of Medicine, in the College, which afterward became the University of Pennsyl- 
vania. He gave at the same time preparatory courses in Botany, Chemistry and 
Materia Medica. 
Dr. Adam Kuhn, a native of Germantown, Pa., pursued his medical studies in 
Europe, commencing the study of Botany and Materia Medica under Linnaeus, in 
Sweden. He wrote with great delight of his teacher, and the study of Botany in 
excursions with him in the early hours of the day, and other studies after these 
excursions. Linnaeus imbued his pupils with his own enthusiasm, and Mr. Kuhn 
seemed to have been a favorite, for it was said of him " Linnceo ex discipulis accept- 
issimus." Leaving Sweden, he continued his studies in the University of Edin- 
burgh, where he was graduated in 1767. Three months after his return to America, 
he entered upon his first course of instruction in Botany, in May, 1768, and for 
twenty years taught Materia Medica in the Philadelphia College. This history 
shows us that these studies were introduced and conducted by the most thoroughly 
educated, men of the time, and their education was conducted by the faculty of the 
University of Edinburgh; so earjy was there professional unity between the mem- 
bers of the profession on the Western and Eastern sides of the Atlantic; and this 4 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
has been strengthened by intercourse, in these later days, with the teachers of the 
schools and hospitals of London, Paris, Vienna, and Berlin. In 1788 the matter of 
forming a pharmacopoeia was brought before the College of Physicians of Philadel- 
phia. A committee to consider it was appointed, but nothing further was done. It 
proved, however, that there was a need felt in the profession for a work of this kind. 
The first Dispensatory was published by Dr. John Redman Coxe, who was 
Professor of Materia Medica and Pharmacy in the University of Pennsylvania. At 
the early age of ten years he went to Europe, and completed his classical education in 
Edinburgh. He then attended a course of medical lectures there. His medical 
studies were continued in Philadelphia, and he was graduated at the University in 
1794. He then returned to Europe, was a pupil in the London Hospital for a 
year ; studied again in Edinburgh, as well.as in Paris, and returned to Philadelphia 
in 1796. 
Dr. Carson, the historian of our Pennsylvania University, says, " The American 
Dispensatory (Dr. Coxe's work just named) was largely derived from Duncan's Edin- 
burgh Dispensatory." The edition which was in use when I entered the Uni- 
versity was published in 1831, and was the ninth edition. There is nothing in the 
preface of this edition from which one may learn when the first edition was pub- 
lished. It is very certain, however, that it held a very high place among the. physi- 
cians and pharmacists of this country for many years. It is possible that Dr. James 
Thacker wrote as early as Dr. Coxe, for I have found that he published "The 
American New Dispensatory," second edition, 1813. 
Dr. Nathan Chapman, in 1817, published the first American work on Materia 
Medica and Therapeutics. I first became acquainted with this work in 1832, in the 
University. At that time the sixth edition was our text-book. I remember the 
great delight the study of it afforded me; the style was beautiful, and the instruction 
was very practical. The pupils of the University of that day have not forgotten this 
excellent treatise, nor the interesting lectures on the Practice of Medicine which its 
author delivered. Dr. Chapman refers with high commendation to Dr. Benjamin 
Smith Barton, as one who had done much to make known the medical botany 
of the United States. Dr. Jacob Bigelow, of Boston, succeeded Dr. Barton as a 
cultivator of the same field. 
The Pharmacopoeia of the United States was published in 1820, and was a 
valuable work, making known to the physician and pharmacist the properties of the 
officinal articles of the Materia Medica, and the method of preparing the standard 
preparations. Its regular publication and constant improvement every .ten years 
from the first issue of it, has done much to advance the proper study of our science. 
The very able work of Drs. Wood and Bache, "The Dispensatory of the United 
States," appeared in 1833. The sale of no medical work ever equaled the sale of this ; 
the 15th edition appeared in 1883, "rearranged, thoroughly revised and largely 
rewritten, edited by Dr. II. C. Wood, Joseph P. Remington, ph.q., and Samuel 
P. Sadtlcr, ph. n. and F. c. s." 
There were other treatises in the earlier years of the professional history of our 
science which were valuable helps to the study of Materia Medica, of which I should 
make mention : A third edition of Cullen's " Materia Medica " was published in 
this country in 1808; "Indigenous Medical Botany," three volumes, by Jacob 
Bigelow, m.d., 1817-1820 ; John Eberle, m.d., " Materia Medica and Therapeutics," 
two volumes, fourth edition, 1834; and Dr. Thos. D. Mitchell's " Materia Medica and 
Therapeutics, " 1850. 
Of the works of American authors, those of Drs. Geo. B. Wood and H. C. Wood SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
5 
are worthy of the highest commendation. Dr. Geo. B. Wood's "Therapeutics and 
Pharmacology" appeared in 1856. Dr. Wood had filled the chair of Materia Medica 
in the University as well as that of the Theory and Practice of Medicine, and as a 
teacher had occupied an important place in the institution. He was able, financially, 
to do much for his class. He erected a hot-house and from it exhibited rare living 
plants which had medicinal properties. His nephew, Dr. H. C. Wood, now Pro- 
fessor of Materia Medica and Therapeutics, published his work on "Therapeutics, 
Materia Medica and Toxicology" in 1875, and new editions have appeared almost 
annually. The work has been highly educational through its presenting so well the 
physiological action of medicines. The publication in this country of Pereira's "Ele- 
ments of Materia Medica and Therapeutics ' ' marks an important era in the issuing 
■of works of this class. 
Our American edition was beautifully dedicated to Dr. Geo. B. Wood, and was 
the most complete work published up to that period in the United States. It passed 
through three editions, the lamented author dying while the second volume was pass- 
ing through the press in England. The work is characterized by the exhaustive study 
of the subjects of which it treats. It is pleasant to read, in the author's preface to 
the third edition, that "Messrs. Blanchard and Lea, the respectable publishers of 
Philadelphia, having informed me of their intention to bring out a new edition of my 
' Elements of Materia Medica ' for the American market, I undertook the correc- 
tion of the last London edition. ' ' 
In 1879 Wm. Wood & Co. published in their Library, "Materia Medica and 
Therapeutics-Vegetable Kingdom," by Dr. Charles D. F. Phillips, of London; and 
in their Library, 1882, " Materia Medica and Therapeutics-Inorganic Substances," 
by the same author. Dr. Phillips gives the physiological action of remedies as far 
as they have been determined, and the publication of his works in Wood's 
Library has given them a wide circulation in this country. In 1882 Messrs. Wood 
published an edition of Trousseau and Pidoux's "Treatiseon Therapeutics," from 
the ninth French edition. 
In 1884 they published a " Manual of the Medical Botany of North America," 
by Dr. Lawrence Johnson, Lecturer on Medical Botany, University of the City 
of New York; Robley Dunglison, M.D., "General Therapeutics and Materia 
Medica," two volumes, fourth edition, 1850. 
Dr. John B. Beck, Dr. Harrison, Dr. Biddle, Dr. Riley, added to our knowledge 
of Materia Medica, and there are many living teachers whose names should be 
mentioned. Profs. Stillé and Maisch, are the authors of a popular Dispensatory. 
Roberts Bartholow, Professor of Materia Medica and General Therapeutics in 
Jefferson Medical College, in 1876 published a " Practical Treatise on Materia Medica 
and Therapeutics. ' ' This work has passed through several editions. 
Prof. H. C. Wood, of Philadelphia, and Isaac Ott, of my native city, have done 
much valuable work in determining the physiological action of medicines, and other 
living teachers and students of Materia Medica have added much to our knowledge 
of these properties of medicines within the few years past. Our fellow-laborers in 
Europe have done much to increase our knowledge of the physiological action of 
medicines, at this time the most important part of our study. We shall have reports 
in this line of work during the meetings of our Section, especially from Dr. Phillips, 
of London, now present with us ; Dr. Stockman, of London, and Dr. Atkinson, of 
Edinburgh. 
It should be stated, as important in the history of the subject now presented, that 
at the first meeting of the American Medical Association, 1848 ("Transactions Ameri- 6 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
can Medical Association," vol. I, p. 341), a paper was read on the Indigenous Medical 
Botany, and it was recommended by the Committee who made the report, that 
Botany should be made an indispensable study in a medical preliminary education. 
Dr. N. S. Davis was the Chairman of that Committee, and has taken great interest in 
everything connected with medical progress, and now is honored as President of this 
Medical Congress. 
In 1849 another report was made by Dr. Davis, vol. II, " Transactions American 
Medical Association ; " one by Dr. Porcher on the " Medicinal J'lants of South Caro- 
lina." This was a very elaborate report, covering 186 large octavo pages. 
In the same year Dr. Williams read a paper on the " Indigenous Medical Botany 
of Massachusetts," vol. II, " Transactions of the American Medical Association." In 
1852, vol. V, Dr. A. Clapp's report was published on the "Medical Botany of the 
United States." It occupied 217 pages of the volume. This is a brief history of 
the progress of our science in this country. It is highly flattering to those who were 
so active in their work. No department of medical science was carried forward with 
equal energy, and none of them produced so many and such valuable works. 
Permit me to say in conclusion, that here, as in all our Societies, we shall find that 
we mutually so help each other that we gain strength for future work. The social 
advantages are not the least of the advantages obtained in associations of this kind, 
friendships and acquaintances being formed which memory will recall in future years, 
and the brotherhood of the profession strengthened in every land represented in 
this Congress. 
Entering upon the business of this Section, I look for your support in the discharge 
of the duties to which I am called as your Presiding Officer. 
References made in the preparation of the above history to "History of the 
Medical Department of the University of Pennsylvania," by Dr. Joseph Carson; 
"A Century of American Medicine, 1776-1876;" "Literature and Institutions," 
by John S. Billings, M. D.; "Transactions of the American Medical Association." 
Dr. Phillips.-I wish to express my own satisfaction, and the pleasure of all who 
listened to the address of Dr. Green, with the tenor of his remarks. For myself 
and my friends in England, I desire to say that we are greatly indebted to American 
physicians, to Dunglison, Wood, Stillé, and many others, which have stimulated 
us to greater industry in the field of Materia Medica and Therapeutics. Personally, 
I have for many years taken great interest in therapeutics. The paper which I propose 
to read to-morrow, on the action of certain drugs on the circulation, will illustrate 
Dr. Green's views, since it is based upon exact observations upon the size of the 
kidney under the effect of different drugs, by the use of Roy's onkometer. 
On motion, a vote of thanks was tendered Dr. Green for his address. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
7 
The following abstract was read :- 
INTRODUCTION TO A SYNOPSIS OF THE MEDICAL BOTANY OF 
THE UNITED STATES. 
INTRODUCTION À UNE SYNOPSIS DE LA BOTANIQUE MÉDICALE DES ETATS UNIS. 
EINLEITUNG ZU EINER ÜBERSICHT ÜBER DIE MEDICINISCHE BOTANIK DER 
VEREINIGTEN STAATEN. 
The study of medical plants growing in the United States is exceedingly interesting 
and important. Many physicians have worked in this field and much has been accom- 
plished toward furnishing the medical profession a valuable list of medical plants. 
The writer has prepared a synopsis of the medical plants of this country, which 
includes 140 orders, 620 genera, and more than 1300 species and varieties of native and 
naturalized plants. The list of vegetable remedial agents in this country has been 
increased to this number by the combined efforts of physicians and botanists who have 
made extensive investigations during the past few years in the Western and South- 
western States and Territories. 
Much of the work has been done by the aid of the Government. Among the most 
eminent botanists to whom we are indebted for success in this work are Warren 
Upham, Minnesota Report on Botany; Prof. J. M. Coulter, Botany of the Rocky Moun- 
tain Region; Prof. Gray, and Brewer and Watson, in Botany of California and Pacific 
Region, and Dr. Rothrock, in Report on Botany of Southwestern States and Territories, 
in Wheeler's Geographical Survey. Prof. Gray's standard works and Chapman's 
Botany of the Southern States are invaluable to those who wish to examine medical 
plants. 
It is well known that many of our medical plants are immigrants, coming to this 
country from across the Atlantic in most instances, though we have many introduced 
from warm southern climes. 
Of the 500 plants described by that great Greek medical botanist, Dioscorides, 
nearly 2000 years ago, 100 or more are found in the United States as native or natural- 
ized species. The naturalized plants embrace, among others, Conium Maculatum, Sola- 
num Dulcamara, Aconitum Napellus, Marrubium vulgare, Anthemis Cotula and Datura 
Stramonium. The following are some of the plants described by Dioscorides found 
native in the United States: Achillea Millefolium, Brunella vulgaris, Juniperus com- 
munis, Polygonum Hydropiper, Lycopodium clavatum, Convallaria majalis, Geranium 
Robertianum, and Galium Aparine. 
Of the order Ranunculaceæ, or Crowfoot family, we have in the United States 
some 17 genera and 40 species used in the treatment of disease. This number includes 
both native and naturalized species. The most familiar of these are, Aconitum, Hydras- 
tis, Coptis, Cimicifuga, Hepatica, Caltha, or Marsh Marigold. Others, as Clematis, 
Anemone, Ranunculus, contain valuable species. 
The order Cruciferæ, or Mustard family, has 16 genera and 30 species known to 
possess medical properties. 
The order Leguminosæ, or Pulse family, is represented by 27 genera and 45 species. 
The most familiar genera are: Trifolium, Glycyrrhiza, Baptisia and Cassia, or Senna. 
The order Rosaceæ, or Rose family, has only about 15 genera, but 57 species, some 
of which are very important. Prunus, Geum, Fragaria, Rubus, and Potentilla belong 
to this order. 
The order Umbelliferæ, or Parsley family, is represented in the United States by 43 
J. M. G. CARTER, M. A., M. D., Sc. D., PH. D., 8 
species and 26 genera. Of these I have lately found Conium maculatum growing wild 
in Illinois, probably introduced from Eastern States. 
The most important family, as regards the number of medical plants it contains, is 
the Compositæ. Of this order there are in this country more than 180 species of thera- 
peutic value, represented by 67 genera. Some of the most valuable of these are Eupa- 
torium, with 14 species and varieties; Grindelia, with four species; Erigeron, with four 
species; Anthémis, with four species; Senecio, with eight species and varieties; and 
Taraxacum. 
Ericaceae, or Heath family, supplies our Materia Medica with 43 plants in 19 genera. 
Besides some of our edible berries, some of the important genera we have in this order 
are, Arctostaphylos, Gaultheria, Chimaphila, and Pyrola. 
The Nightshade family, Solanaceæ, embraces Stramonium, Hyoscyamus, Capsicum, 
and Tobacco with other genera, altogether 29 species. 
The Figwort family, Scrophulariaceæ, although not so important in a medical 
point of view, contains 15 genera and 31 species, used to modify or mitigate disease. 
Mullein, Toad-flax and Scrophularia are familiar plants of this order. 
The order which contains the greatest number of native species, after Compositæ, is 
Labiatæ, or the Mint family. There are at least 65 species in the United States, in 
31 genera. Some of the most common and important genera are Mentha, with eight 
species; Lycopus, with three species; Hedeoma, with one species; Monarda, w'ith three 
species; Nepita, two species; Scutellaria, with five species; Marrubium, one species. 
The Cone family gives us 30 species of medical value; the Lily family, 38; the Grass 
family, 18, and the Fem family 24 species. 
The remainder of the 140 orders have from one to eleven genera and from one to 
twenty-three species. 
It will be seen from this that the vegetable Materia Medica of our country is very 
extensive. Yet the study may be greatly simplified if we keep in mind the fact that 
species of the same genus have similar medical properties, and differ only in degree. On 
account of the greater strength of one property above another in different species of 
a genus, one plant may be very popular for certain diseases, while the other species 
are scarcely known. In the genus Grindelia, the G. robusta is a popular remedy for 
asthma and bronchial affections ; while G. squarrosa is less known, and G. hirsutula and 
G. glutinosa are scarcely known at all out of their own locality. The principle men- 
tioned just now, that all species of the same genus have similar properties, would make 
us understand that all the Grindelias are useful in the treatment of asthma, but that 
the G. robusta leads the list; likewise it teaches us that they are all valuable in mala- 
rial affections, but the G. squarrosa heads the list as a remedy in these diseases. The 
same may be said of many other genera, some species of which are popular remedies, while 
others are very little known. Since the therapeutic value of a plant so frequently 
resides in its fluid or exudative products, whatever affects these, by changing in any 
way their composition or modifying their elemental combinations, must modify the 
remedial action of the agent. 
That plants vary in their therapeutic virtues, especially when grown under different 
conditions, has been shown by Prof. A. Vogel. He has observed that characteristic 
alkaloids are sometimes absent, when plants are grown under other than their natural 
conditions. For instance, hemlock does not yield conine when grown in Scotland; 
cinchona plants growing in hot-houses are nearly free from quinine; and tannin is found 
in greatest quantities in trees exposed to a full supply of sunlight. These observations, 
which it is hoped may be extended, lead us to infer that the different results obtained 
by different physicians, when administering the same vegetable drug, may be due often 
to the difference in the preparations themselves, produced, perhaps, by the atmospheric, 
climatic and geographical differences in the places of growth. 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
9 
According to the principle j ust stated, we should expect the Grindelia hirsutula and 
G. glutinosa to have medical properties more nearly corresponding to G. robusta than 
to G. squarrosa, for the first three grow in California while the last-G. squarrosa-is 
found chiefly upon the plains east of the Rocky Mountains, although to some extent 
growing in the valleys of the mountains. 
Of the many new remedies that have been introduced into our Materia Medica dur- 
ing the past few years, I wish to invite special attention to the American Mistletoe- 
the Phorodendron flavescens, and the Black Haw-Viburnum Prunifolium. I consider 
these plants two of the most important that have been added to our Materia Medica 
list. They are both, in the main, sedatives; the former being a sedative to urethral 
irritations, and the latter a sedative to uterine irritations. 
DISCUSSION. 
Dr. F E. Stewart, of Wilmington, Del.-The fact mentioned by the speaker, 
with regard to the variation in medicinal activity of drugs owing to circumstances 
attending their growth, reminds me of the statement made by Dr. Rusby with regard 
to the alkaloids of the Erythroxylon Coca. This gentleman has just returned from 
a scientific expedition across the South American Continent, during which he 
paid particular attention to the collection, mode of preparation and chemistry of 
commercial coca leaves. It is a current belief among those engaged in collecting the 
leaves, that there is contained in them a volatile active principle, which can be 
extracted from the leaves recently gathered, but is missing in the dried leaves. Dr. 
Rusby is, therefore, of the opinion that the ordinary preparations of coca do not 
represent the full therapeutic qualities of the drug, since they contain, besides 
cocaine, a volatile principle which is decidedly stimulating in its effects. Dr. Rusby 
has apparently confirmed this by his own investigations. He has analyzed the fresh 
leaves, and finds a new alkaloid to which the peculiar stimulating properties ascribed 
to the drug in South America are attributable ; it is not present in the preparations 
made from the leaves in this country, and merely a trace can be detected after the 
leaves have been gathered for a few days and exposed to the air. 
Dr. J. G. S. Coghill, of Ventnor, Isle of Wight.-In common with my pro- 
fessional brethren on the other side of the Atlantic, I feel very much indebted to the 
recent additions to our Materia Medica from the native plants of the American 
Continent. I have used most of them with much satisfaction, but what seems to 
me to be wanting is more precise knowledge of the purely physiological actions of 
these remedies as distinguished from their therapeutic actions. This is greatly 
wanting, as a remedy can never be used with that confidence and persistence in 
diseased conditions which is essential to success, unless we are thoroughly acquainted 
with their physiological action. I am sure this want of knowledge and uncertainty 
as to their effects on health has greatly interfered with their acceptance by the 
profession. 
Dr. Chas. D. F. Phillips, of London.-I must also compliment the speaker 
upon the able presentation of an important subject. American drugs should be better 
known than they are. Some years ago, haring had my attention called to Grindelia 
as a remedy in asthma, I used it with remarkably good effect. It seems most use- 
ful in cases of asthma with dilated heart, and is a good addition to the armamenta- 
rium of the physician. 
Dr. Wm. Murrell, of London.-There is a remarkable difference in the strength 
of some drug preparations which are sent for experimentation as samples, and the 10 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
same agent when dispensed by the apothecary. As a rule, the sample bottles are 
much more effective in the same doses. 
Dr. Frank Woodbury, of Philadelphia.-The subject of the indigenous 
medical botany of the United States is one which should not be allowed to pass 
without discussion by American physicians. The mistletoe of Europe is a powerful 
cardiac stimulant ; and probably the American variety (Phoradendron flavescens) 
will be equally effective, since it has been used for its contracting influence upon 
unstriped muscular fibre, in uterine hemorrhage, and as an oxytocic. Rhamnus 
purshiana clinically is an acceptable substitute for rhubarb, and possesses decided 
cholagogue effects. It is useful in the treatment of a coryza by revulsion, twenty 
drops of the fluid extract being administered every two hours until several loose 
evacuations are obtained. This breaks up a cold in twenty-four hours or less. 
Dr. F. E. Stewart read- 
A PROPOSED INVESTIGATION OF THE MATERIA MEDICA OF 
THE WORLD BY THE GOVERNMENT OF THE UNITED 
STATES. A PLAN TO PROMOTE PROGRESS 
IN THE SCIENCE OF DRUGS. 
UNE INVESTIGATION PROPOSEE DE LA MATIÈRE MEDICALE, DU MONDE PAR 
LE GOUVERNEMENT DES ÉTATS-UNIS. UN PLAN POUR PROMOUVOIR 
LE PROGRES DANS LA SCIENCE DES DROGUES. 
EIN VORSCHLAG ZUR UNTERSUCHUNG DER MATERIA MEDICA DER WELT DURCH DIE 
REGIERUNG DER VEREINIGTEN STAATEN. EIN PLAN ZUR FÖRDERUNG 
DES FORTSCHRITTES IN DER PHARMAKOLOGIE. 
BY F. E. STEWART. M.D., PH. G. 
We are overrun with "new therapeutic agents." They come to us from various 
sources. Teachers in therapeutics, physicians in every clime, missionaries all over the 
world, enterprising drug concerns, patent medicine houses (aided by the clergy), have 
united in one grand effort to discover some new agent to benefit the cause of humanity, 
until the market is flooded with a host of medicines bewildering to the senses. 
Some of these "new therapeutic agents " are of undoubted merit; some of them are 
of little value; some of them are trash. Some have been introduced by honest means; 
some have been introduced by fraud. 
Medical, religious and secular press are united in one grand system of advertising to 
create a demand for these new articles. They are introduced directly to the public, or 
indirectly through physicians' prescriptions. 
The science and practice of pharmacy is being rapidly swallowed up by this busi- 
ness, and the practice of medicine seriously injured by it. What reasons have I for 
making these serious charges, and what plans have I for reform ? It is the object of 
this paper to state the reasons and the plan. 
I wish it to be clearly understood, from the start, that I oppose the introduction of 
new therapeutic agents by anybody, whether physician, pharmacist, manufacturing 
chemist, wholesale druggist or patent medicine house, except it be through some chan- 
nel which shall thoroughly prove their merits before such powerful agents for good or 
evil are thrown open to the indiscriminate use of an innocent public. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
11 
1st. The manufacture and sale of medicines are being diverted from the legitimate 
channel, which consists of the physician's prescription compounded by the educated 
apothecary, and directed into the hands of uneducated drug merchants ignorant alike 
of disease or its treatment. These mercantile concerns have as their object money mak- 
ing, and in this respect they differ from the professional ideal that service to suffering 
humanity is of primary importance, and money making secondary to that. Therefore, 
they do not hesitate to enter a field for which they are in no way fitted, and have 
become competitors of both the physician and pharmacist, for they furnish the public 
with ready-made compounds labeled with directions for use and accompanied with cir- 
culars describing the disease for which their prescriptions are highly recommended as 
positive specifics. 
2d. The pharmaceutical profession, who suffer much through this competition, are, 
to no small degree, usurping the prerogative of the medical profession, and many phar- 
macists prescribe over the counter, and even go out of their shops to visit patients. 
This has caused a feeling of extreme jealousy between the two professions. 
3d. Though poor therapeutists, the great manufacturing houses, by employing 
skilled labor, are turning out elegant goods. But, being animated by a trade motive 
only, they do not publish their formulas and processes, but retain them as trade secrets, 
thus hindering progress in this branch of the science of medicine. Pharmacy, in their 
hands, is in danger of injury for want of this publication, and the time may come 
when valuable processes now in use will be lost arts. 
4th. Pharmacopoeias and text-books depend upon this knowledge for their growth 
and improvement. Much of modern pharmacy has no place in literature whatever, for 
the knowledge is retained in the private formula books of the manufacturers. 
5th. Students in our medical colleges are not instructed in the composition and 
uses of the medicines which they are to use afterward in their practice. The reasons 
for this are obvious. 
6th. The names of many of these compounds are not only unscientific, and there- 
fore unsuited for scientific nomenclature, but they are also claimed as the private pro- 
perty of the manufacturers. How can pharmacopoeias and text-books be founded on 
such a basis as this ? 
7th. If the knowledge of drugs is to be a science, it must be classified in scientific 
form and protected by a changeless nomenclature. " Science professes to exhibit what is 
actually known or may be learned in scientific forms, viz. : in the forms of exact obser- 
vation, precise definition, fixed terminology, classified arrangement and rational 
explanation."* How is it possible to rationally explain the action of a compound whose 
exact composition is not known? Exact observation is impossible under such cir- 
cumstances. How can partial knowledge be accurately defined? How can a fixed 
terminology be determined when the prefixes and sufiixes on which it so greatly depends 
are used indiscriminately to represent active principles and compounds without refer- 
ence to the plain requirements necessary to a scientific nomenclature ? 
8th. Physicians who employ the drugs and compounds brought to their notice by 
the manufacturing houses do not, as a rule, report the results of their observations con- 
cerning their effects to the medical journals. There are several reasons for this. In 
the first place, publishers of medical journals object to receiving such reports. First, 
because they are afraid that readers will think admittance to their columns has been 
gained through bribery; second, because they prefer that all such mention shall go 
through the advertising columns and be well paid for. The result of it is, that very 
little is actually known regarding the true therapeutic value of a large proportion of 
the drugs and medicines introduced during the past fifteen or twenty years. Even if 
* This definition of what constitutes a science is drawn from Porter's Psychology. 12 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this mention were made, unless the knowledge of the composition and art of manufac- 
ture of these medicines is published in standard literature, it would avail but little to 
future generations, for the time would finally come when many of the articles referred 
to would exist only in name. 
9th.. Medical journals derive their principal support not from their subscribers, but 
from their advertisements. Naturally, they are loth to say anything to injure their 
advertising patronage. For this reason they are usually silent in all matters relating 
thereto. 
The secular and religious press also receive a large subsidy in this way from the 
manufacturing houses, and they, too, are silent. Therefore, to a greater or less extent, 
the entire press of the country is under the control of their medical advertisers. 
10th. The manufacturers are twisting the patent, copyright and trade-mark laws 
around, for the purpose of obtaining a legal protection never intended by those who 
framed them. 
' ' The policy qf the patent law is, primarily, a selfish one on the part of the public, 
and only secondarily intended for the benefit of inventors, and then as a means to an 
end only. The Constitution of the United States gives Congress the power ' to pro- 
mote the progress of science and the useful arts, by securing, for limited times, to 
authors and inventors, the exclusive right to their respective writings and discoveries;' 
thus showing, in this fundamental legislation, that the object sought is a benefit accru- 
ing to the public."* 
" The theory of the law is, that the promotion of science and the useful arts is of 
great benefit to society at large, and that such promotion can be attained by securing to 
inventors and authors, for limited times, the exclusive right to their inventions and 
writings. That such theory is correct, it is needless to say. It is almost self-evident, 
or, at any rate, susceptible of proof, that the magnificent material prosperity of the 
United States of America is directly traceable to wise patent laws and their kindly 
construction by the courts." 
" The patent laws promote the progress of the useful arts in at least two ways: 
first, by stimulating inventors to constant and persistent effort in the hope of prod ucing 
some financially valuable invention; and, second, by protecting the investment of 
capital in the working and development of a new invention from interference and com- 
petition ' till the investment becomes remunerative.' "f 
" A patent is a contract between the inventor and the Government, representing the 
public at large.| The consideration moving from the inventor is the production of a 
new and useful thing, and the giving to the public of a full knowledge thereof by means 
of a proper application for a patent, whereby the public is enabled to practice the inven- 
tion when the patent expires. The consideration moving from the Government is the 
grant of an exclusive right for a limited time, and this grant the Government protects 
and enforces through its courts. ' ' 
But the manufacturers are not satisfied with a control over their products that is 
limited in time, and to gain which they must publish their formulas and processes. 
They desire an unlimited control which shall last to all time, and they also desire to 
retain the knowledge of their processes as trade secrets. Furthermore, it would be a 
difficult matter for them to prove that their alleged inventions and discoveries are new 
and useful therapeutic agents deserving a patent. So, without conforming to the just 
requirements of the patent law, they endeavor to create lasting and secret monopolies 
* Simond's "Manual of the Patent Law," containing quotation from Day rs. Union Rubber 
Co., 3 Blatch., 500 ; Kendall vs. Winsor, 21 Howard, 327. 
f Simond's " Manual of Patent Law." 
J Ransom vs. New York, 1 Fisher's Patent Cp-ses, 252. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
13 
by law, contrary to the beneficent idea of the patent laws. In fact, if the requirements 
of the patent laws were enforced, it would soon end their monopolies. 
The method adopted by the manufacturers to secure the protection, of the law is 
this : When it is desired to market a compound, a name is coined for it and the article 
introduced under the coined name. This name the introducer claims as his trade-mark, 
and says to the public, "you have no right to market a similar product under that 
name." All the advertising machinery is now put in motion to create a demand for the 
article under the coined name, and, of course, the owner of the name practically 
monopolizes the sale of the article so named.* 
As a trade-mark can be owned forever, the monopoly is practically everlasting, and 
as the use of a trade-mark does not necessitate the publication of the formula or process 
for preparing the article, this knowledge is retained indefinitely by the manufacturer. 
The trade-mark law, however, was never designed to take the place of the patent 
law. It was never intended that the use of a trade-mark should give any exclusive con- 
trol over the article upon which it is marked. A trade-mark is merely a mark of trade 
to distinguish one brand of an article from another brand of the same article. If I mark 
the letter " A " on iron manufactured at my establishment, that can in no way prevent 
you from manufacturing iron. But it is the intent of the manufacturers in the cases 
mentioned to prevent any one else from making the articles referred to. 
It is an axiom of law, however, that a proper or descriptive name cannot be a trade- 
mark. And the courts have defined the descriptive name of an article to be the name 
used by the public when purchasing it. f Now, these coined names are the names by 
which the public distinguish the articles referred to when purchasing them. They can- 
not, therefore, be trade-marks. For example, " Cosmoline," " Vaseline," " Petrolina," 
etc., are synonymous names for the Petrolatum of the U. S. P., and the article is well 
known to the public by these names. They cannot, therefore, be trade-marks, as 
claimed. 
Again, the public owe their safety to the fact that these names are the proper or 
descriptive names of the articles in question. If they are trade-marks they can be used 
with equal propriety on other classes of goods. It would be equally proper to use the 
name " Ingluvin " as a trade-mark on guano, as upon the excellent compound of chicken 
gizzard now known by that name, and claimed as a trade-mark by the introducer. 
Imagine the consternation that would occur if a physician wrote a prescription for 
"Ingluvin," and bird lime were furnished to his patient by the apothecary. " lodia" 
might be used with equal propriety as a trade-mark on Paris green or rat poison, as on 
the well known sedative prescribed under that name. No, these names are descriptive, 
and it is fortunate this is a fact. 
Most of these compounds are mere aggregations of old and well known drugs, and 
are not new and useful inventions for which a patent should be granted. As well might 
a patent be granted for every similar prescription written by a physician. It would not 
take long to lock up the whole Materia Medica to the exclusive control of a few monop- 
olists at that rate. 
The system under which these new remedies are usually marketed is known to the 
trade as the "Patent " or proprietary medicine system. From what I have already said 
it will be seen that the term "Patent " is a misnomer, and calculated to deceive. As I 
have already demonstrated, the patent law is scientific in its ends ; and under its work- 
ing secrecy is abolished, and monopolies can last only during the limited time that the 
patent holds. But the so-called "Patent " medicine system is one of secrecy and ever- 
lasting monopoly. The term "proprietary" expresses more properly what is claimed 
* See claims made by Allen & Hanbury's, of London, against Parke, Davis & Co., in " Tonga " 
case. f Brown on " Trade Marks." 14 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by the manufacturers, namely, that their alleged remedies are property, in which they 
have a natural right, irrespective of law. 
" The belief is very generally entertained, that inventors have a natural right to 
their inventions, of the same kind given by the statute, irrespective of the actual 
passage of the law.* 
" Such is not the fact. J 
"The right to the exclusive use of an invention is not a natural right-that is, 
pertaining to a man in a state of nature ; but, when it exists at all, it is a civil right, 
pertaining to a man under the protection of a civil government. J 
" All will concede that one natural right of man is, to have an equal chance with 
his fellows to gather and amass the goods of this world. Suppose two men, under the 
protection and control of no human government, to be occupying and cultivating tracts 
of land side by side; for years they plough, sow and reap in the same manner and with 
the same rude tools. Finally, one of them invents a plow, with which he can cultivate 
twice as much land in the same time as before and do it better. There is no principle of 
natural justice which forbids the neighbor, upon seeing how well the plow works, from 
making and putting to use one like it. The doing so by the neighbor does not injure 
the inventor in any possible way. If the neighbor has not the right to make and put 
to use a plow like the inventor's, he is shut off from an equal chance with the inventor 
of amassing wealth, and this when his hindrance is no help to the inventor, j: 
" Not only this, but the neighbor, at the time the inventor made his plow, might 
have already begun to ponder upon the poor work done by the old plow, and set about 
making a better one, and would have soon invented the plow himself, and thus acquired 
as good a title to the exclusive use of it as the prior inventor-a use, however, from 
which he would be debarred by a person having no better title than himself, a thing 
that would be clearly unjust, j: 
" This last is by no means a merely suppositious case; for Patent Solicitors and 
Patent Office Examiners well know that the same inventions are made over and 
over again by independent inventors. . . . The frequency with which this is 
done would be most surprising, were it not another and a recognized fact, that the mind 
is governed by laws of action just as much as the body ; so that, given a certain inven- 
tion to produce, and two minds of similar knowledge and habits to produce it, they 
will be quite likely to travel through the same road to the same result. 
An invention is merely knowledge crystallized into practical form. In other words, 
the inventor merely takes knowledge, which is the common property of us all, the results 
of the accumulated experience of ages, and by some fortunate thought puts that knowl- 
edge in a new and practical form whereby he can produce results hitherto unobtainable. 
Does the inventor owe nothing to the world for this knowledge which he had no share 
in discovering ? What right has he to monopolize a new use of it forever simply because 
he discovered it ? Morse discovered a method whereby electricity could be made to 
carry messages long distances over a wire. Had he the right, therefore, to monopolize 
the whole telegraph system of the world and hand it down to his heirs forever? Sup- 
pose that he had such a right, then the same right belongs to every inventor. The 
inventors of pens, ink, paper, cotton cloths, the printing press, steam engine, etc., etc., 
possess the same right. Under such ruling nearly every trade in the world is the prop- 
erty of some individual or his heirs and the rest of the world who use them are thieves. 
Suppose for a moment that all these trades were locked up to the exclusive monopoly 
of individuals, what would be the result? The many certainly would never permit the 
* Simonds "Manual of the Patent Law." 
f Simond's " Manual of the Patent Law;" Traite des Brevets D'Invention, par C. Renvivard. 
Phillips on Patents. t Simond's " Manual of the Patent Law." SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
15 
whole commerce of the world to be controlled by the few. They would rise in their 
might and soon put an end to such monopolies. 
' ' In theory, his every neighbor is as strong as the inventor, and combined, they are 
much stronger. In a state of nature, therefore, the inventor would have no power to 
enforce his rights. ' ' 
' ' An inventor, ' ' then, '' has no right to his invention at common law. He has no right 
of property in it originally. The right which he derives is a creature of the statute and 
of grant, and is subject to certain conditions incorporated in the statutes and in the 
grants. If to-day you should invent an art, a process, or a machine, you have no right 
at common law, nor any absolute natural right to hold that for seven, ten, fourteen, or 
any given number of years, against one who should invent it to-morrow, without any 
knowledge of your invention, and thus cut me and everybody else off from the right to 
do to-morrow what you have done to-day. There is no absolute or natural right at 
common law that I, being the original and first inventor to-day, have, to prevent you 
and everybody else from inventing and using to-morrow or next day the same thing."* 
Now, it is a plain thing to be seen that the proprietary medicine trade are attempt- 
ing to create monopolies over various medicinal preparations by means of secrecy and 
by claiming exclusive ownership in the names of these articles. But the public have 
an equal right with the manufacturers to manufacture and sell the articles referred to. 
The proprietary trade are therefore arrogating to themselves rights which do not belong 
to them, but are public property. They, then, not the public who occasionally make 
and sell their alleged inventions, and who are bitterly denounced for infringement in 
consequence, are the thieves. 
Finally, to sum the matter up, the proprietary medicine system is not only 
unscientific in that it is a system of secrecy and everlasting monopoly, illegal in that it is 
perverting the meaning of the patent and trade-mark laws, and attempting to obtain 
rights never contemplated by law, but it is unethical as well, for it deprives every man 
of his natural right, which is the free use of knowledge. 
I have said enough to demonstrate the need of reform in our present methods of 
introducing new remedies. No reformatory measure will be successful, however, 
unless it be practical and progressive in its nature. It would be equally impossible 
and undesirable to stop the introduction of new remedies. But this introduction 
should be done in a proper manner. The present system is a hindrance to progress in 
the science of medicine. We need a system that will promote progress in this science, 
and in the useful arts connected therewith. It is the purpose of my paper to again call 
the attention of the profession to a plan that I have devised with this end in view. 
My suggestions are as follows :- 
1st. I would suggest that the medical and pharmaceutical professions unite in the 
formation of an association, to be known as the American Pharmacological Association. 
I would suggest that this Society have as its object a systematic investigation of the 
Materia Medica of the world. And I would suggest that this investigation be con- 
ducted under the auspices of the United States Government. 
2d. For the purpose of testing the value of all drugs and compounds now in use, 
as well as all new introductions in the future, I would suggest that there be estab- 
lished, at the National Museum in Washington, a laboratory for investigating the 
physical structure, chemical composition, physiological actions and therapeutic proper- 
ties of drugs, and that this laboratory be manned by physicians and chemists selected 
from the medical departments of the Army, Navy, and Marine Hospital Service. 
3d. I would suggest that a national law be passed, requiring every manufacturer to 
* Simond's " Manual of the Patent Law;" Am. H. & L. S. & D. Mach. Co. vs. Am. Tool <fc 
Mach. Co., 4 Fisher's Pat. Cases, 294. 16 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
publish the true formula aud method of preparing medical preparations made by him, 
and that such publications be put on file at the laboratory, and a copy furnished to any 
one sending for and paying a nominal price for the same. A similar plan is adopted at 
the United States Patent Office. 
4th. I would insist that patents should never be allowed by the government for a 
medicinal compound, unless it be first proved a new and useful invention in therapeu- 
tics in the hands of a commission of competent physicians appointed by the National 
Pharmacological Association for that purpose. 
5th. To test therapeutic properties of a new drug or compound, I. would suggest 
that it be first tested upon animals if possible, and then sent to the hospitals and dis- 
pensaries for further test, before it is placed on the market.* "Working bulletins" 
containing all obtainable information concerning the drug or compound to be tested 
should be sent with it. 
6th. I would suggest that a monthly journal be published as the organ of this work. 
To adopt such a plan as this, would unite the Medical and Pharmaceutical profes- 
sions as members of an association. Both professions would have a common object 
and mutual interests. This would heal the breach now existing between them. It 
would place the manufacturer of medicines on a scientific basis conformable to the 
demands of science, and compatible with scientific nomenclature. It would free the 
press of the country from an incubus which sits like a nightmare upon it. It would 
do much toward sifting the good from the bad, and clearing our Materia Medica from 
trash. It would give the profession new and valuable medicinal agents, and in this way 
benefit not only the physicians, but it would benefit commerce as well, and be a great 
boon to the cause of suffering humanity. And last, but not least, it would be the 
means of saving a great many clergymen, as well as physicians, from the danger now 
menacing their eternal salvation, from the testimonial business. 
I cannot close this paper in a more appropriate manner than by adding a compilation 
of the opinions and comments of leading physicians, pharmacists and scientists which 
I have received from time time, since my first paper referring to the plans which I 
have set forth herein. 
Prof. Spencer F. Baird, Secretary of the Smithsonian Institution, when I submitted 
the plan to him originally, said that I might tell my friends that in his opinion it was 
one of the most important plans ever submitted to the Institution. 
Prof. H. G. Beyer, Curator of the National Museum, in a letter written Oct. 20th, 
1885, says: " I most sincerely sympathize with you in your plans of trying to organize 
the Association you speak of, and you may depend on my hearty cooperation in the 
matter, so far as I am able to assist you." " I think your conception of establishing a 
Bureau or Department of Pharmacology under the Government a grand one, and no 
doubt one that ought to be carried out. We have here all sorts of scientific Bureaus, 
and it seems to me not one which is calculated to be of such immediate benefit to man- 
kind as a Department of Pharmacology would be to the American people, not to speak 
of the immense scientific value it would be to medicine and pharmacy. I, for one, 
should certainly hail the inauguration of such an institution with great defight. It is 
exactly what I have been having in mind for the last year and a half. ' ' 
Dr. J. M. Flint, u. S. N., formerly Curator of the National Museum, in a communi- 
cation addressed to the Smithsonian Institution, in March, 1884, said : "I would res- 
pectfully recommend that the organization of such a department be favored, as far as 
may be consistent with the general plans of the Institution, and such opportunities of 
special study offered as the means at your disposal will allow." 
Horatio C. Wood, M.D., Prof, of Materia Medica and Therapeutics in the University 
* I have been criticised for advising experiments on patients in hospital. Better that than 
experiment on the public at large, as is now the case. Patent medicine manufacturers, ignorant 
alike of disease or its nature, are now doing this. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
17 
of Pennsylvania, and author of a work on therapeutics which has already been trans- 
lated into five different languages, in discussing my paper referring to this subject, read 
before the Philadelphia County Medical Society, June 25th, 1884, and published in the 
Proceedings of the Society for that year, said : " What seems to me the most important 
part of this paper of Dr. Stewart, is that in reference to the formation of a National 
Pharmacological Association, in which both doctors and pharmacies may meet. I 
think that that is probably practicable, as it is desirable. It would certainly be very 
desirable to have in connection with the National Museum at Washington a laboratory 
of original research in this regard. As is well known, the policy of this government is 
to maintain a speck of a regular army, which shall be the skeleton of an organization 
that shall expand indefinitely in time of war. It seems a necessity of this plan of 
organization that there should always be in the employ of the government numerous 
medical men for whom there is very little work, but who would be essential for the 
opening out of the executive minutiae of hospitals in time of sudden war. Without 
expense to any one, some of these men could be well employed in connection with tho 
National Museum, in Pharmacological research. It is well known that now at least 
one officer of the United States Army is employed in the National Museum, to collect 
drugs and do the materia medica part of the work. 
" If we make a great ado about this matter, and attempt to found a great Pharmaco- 
logical laboratory, which like Jonah's gourd will arise in a day, it will wither when the 
sun comes out. What is wanted is to get the attention of two or three men of great 
mind and equal influence at Washington, and having done this, allow this thing to 
grow, until it cannot be set aside." 
Frank Woodbury, M. D., Prof, of Materia Medica and Therapeutics in the Medico- 
Chirurgical College of Philadelphia, and Editor of the Philadelphia Medical Times, in 
discussing this paper said : " With regard to the proposition for a national organization 
of physicians and druggists, it seems to me that there is a good nucleus for such an 
organization in the committee for the revision of the National Pharmacopoeia. I am 
not aware that it was the fault <5f the physicians that they were not continued on the 
combined committee. I think that that should be- the commencement of such an 
organization, and I should advocate the addition of physicians and pharmacists to that 
committee, in order to make a National Pharmacological Association. 
With regard to a National Pharmacological Laboratory at Washington, the idea is a 
good one for utilizing some of the idle talent which is at the service of the Government 
in Washington, and it might be made useful to science. This seems to me the only 
practical proposition which has been submitted, and, perhaps, it is really the point 
which Dr. Stewart wished us to discuss. Such a laboratory would very properly come 
under the care of the National Board of Health. With it might be combined a Board 
of Public Analysis, which might furnish us with the composition of the various pro- 
prietary and patent medicines which are supplied to the people." 
Joseph P. Remington, ph. g., Professor of Pharmacy in the Philadelphia College of 
Pharmacy, and one of the committee for revising the United States Pharmacopoeia, in 
discussing the same paper, said: " Dr. Woodbury touched on a point which, I think, is 
the key-note of the whole discussion, that is, the formation of the National Pharmaco- 
logical Association from a committee of physicians and pharmacists who have charge 
of the revision of the National Pharmacopoeia. There is a definite aim. If a pharma- 
cological association could be formed in which physicians and pharmacists could meet 
on a common ground, and in which there was a provision in the Constitution or By- 
Laws shutting out entirely any discussion about business or trade interests, and allow- 
ing simply the discussion of scientific subjects, I think we should find that through 
the influence of such a Society we should have in 1890 a Pharmacopoeia which would 
not be the subject of so much adverse criticism as the Pharmacopoeia of 1880« 
Vol. Ill-2 18 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Finally, in regard to the discouragements met with in advocating this plan for 
investigating the Materia Medica of the world:- 
Prof. Beyer, whose letter I have already quoted, says: " I wish it were in my power 
to take steps in regard to establishing such an agency ; but at present we have no rooms 
available for the purpose and no funds with which to sustain it." 
Dr. Flint, the former Curator of the National Museum, says: " I infer, however, 
that at present neither space nor funds are available for such a purpose." 
Prof. S. F. Baird, Secretary of the Smithsonian Institution, tells me the same thing 
in regard to money and means. How can the money be raised for such investigations ? 
If an organization of earnest workers were effected with this end in view, the money 
would be forthcoming. There are experts enough in the employ of the Government 
who could be spared for work in the laboratory without extra expense to the Govern- 
ment. Very little expense would attend the collection of specimens through physicians 
in the employ of the Army, Navy and Marine Hospital Service. A building for doing 
the work would not be very expensive ; exploring expeditions are continually being 
sent out by the Government for other purposes ; and Government physicians and botan- 
ists could accompany them without costing much more ; the main cost would be for 
animals, drugs and materials used for analysis, together with publishing the results of 
the investigation. An appropriation for this would not be hard to get if the matter 
were taken hold of in earnest by the right kind of workers. 
DISCUSSION. 
Dr. H. H. Rusby, on invitation of the Chair, spoke in favor of the proposed plan. 
No such opportune time has offered, or is likely to offer, as the present for taking 
action on the matter just brought to the notice of the Section, for the following 
reasons : (1) There is a general feeling on the part of the scientists of this country 
that the botanical department of this Government should be reorganized, with greater 
facilities for its work than it has hitherto possessed. (2) A committee to secure 
such a result was appointed at the last meeting of the American Association for the 
Advancement of Science in New York; and (3) A resolution will be passed by the 
National Association of Pharmacists at Cincinnati asking Congress to establish a 
department of Medical Botany. Action taken by the present International Medical 
Congress would doubtless add sufficient influence to produce the result desired. 
Drs. Wade, Brackett and others spoke in condemnation of patent medicine 
legislation, as the business is one which seriously affects the health of the community. 19 
SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
SECOND DAY. 
Dr. Traill Green, President, in the Chair. 
Dr. Hugh Hamilton, of Harrisburg, Pennsylvania, read a paper on- 
THE CHEMICAL PHILOSOPHY IN REMEDY. 
LA PHILOSOPHIE CHIMIQUE DANS LE REMÈDE. 
DIE CHEMISCHE PHILOSOPHIE IM HEILMITTEL. 
BY HUGH HAMILTON, M. SC., M. D., 
Harrisburg, Pa. 
Mr. President, Ladies and Gentlemen :-The activity in bacteriology and 
the advances in chemistry suggest that tHere is a chemical philosophy in remedy. 
The lack of health may be termed disease. There is yet left the question, What is 
health ? However, ill health may be divided into processes, at any time disturbing 
nutritive functions; or, secondarily, affecting them through traumatism. 
The causes, have been a peculiarly tempting field for speculation in all ages. To 
name the numberless evanescent theories is unnecessary, because ingenious experiment 
has given a rational basis for etiology, insisting upon collective observation and the 
skillful use of instruments of precision, for determining the operation of physical law 
in, as well as without, the body. 
Devotees of inorganic chemistry searched by analysis for the ' ' elixir of life. ' ' To-day 
organic chemical synthesis performs on a grand scale some metamorphoses not long 
since dependent alone upon vegetable physiology and the circumstances of climate and 
locality. While even the animal physiological economy is forced to contribute its share 
to supply the wasted abstract or approximate elements of the human body for use in 
medicine. 
The theory of the genesis of disease is now traced to micrococci, which seems reason- 
able, and the multiplication of specific germs for given-named diseases, when they 
occur synonymously, often permit great scope in generalization. 
The brilliant deduction of Lister, from the investigation of Dr. Williams,* of 
London, in 1846, gave a practical impetus to this factor in disease. 
The presence of masses of putrefying material, not among crowded human habita- 
tions, though filled with bacteria capable of producing disease, does not occasion sick- 
ness, while if oppositely situated may affect the organism. 
Possibly these germs, to fulfill their life-cycle, require a longer or shorter residence 
in the body. The life-epoch may be slow or so rapid that the microscope, aided by 
electricity and photography, only can detect their changes, f They, when increased 
enormously, form débris, oppressing the function of the organs to dispose of it, thereby 
irritating the nervous system, creating the phenomena of fever, followed rapidly by 
ether symptoms and signs of disorder. 
-X- Proceedings Royal Soo. London, 1846, p, 1461. 
f See article on Photographic Motion. Century, for July, 1887. 20 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I. The chemical constituents of these lowly forms, whether vegetable fungi or 
animalcules, are a cell wall of carbon or carbon-hydrogen, enclosing a liquid more or 
less rich in nitrogen, possessing the physical property of endosmose and the vital 
functions of assimilation and multiplication; as soon as exosmose takes place disinte- 
gration and death of the germ ensues. 
During life these minute creations must either absorb carbonic gases or oxygen, as 
the case may be; to the human organism the result is the same; a certain degree of 
[carbonic acid gas] blood poisoning. 
Doubtless, then, germs are active in altering, by fermentation, the normal organic 
constituents of the blood into noxious ones, the result not unfrequently proving fatal. 
Exhibited in the following Table :- 
TABLE I. 
Names. 
Approximate 
Elements. 
Chemical Formula. 
Remarks. 
Lipacidæmia 
Oleic Acid 
Lipæmia 
Stearin 
C')8H36O2 
Cholæmia 
Cholein 
C26H44O 
Uræmia 
Urea 
2CH4NO 
Ammoniæmia 
Ammonia 
nh4o 
Acetonæmia* 
Acetone 
CH3.CO.CH3 
Di-JfcfAyZ-Ketone 
Even their excessive life or extreme mortality exert similar influences, giving rise 
to the febrile movement, which may be defined as an irritation of the peripheral 
nerves, in turn acting inhibitorily upon a centre supposed to be in the bulb, allowing 
unlimited vital activity, f 
Whether this irritation be applied to the skin, injected beneath it, absorbed by the 
receptive organs naturally, or through traumatic injury, increased appropriation of 
oxygen and expiration of carbonic acid gas is noted. 
Exactly what the heat is caused by-a chemical action or reaction-is imperfectly 
known, e. g.- • 
1. Action HO + SO3 evolves heat. 
2. Re-action HO -j- SO3 4- NaOCO2 evolves heat and gives off an unseen product, 
Carbonic acid gas. 
Nevertheless, germs do lodge and multiply, compelling the organs to unwonted 
activity, develop fever and fermentive processes, cause inflammation inducing exuda- 
tion, transudation and infiltration, until hypertrophy follows. 
If, from some unknown cause, one organ neglects its duties, an atrophy is the 
consequence. 
Germs appear to enjoy periods of prolific existence analogous to the vast zoological 
life-areas found in geology; the life epochs in scarlatina and variola seem to confirm 
this view, as they seldom again attack the system in such hordes, j: 
* Klinische Diagnostik innerer Krankheiten mittels bakteriologischer, chemischer und mikro- 
skopischer Untersuehungsmethoden. Von Dr. Rudolph v. Jaksch. Wien und Leipzig, Urban <t 
Schwarzenberg, 1887. f On Fever. Prof. H. C. Wood. 
J Drs. Edus & Jameson, in July number Brit. Med. Jour., 1887. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
21 
The commencement and progress of convalesence from fevers marks the decadence 
of this vast internal parasitic population, whose death-débris of extra quantities of 
carbon and nitrogen, etc., in whatever shape they may be presented for elimination, 
greatly tax the individual organs. 
II. To assist in clearing the system of this life activity, or to aid in rapidly removing 
these effete bodies, constitutes the aim of remedy; so that remedy might be defined 
as the use of means to restore the body to healthy condition by prophylaxis, repair of injury 
or the correction of nutrition. 
Germs contain albumen; so, if subjected to the physical effects of vacuum, freezing, 
boiling or incineration, they suffer or perish. Chemically they succumb to the use of 
mineral acids, alkalies, certain salts and organic radicals. In a word, the deprivation 
of oxygen, either directly by oxidation of another substance capable of attracting and 
retaining it, by the loss of hydrogen, by the subtraction or substitution of elemental or 
approximate radicals. Consequently we can successfully exclude, arrest the develop- 
ment of, or totally destroy the bacteria. Therefore, prophylaxis occupies hygienic 
thought, and is the expression of ideal medicine. What advances ! The germ discovery, 
disinfection, antisepsis, vaccination with the attenuated virus, internal antisepticism 
and the addition of certain animal digestive ferments to assist assimilation and nutrition. 
Surgery points with pride to the protection of injured parts from active oxygen, so 
that no bacteria can exist; therefore, absence of irritation ; hence no fever. 
The general constitution of the blood may be altered through the presence of bac- 
teria, and of free or nascent oxygen, realizing the same conditions of fermentive 
action as exist in the pile of refuse, capable of originating such pathological changes 
as are noticed in several anaemias. (See Table I. ) 
One more step in the process and we are introduced into the domain of partial and 
complete disintegration. 
The ptomaines engendered by bacteria are divided into several classes, and upon 
subsequent elemental analysis show that they contain certain homologues of organic 
radicals.* 
TABLE II. 
Ptomaines. 
Chemical Formula. 
Choline 
c5h15no 
Neuridine 
C5H14N2 
Cadaverine 
C5H16N2 
Putrescine 
c5h12n2 
Saprine 
c5h16n2 
Tri-Methyl- Amine 
(CH3)3N 
Mydaline 
•Cornil et Babes, " Les Bactéries," Paris, 1887, p. 57. 
The application of disinfectants suggested antiseptics, and leads us to anticipate 
their modified use in internal medicine. 
* Remsen's Theoret. Chemistry, 1887, 3d rev. ed. "Animal alkaloids," Aitken, Bond., 
1887. "Ptomaines," Brown, Bond., 1887. 22 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
TABLE III. By Duclaux. 
Chemical 
Formula. 
iöööüij iu 1 of Liquid. 
Substance. 
Amount to stop 
development of 
germs. 
Amount not suf- 
ficient to stop de- 
velopment. 
Amount required 
to destroy the 
germs. 
Amount in which 
germs could live 
but not multiply. 
Amount required 
to preserve 1000 of 
soup. 
Amount which 
would not preserve 
1000 of soup. 
H£C!a. 
Corrosive Sublimate 
40 
20 
170 
154 
80 
66 
Chlorine 
33 
24 
44 
33 
2.320 
2,170 
CaCl. 
Calcium Chlorid., 80° 
90 
76 
268 
224 
5,880 
3,875 
SO2. 
Sulphurous Acid 
155 
117 
500 
200 
5,265 
3,660 
so8. 
Sulphuric " 
170 
120 
500 
300 
8,620 
4,900 
Br. 
Bromine 
155 
126 
392 
250 
2,975 
1,820 
I. 
Iodine 
200 
150 
646 
500 
2,440 
1,916 
AI2O3 4- A. 
Acetate of Alumina 
235 
184 
2,350 
1,200 
15,620 
10,870 
Ess. of Mustard 
300 
175 
1,690 
1,220 
35,700 
25,000 
Acid Benzoic 
350 
250 
2,440 
1,960 
8,265 
4,760 
Borax-Sal 
350 
264 
13,890 
9,090 
33,330 
20,000 
Picric Acid 
500 
330 
1,000 
700 
6,660 
5,000 
Thymol 
145 
450 
9,175 
4,715 
50,000 
27,780 
Salicylic Acid 
1,000 
893 
18,660 
12,820 
28,570 
Pot. Permang 
1,000 
700 
6,060 
5 000 
6,660 
5,000 
Carbol 
1,500 
1,000 
45,450 
23,810 
376,000 
250,000 
Chloroform 
11,110 
8,930 
8,930 
7,460 
1,250,000 
Borax 
15,140 
12,990 
20,830 
14,500 
83,350 
847,000 
Alcohol 
47,620 
28,570 
227,300 
116,600 
Eucalyptol 
71,400 
50,000 
8,900 
4,800 
171,570 
Cornil et Babes, 
loc. oil., 
p. 46. 
III. Clinical experience has shown that remedies, although often empirically 
selected, are those containing efficient oxidizers, active appropriators of hydrogen, or 
by the substitution of radicals succeed in destroying the pernicious products of the 
germ, its spores, or the consequences of its mere existence in the vital fluid, e. g., 
acetanilid, salol, quinine, atropine, and a host of others. 
These facts, drawn from the domain of theory and the field of practice, bring to 
view an outline for the philosophy in the choice of remedial agents. When the exact 
laws of physics and chemistry are intelligently and successfully used to restare nutri- 
tion, the study of medicine will possess additional charms and the practice become a 
recreation. 
DISCUSSION. 
Dr. Wm. Murrell.-The subject is one of great interest. The branch of inves- 
tigation is important, but there are very few workers in it. The contributions of 
Dr. Wormley in this country, and Dr. Stockman in Edinburgh, I regard as of 
special value. 
Dr. Rai,ph Stockman.-With regard to the part played by ptomaines in causing 
the symptoms in infectious diseases, I may here refer to some recent work by Dr. 
Phillip, of Edinburgh, on the formation of toxic bodies in phthisical cavities. He 
finds that if phthisical sputum be kept at the body temperature for some hours, and 
then treated by the Stas-Otto method for the separation of alkaloids, there is 
obtained an alkaloidal body which is an active poison. 
This substance administered to frogs caused rapid general paralysis and slowing 
of the heart. In mammalia, a very large dose caused death, while small doses 
frequently repeated induced emaciation, rapid loss of weight and fever. One of 
the most interesting parts of the investigation is the fact that the toxic action of 
this body is, to a very large extent, antagonized by atropine, and this may account 
for the large use of atropine and belladonna in the treatment of phthisis. It seems SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
23 
probable that further investigation will prove that in most of the infective fevers the 
symptoms are largely the result of ptomaine formation, and that the ptomaines result 
from the decomposition of albuminous matter by germs. 
Dr. J. G. S. Coghill.-The interesting fact just mentioned, showing antagon- 
ism between atropine and the products of the bacillus tuberculosis, receives some 
corroboration, clinically, since patients suffering with phthisis will bear much 
larger doses of belladonna without producing, toxic symptoms than they could 
in health. It is by working on this line that we will attain to a really scientific 
treatment of disease. 
CHLORATE OF POTASH. 
CHLORATE DE POTASSE. 
DAS CHLOR-KALIUM. 
BY J. G. SINCLAIR COGHILL, M.D., F. R. C. P. 
The history of Chlorate of Potash affords an interesting example of the vicissitudes 
of remedies in medical opinion. Late, comparatively, in therapeutic recognition, to many 
of the other potash salts, it very rapidly rose in professional esteem. At first lauded 
as a benign panacea in nearly every physical ill that human flesh is heir to, then almost 
as quickly consigned to the limbo of dangerous and doubtful drugs, latterly it has 
come, for the most part, tobe regarded as either harmless or useless, except as a purely 
topical medicament. Prof. Oertel,1 of Munich, declares it has no more therapeutic 
properties than common salt. An opinion very properly traversed by his learned trans- 
lator, Dr. Burney Yeo. Dr. Ringer 2 concludes a meagre account of the chlorate with 
the discouraging remark, " Its influence, if any, on the organs of the body is unknown. " 
According to Stillé and Maisch 3 it should only be used as a local remedy. Dr. Lauder 
Brunton, 4 however, gives it credit for a somewhat wider sphere of usefulness. 
This paper is an endeavor to ascertain, as far as the present state of our knowledge 
of the subject will permit, the true value of Chlorate of Potash in the Materia Medica. 
Chlorate of Potash was apparently the subject of notice by Glauber as early as 
1657 ; it was first obtained by Higgins in 1786, and believed by him to be a kind of 
saltpetre ; and later by Bertholet, who described it as the compound of a potash base 
with some unknown acid. It seems to have been first used in England, in the treat- 
ment of disease, by Dr. Garnett,5 in 1795, and subsequently by Drs. Ferriar, 
Stevens,6 and Kohler.7 Its chemico-physiological properties were early investigated 
by Davy and by Stephens. It was made the subject of an elaborate series of experi- 
ments in animals by O'Shaughnessy,3 in 1831 ; and on which probably the suggestions 
for its employment in medicine subsequently were, to a large extent, furnished. He 
found that when 30 to 60 grains dissolved in three ounces of tepid water were injected 
slowly into the cervical vein of a dog, no ill effects followed. The pulse rose in fre- 
1 Ziemesen's Handbook, Vol. Ill, p. 177. 
' " Handbook of Therapeutics," p. 163. 
3 National Dispensatory," p. 1221. 
4 " Pharmacology," p. 539. 
5 Duncan's "Annals of Med.", p. 1797. 
6 " Pereira," Vol. i, p. 493. 
7 Lancet, 1836, p. 73, Vol. I. 
8 Lancet, 1831, Vol. I, p. 369. 24 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
quency and fullness, the blood of the tracheal veins became of a fine scarlet color, 
and in a short time traces of the salt were detected in the urine. The peculiarities of 
its chemical composition, the large proportion of oxygen, and the readiness with which, 
outside the body at least, it parts with that constituent; its great diffusion power ; and 
the potential energy of many of its chemical combinations, all indicated, and no doubt 
led great expectations to be formed of, its medical efficacy. It was at first certainly 
employed in medicine on the theory that it yielded oxygen to the system, in diseases 
in which the blood was held to be deficient in that element. Hence, its earliest exhi- 
bition was in the various forms of scorbutus. Dr. Hunt, in 1843, seems first to have 
ascertained its value in cancrum oris, by whom also it was suggested to Herpin, of 
Geneva, and Bergeron of Paris, in mercurial salivation. It was first recommended by 
Dr. West, in membranous and ulcerative stomatitis in children. Mr. Corner,1 of the 
" Dreadnaught, " found " it acted like a charm in follicular, ulcerative and phagedenic 
stomatitis also in scurvy more rapidly than any other remedy. Drs. Budd and 
Sankey2 remarked its effects in the cyanosis and dyspnoea of pneumonia and croup, with 
depressed circulation. They concluded the salt must be decomposed, from the marked 
and rapid effect. Weedon Cooke3 spoke of it as a tonic of the highest value in all 
adynamic conditions, especially in hectic states of the system, when quinine and iron are 
inadmissible, "so powerful is it in oxidizing or decarbonizing the blood when liver 
and skin have failed in their offices." There is no tonic comparable to it, he says, in 
the sequelae of the exanthemata, in cachexia of all kinds, and in all scrofulous diseases. 
Dr. Fountain,4 of New York, in 1859, drew attention to its oxidizing properties, being 
capable of coming to the aid of the respiratory process ; of stimulating secondarily the 
function of absorption ; of relieving the cyanosis of heart disease ; and of dyspnœa in 
cases of pneumonia typhoides, hydrothorax, and thoracic effusion of blood from inter- 
costal wound, ' ' where the chlorate of potash supplied the blood with oxygen sufficient 
to sustain life during the time respiration was seriously impeded." Osborne 5 declares 
the action of chlorate of potash to be chemico-physiological, depending first on its 
oxidizing property when in contact with morbific matter in the blood; secondly, on its 
remarkable physiological action on the muscular fibres of the vessels, causing them to 
contract and thus increase the blood pressure. He was himself singularly sensitive to 
its action. Five-grain doses caused the radial artery to contract to the calibre of a 
bell wire. Its action was similar on the muscular coat of the bowel. It was also 
recommended by Drs. Fountain, Turlé, and Harkin,6 of Belfast-the latter always an 
enthusiastic believer in the virtues of the chlorate-in consumption and scrofula, but 
Austin Flint' declared that fourteen well observed cases failed to show it had any 
specific effect on developed phthisis. Dr. Harkin 8 also, following Hutchinson, urged 
its importance in purpura hemorrhagica. He suggested its use in all maladies depend- 
ent upon defective nutrition, excretion, aeration, and molecular metamorphosis. "It 
possesses the power of developing vital force in weakened constitutions, of retarding 
degeneration of tissues, and frequently of controlling the too rapid advance of senility 
due to climacteric conditions." He believed "a portion was carried off by the kidneys, 
another by diffusion into the liquor sanguinis, the textures, the blood globules and 
the white corpuscles ; a third may be supposed to part with three equivalents of oxygen 
in the blood, leaving behind chloride of potassium, which may be detected in the 
urine as well as in the blood, of which it is an important element." By Seeligmüller 9 
8 Dub. Jour. Med. Sc., Maj', 1861. 
7 American Quart. J. of Med., Oct., 1861. 
8 Dublin Jour Med. Science, 1880, p. 398. 
• Stillé and Maisch, p. 1221. 
1 Medical T., Nov., 1857, p. 476. 
a Guy's Hosp. Rep., Vol. VIII, 1851, p. 331. 
3 Lancet, 1859, p. 449, 29th Sept. 
* New York J. of Med., July, 1859. 
8 Lancet, 8th Oct., 1859. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
25 
and others and by Dr. Hüllmann,1 more recently it has been extolled almost as a specific 
in diphtheria, but as strongly condemned by Isambert, Jacobi, of New York, and also 
by Von Becker, of Vienna, as not only useless, but even dangerous to young children, 
from its depressing effect. I have found it in this disease very efficacious, very sooth- 
ing to the local condition and a great help to maintain or restore the general powers 
and state of the blood. It can only prove "dangerous " when given in too large 
doses, as unfortunately is the tendency on the continent. 
Dr. Mead employed it successfully in chronic dysentery, ' ' one of the most hopeless 
and intractable diseases." He injected twice or thrice a day chlor, pot., gss, glycerin 
3 ss, warm water, 3 iij- 3 iv. It heals the ulcerations of the mucous membranes. At 
first the injection can only be retained half a minute. It has also been recommended, 
both internally and externally, in cancer, by a long list of authorities, from Milsom 
in 1837, Tedeschi in 1846, to Burow, of Königsberg, in 1873,2 Vidal in 1875, and 
Entyboule, 1877.3 The latter advocates a seven to ten per cent, solution to be applied 
locally, but Burow recommends the powdered salts or the crystals. The latter are 
more painful. Its great value as a sialogogue was early noted by Dr. Dethan4 and by 
Headland,5 who pointed out that it may reinforce the pancreatic digestion. For many 
years previous to 1856, Sir James Y. Simpson 6 employed chlorate of potash with 
marked success in cases of placental insufficiency threatening the life of the foetus, as 
he expressed it, ' ' from asphyxia, ' ' resulting either from the defective quality of the 
maternal blood or the reduced extent of healthy placental tissue. He noted also its 
undoubtedly marked influence in promoting the growth and development of the foetus. 
Grimsdale, Bruce, Moir and many other competent observers have recognized its great 
value in this connection. It would be impossible to recite here all the various symp- 
toms and maladies in which chlorate of potash has been successively employed, but the 
only reputation which it has retained and which is universally accepted, is its almost 
specific action in rapidly curing foul and unhealthy conditions of the buccal and 
pharyngeal mucous membrane by local application. Its effect in such cases is too 
much in evidence to be passed over, and, accordingly, to this humble therapeutic rôle 
is the chlorate of potash relegated in the orthodox works on materia medica. 
As the reputation of chlorate of potash rose on one chemical suggestion, so it fell 
mainly on another. Tiedemann, Gmelin, Dumas and Majendie had shown that when 
administered, it could be readily detected in the blood, and it had also been recog- 
nized by various observers unchanged in the urine, but the analysis of Wöhler and of 
Stehberger, declaring that practically all the salt is eliminated by the kidneys, struck a 
serious blow to its reputation, which had been, unfortunately, too exclusively founded 
upon a chemical theory of its action, and which undoubted clinical proofs of its efficacy 
in a variety of morbid conditions were unable to withstand. This unfavorable reaction 
was further accelerated by the fatal consequences resulting in certain cases from too 
large doses of the salt, either accidentally or imprudently administered for the sake of 
experiment. In 1862, Dr. Fountain,7 of Iowa, who had written enthusiastically of its 
virtues, to show his opinion of its innocuousness, took one ounce in a single dose, with 
disastrous effect. "Violent gastro-enteritis was produced; at first there was free diu- 
resis, but suppression followed and death ensued in seven days." Fatal cases have 
occurred from a single dose of 600 grains; from doses of 300 grains on four successive 
days; from single doses of 240 and of 180 grains, which caused death in a young girl in 
1 Deutsche Med. Wochensch., 14th Nov., 1884. 
2 Berlin. Klin. Wochensch., No. 6., Feb. 10th, 1873. 
3 Thèse, Paris, 1877. 8 " Action of Medicine," p. 343. 
* L'Union Médicale, 4th June, 1867. 8 " Obstetrical Works," Vol. II, p. 460. 
7 Bartholow's "Materia Medica and Therap.," p. 180. 26 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fifteen hours.1 Altogether, there are 47 fatal cases of chlorate of potash poisoning on 
record up to 1884. On the other hand, large doses of from 5 j to 3 iij thrice a day 
have been taken with impunity for considerable periods. Germain Sée has given in 
a single day with complete impunity. The fact is, we have, in chlorate of potash, to 
deal with a potent drug. With this, as with every active remedy, the dose and condi- 
tions of administration determine the effect. A small dose may be stimulating, tonic 
and recuperative, a large one depressing and destructive. No rule in therapeutics is 
more invariable, and no rule has to be kept so steadily in view when studying the effects 
of drugs on the system, both in health and disease. It has been well observed, that no 
medicine that has any real power in controlling or arresting diseased action can be 
innocently administered in healthy conditions. We must consider the tolerance of the 
patient, the state of the system, and the conditions of administration. Danger has 
unquestionably arisen and the salt has suffered grievously in repute from being regarded 
as simple and indifferent in its action. Dr. Jacobi 2 has referred to the strange circum- 
stance, that as it declined in professional it increased in popular favor; more so in 
America than any other drug. As a local application, either in powder or crystals, its 
action is distinctly caustic. This, indeed, is the cause of the pharmacopœial and other 
chlorate lozenges in use being so objectionable and inefficient, from their containing too 
great a proportion of the salt. For years I have employed a lozenge prepared with 
sugar only, each containing two and a half grains in the same bulk. In this form the 
affected membrane may be kept continuously laved, by means of the saliva, with the 
chlorate in sufficiently effective solution, by keeping the lozenge between the cheek and 
gums, where with the pharmacopœial or Wyeth's preparations an eschar would be 
produced. 
The symptoms of poisoning with the chlorate will depend on the amount exhibited. 
In large doses it acts as a violent irritant. Physiologically, small doses increase arterial 
tension, stimulate the heart and the respiratory function and redden the blood cor- 
puscles. In poisonous doses these effects are altered in excess. The arterial tension 
gives way to depression and collapse, with fall of temperature, the circulation fails, 
from ultimate paralysis of the heart-Isambert, by injecting a strong solution into the 
veins found that the heart ceased to beat in diastole-the blood corpuscles are destroyed 
by the conversion of their haemoglobin into methaemoglobin. The débris of these 
block up the renal tubules, producing hæinaturia, and subsequently the suppression 
ultimately observed in these cases. Where extremely large doses are given, the result 
may be brought about by the potash base acting directly as a protoplasmic poison on 
the brain and spinal cord, being the most highly organized tissues, as shown by Ringer 
and Murrell. 
Some time ago I was very much struck with the account of Dr. George Henderson's8 
experience with chlorate of potash, recorded in his journey from Lahore to Yarkund, 
over the lofty passes of the Himalayas; and subsequently with the more detailed obser- 
vations of Bellew,4 in his very interesting narrative of his expedition through Kashmir 
to Kashgar, in 1874. To relieve the dyspnoea and general distress, called by the natives 
"Dam," caused by the extremely rarefied air on the higher passes, and which proved 
fatal to Sultan Sa'id Khan Shagi, of Kashgar, Dr. Henderson gave a strong solution of 
chlorate of potash to those su Hering from the symptoms in question ; more as a placebo, 
as he says, than from any belief in its efficacy. It had a good effect, but he professes 
not to know upon what principle it acted. Bellew's account of his experience is more 
i Quoted by Dr. Boude, New York Medical Record, May 8th, 1880. 
» Next) York Medical Record, March 15th, 1879. 
3 "Lahore to Yarkund," by Dr. G. Henderson, 1870, p. 57-58. 
* "Kashmir and Kashgar," by H. W. Beilew, C. S. I. Surgeon Major, 1875. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
27 
detailed and extremely interesting. The following are his own words : "At Gyapthang, 
15,150 feet, and still more, near Karacoram, 18,300 feet, the effects of the rarefied atmo- 
sphere on men and'beasts were extreme. Several of the former tumbled off their ponies, 
from the giddiness produced, and some fainted. My own servant fell three times, and 
the hospital dresser was carried over insensible, but they recovered themselves on reach- 
ing the lower ground on the other side. Several ponies died. Even when seated quietly, 
writing, I found my pen every now and again jerked forward by an involuntary sudden 
gasp to fill the chest and raise the load pressing on it. And worse, just as I was going 
off to sleep, in hopes of forgetting the pain that racked my head and the nausea that 
well nigh floored me, I was started up by a sense of immediate suffocation. A few 
deep-cut, unsatisfying gasps, and a reeling giddiness, brought my head on the pillow 
again, to doze dreamily awhile, only to start up afresh and go through the same process 
again, and so on till the bugle bade me rise. The exertion of dressing-a luxury I 
henceforward carefully denied myself until we got down to a dressing level-well nigh 
finished me, and it was as much as I could do to mount my horse. Availing myself of 
Dr. G. Henderson's experience of his journey across this region in 1870, Iliad provided 
myself with a large supply of the salt he found so useful, and with very satisfactory 
results, as our further progress proved. I distributed little bottles of the chlorate of 
potash among the members of the embassy and such of the followers as needed it, and 
from my own experience can testify to its value in mitigating the distressing symptoms 
produced by a continued deprivation of the natural quantum of oxygen in the atmo- 
sphere. The large proportion of oxygen contained in the salt probably supplies to the 
blood what in these regions it fails to derive from the air, and thus restores through the 
stomach what the lungs lose. Whatever the explanation of its action, however, there 
is no doubt of its efficacy in relieving the dreadful nausea and headache produced by 
the circulation of an indifferently oxygenated blood, and no traveler ought to venture 
across these passes without a supply of this simple remedy in his pocket. ' ' 
I was very much impressed with these very interesting statements. They were so 
entirely confirmatory of my own long acquaintance with the medicinal energy of this 
salt, extending from 1857, when, as assistant to the late distinguished Professor of Mid- 
wifery in Edinburgh, I had ample opportunity of observing its very potent effects in 
his practice, and from which time experience has only increased my confidence in its 
remarkable medicinal properties. I have steadily extended its employment to all cases 
in which the oxygenation of the blood is interrupted or defective from any cause, 
mechanical or constitutional-in fact, so impressed did I become with its undoubted 
power and evident therapeutic activity, that I felt reluctant to accept the catalytic 
explanation of its modus operandi, and indeed became rather skeptical as to the relia- 
bility of the original investigations of Wöhler and others, to which I have already made 
reference. Accordingly, with a view to test this question, I had, in association with 
my friend, Mr. Otto Wehner, F. C. S., three separate series of experiments made, and 
to eliminate as much as possible sources of fallacy, each observation made in duplicate 
and the mean taken, while a different analytical process was used in each series. The 
following is a résumé of the methods of analysis followed and of the results obtained :- 
1. Methods of Analysis.-The old indigo test, most sensitive as a qualitative, being 
found both inconvenient and unsatisfactory in a quantitative examination of a fluid 
containing much organic matter, other modes had to be adopted. 
The total amount of chlorine or of chlorides contained in urine is, as a rule, deter- 
mined by evaporating a measured quantity of urine, incinerating the residue with the 
addition of a little pure potassium nitrate, dissolving the fused mass remaining in dis- 
tilled water, acidulating with nitric acid, neutralizing the excess of acid by means of 
calcium carbonate, and titrating the chlorine by means of standard nitrate of silver 
solution. It is apparent that should chlorates be present in the urine, they would part 28 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
with their oxygen during the process of incineration and become converted into 
chlorides. 
If urine be treated with a solution of potassium permanganate, uhtil all the organic 
matter has been destroyed, the dioxide of manganese separated by filtration, and 
the excess of permanganate carefully removed by the addition of oxalic acid, the 
chlorine may be directly determined as above indicated. By the treatment with per- 
manganate of potassium, chlorates are not altered, and hence that part of the chlorine 
which is present as chloride is only obtained. By subtracting the amount of the chlor- 
ine present as chloride from the total amount, that portion of chlorine which is present 
as chlorate is obtained. The amount of chlorides in normal urine is fixed and constant. 
As test experiments the amount of chlorine was determined in normal urine, after 
destruction of organic matter by permanganate. A known quantity of chlorate of 
potash was then added to a corresponding amount of urine, and the amount of chlorine 
again determined as above. The same figure being obtained showed that the chlorate 
does not decompose by treatment with permanganate. After incineration of a meas- 
ured quantity of urine to which a weighted quantity of chlorate has been added, an 
amount of chlorine was found equal to that obtained in the previous experiment plus 
the exact quantity added as chlorate. 
After these tests experiments, I ordered a patient to take, for six days, 120 grains of 
chlorate of potash, in four equal doses, collect the urine for twenty hours, and submit 
an ascertained proportion each day for examination. 
1st exam. 
120 grs. 
excreted 
57.02 grs. 
47.5 per cent. 
2d 
120 " 
u 
122.56 " 
102.1 
C I 
3d 
120 " 
u 
141.01 " 
117.5 
u 
4th • 
120 " 
44 
101.77 " 
84.8 
44 
5th 
120 " 
44 
162.52 " 
135.4 
44 
6th 
? 
12.81 " 
10.6 
44 
7th 
none 
none 
none 
Total taken, 
600 " 
44 
597.69 " 
497.9 
44 
• 
Average, 
99.6 
44 
It follows from these results that aH the chlorate was excreted hy the kidneys as 
such, without its having parted with any oxygen contained in it. The total quantity 
taken was practically found in the urine, the very slight difference being doubtless due 
partly to- 
1. Error of experiment; 
2. Impurities of the salt employed ; 
3. Unavoidable loss in administering and collecting secretions. 
One interesting circumstance was that analysis reflected exactly, in the varying 
amounts of chlorate collected in each experiment, any irregularity in the times of the 
patient taking the dose. For instance, the great fluctuations in experiments 4 and 5 were 
ascertained to be due to the patient having forgotten to take the dose at the right time, 
and instead of being found in sample 4, it came out in sample 5, the latter containing 
the exact quantity deficient in 4. The patient was also instructed to take six daily 
quantities, and the analysis was carried out on that supposition, but five daily quanti- 
ties only could be recovered, and it was subsequently ascertained that the patient only 
took the doses on five instead of six days. 
In the second series of experiments the copper zinc couple described by Gladstone 
and Tribe was used by Mr. Wehner as a reducing agent, instead of the former method, 
because, on incineration a little chloride may be volatilized; and because some chlorate 
may escape perfect decomposition. This couple is prepared over 1 metre of well- 
crumpled, very thin zinc foil cut in shreds, a solution of 15 grammes of sulphate of SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
29 
copper, the resulting black spongy mass being well washed with water. It reduces 
chlorate of potash in aqueous solution with the evolution of hydrogen with extreme 
rapidity, at a temperature near boiling point. The reduction takes place much slower 
when urine is the solvent of the salt. 
In this second series of seven experiments Mr. Wehner himself, at 1.35 P.M., on the 
12th of February, took 2 grammes of pure, dry chlorate, and separately collected and 
analyzed every batch of urine passed, swallowing the saliva all the time carefully. As 
a result of the sum of these observations it Was found that of the 2 grammes of chlorate 
swallowed, 1.8764 gramme, or 93.82 per cent., had passed through the kidneys in 29 hours 
and 40 minutes. The seventh sample passed after this was found free from chlorate. 
1st specimen 1.35 p.m., 17.23 % chlorate. Rate per hour excreted 11.49 %. 
2d " 5.05 P M., 23.62 " " " " " 11.81 " 
3d " 7.05 P.M., 16.08 " " " " " 8.04 " 
4th " 10.00 P.M., 10.91 " " " " " 3.74 " 
5th " 10.00 A.M., 15.01 " " " " " 1.25" 
6th " 7.15 P.M., 10.98 " " " " " 1.18 " 
7th " 9.30 p.m., none " " " none. 
To state it differently, of the dose there was excreted- 
After 1 hour and 30 minutes, 17.23 of the chlorate taken. 
After 3 " 30 " 40.84 " " 
After 5 " 30 " 56.92 " " " 
After 8 " 25 " 67.83 " " " 
After 20 " 25 " 82.84 " " " 
After 29 " 40 " 93.83 " " 
Total 98.83 per cent, recovered, or 29 grains out of 31 grains, in round numbers. 
It will be noted that the rate of secretion is constant for the first period of 3| hours, 
viz. : 11 per cent, per hour, and that during this time nearly one-half of the whole 
amount taken has passed through the kidneys, the rate of elimination then, for a time 
gradually, and toward the end of the period rather quickly, decreases. 
In the third series of experiments Mr. Wehner took within two hours 8 grammes 
(about 123 grains) of pure chlorate of potash, and carefully collected all the urine passed 
for nearly three days-until a qualitative test for chlorate gave a negative result. The 
amount collected was nearly four litres. The different portions were mixed and made 
up with distilled water to 4000 cubic centimetres. From 40 cc. the chlorides were 
removed by a mode to be subsequently described, and the chlorate reduced with zinc 
and sulphuric acid ; 0.0884 gramme AgCl were obtained. A second experiment also 
yielded 0.0884 gramme AgCl, corresponding to 0.07552 gramme KC1O2, or 7.552 in the 
total volume. 94.40 per cent, of the chlorate taken was, therefore, excreted by the 
kidneys unreduced. The remaining 6 per cent, was probably eliminated by other natural 
channels. It is improbable it was decomposed within the system, because if such 
reduction took place, it ought to have been proportionally much greater in the case of 
the small dose, than in the case where a large dose is taken. 
The latter results were obtained by electrically reducing the chlorate to chloride. 
A large number of test experiments proved the method quite an original one, quite sim- 
ple and exceedingly accurate. 
Several interesting points developed themselves in the course of these experiments. 
The appetite became greatly improved-indeed voracious, even when the system was 
saturated with the largest amounts of the salt. The salivary secretion became intensely 
acid, as the dose of the salt was pushed beyond forty-five grs. per diem-the teeth even 
showing evidence of corrosion. The nature of this acid has not yet been determined. 
It is neither hydrochloric nor phosphoric. It may probably be sulpho-cyanic acid. 30 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The specimens of urine, also, voided during the exhibition of the chlorate, remained for 
an indefinite time unchanged, as regards odor and appearance, although swarming with 
bacteria. This, so to speak, chemical antiseptic action of the chlorate is a most invalu- 
able one, and has been largely made use of in appropriate cases, when the urine tends to 
decompose in the bladder under certain morbid conditions.1 It is evident, however, in 
the light of our analysis, that it cannot act as an antiseptic by parting with any portion 
of its oxygen. 
If we are to accept these results as conclusive and final, we are driven necessarily 
to the view that chlorate of potash acts by its mere presence in the blood or system 
generally, as a catalytic simply. In this respect resembling iodide of potash, of which 
(Scharlar found fifty-three grammes in the urine, and two grammes in the saliva, sweat, 
tears, etc., out of a total amount of fifty-three grammes administered. There are many 
other medicinal substances, organic as well as inorganic, although very active, which do 
not change in the body-or, at least, go out of it in the same form in which they entered 
it. Chemists, however, are inclined more and more to regard with doubt and disfavor 
so-called contact actions, where bodies act by their presence merely without themselves 
undergoing change. Chlorate of potash cannot in itself, under ordinary conditions, by 
precipitation of bases, produce free acid ; first, because it does not form any insoluble 
salts ; and secondly, even if it did, it could not liberate acid, as it is a neutral salt itself, 
and in all its decompositions with other salts, would still remain neutral or produce 
neutral derivatives. 
The accuracy of these and previous analyses were, however, challenged by Prof. 
Ludwig, of Vienna,2 in 1881, and subsequently by Dr. I. Von Mering,3 of Berlin, in 1884. 
Ludwig states that in a poisonous dose chlorate of potash acts like arsenic and phos- 
phorus, and, the blood corpuscles being destroyed during the conversion, it is reduced by 
the blood to the condition of the chloride, for it could be detected neither in the blood, 
urine, nor contents of the stomach. Again, the chlorate can be decomposed in the 
kidneys, by feebly acid urine, into a base and an acid, and the chloric acid thus formed 
is energetically toxic. Professor Ludwig points out that the examples are increasingly 
numerous of stronger acids, under certain conditions, being separated from their bases by 
weaker acids, and therefore, it should not be surprising that the feebly acid urine should 
so act in this instance. These opinions were founded on a case of lithotripsy, in which 
Billroth had ordered, as usual in his clinique, a five per cent, solution to the extent of 
five grammes in twenty-four hours. The patient, aged 64, was found dead, and 
declared, by Ludwig, to have died with all the symptoms of chlorate of potash poison- 
ing. It was ascertained that he had been given fifteen grammes by mistake. In the 
interesting discussion on this case in the Medical Society of Vienna, Ludwig 4 declared 
that the chlorate had been reduced in the economy, and had passed into the chloride of 
potassium, adding that it was no longer doubtful that the chlorate, under certain cir- 
cumstances we are at present ignorant of, may become wholly, or in great part, reduced 
within the body. He referred to the opinion of Prof. Binz, who first pointed out that 
many organic substances (such as blood, fibrin, yeast, etc.,) when passing into a state 
of putrefaction, may decompose chlorate of potash. It is quite impossible, in the face 
of the elaborate and repeated analyses of Wehner, and other reliable chemists, to accept 
without reserve the inference sought to be drawn by so eminent an authority as 
Ludwig, that the whole of a poisonous dose of chlorate, amounting in this instance, to 
1 The power of the chlorate " to counteract putrescence of the fluids in scarlatina, typhus and 
cholera," was pointed out by Royle and Headland, " Mat. Med.," p. 96. 
2 Jour, de Pharm. et de Chimie, Sept., 1881. 
» " Das Chlorsäure Kali," Berlin, 1884. Dr. Thos. Stevenson, in London Med. Rec., 1884, 
p. 518. * Allgem. Wien Med. Zeit., Noa. 44, 45. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
31 
fifteen grammes, could be entirely reduced in the living body. It is equally opposed to 
all chemical experience. I am inclined to seek an explanation in the theory that this 
large dose, more than half an ounce of the salt, acted directly as a caustic, destructively, 
on the tissues and blood vessels, thus supplying the putrefactive organic material, which 
according to Binz's experiments, is sufficient to decompose the chlorate, and that the 
complete reduction found by Ludwig, was due to post-mortem changes. Wehner 1 has 
suggested in this connection, that all the salt may have been separated by the kidneys, 
before the death of the patient, but his own experiments, showing how unvarying is 
the rate at which the chlorate is eliminated in the urine, render this explanation 
untenable. 
In the same discussion Dr. Mezek stated that he had given sixty grammes spread over 
an average of fourteen days, in seventy cases of cystitis and cysto-pyelitis, simple and 
specific, and that neither he nor his colleague, Dr. Englisch, had observed any ill 
consequences. The acid reaction in the urine usually commenced on the second day ; 
the triple phosphate disappeared from the sediment, which gradually lessened and 
became less viscid, while the irritability of the bladder correspondingly diminished. 
Dr. Von Mering has carried out an elaborate experimental investigation into the 
action of chlorate of potash under different conditions. He has arrived at the conclusion 
that "this salt, under the influence of carbonic acid, and probably other acids, is decom- 
posed in the system with the gradual liberation of chloric acid, which tends to reduce 
the alkalinity of the blood; and in this lies the key to the right understanding of the 
action of chlorate of potash." I confess my inability to reconcile this view with the 
considerations previously advanced. It is exceedingly improbable, within the body, that 
so very feeble an acid as carbonic acid could decompose chlorate of potash in an organic 
solution, liberating so strong an acid as the chloric. It is not impossible, of course, 
reasoning by analogy, for chloride of sodium is so reduced in the stomach into soda and 
hydrochloric acid, but in this instance there is a special provision and apparatus to 
accomplish the reduction. Chloric acid in solution gives off its oxygen much more 
readily than its potash salt does. If chloric acid were liberated it should certainly be 
expected to yield up its oxygen and become reduced, but Wehner's repeated experi- 
ments conclusively showed this not to be the case. The only other possible theory that 
can be advanced with a view to reconcile such experimental discrepancies is to suppose 
that the salt in its passage through the system is capable of gradual-it may be also 
partial-decomposition, and of the ultimate reconstruction of its constituent elements. 
The means of determining such a process are unfortunately not at present within our 
reach. 
It is not, however, necessary, much less essential to belief in the efficacy of a remedy, 
that we should be able to follow and recognize the chemical processes within the organ- 
ism by or through which its curative influence is attained. This most desirable con- 
summation in the case of every drug, will doubtless come in due course with the progress 
of science, but we are not meantime to refrain from using them. 
The limits to which this communication has already extended render it necessary 
for me now to describe, or rather to state briefly those marked conditions in which the 
exhibition of the chlorate is indicated, and has been found an efficient remedial agent 
when administered judiciously, with reference to dose and other pharmacological 
conditions. 
The therapeutic properties may be stated generally as those suggested by its chem- 
ical constitution and affinities. As a salt exceptionally rich in oxygen, it has, without 
decomposition, the valuable property, per se, by its mere presence apparently, of oxygen- 
ating or aerating the blood, and so by restoring or exalting this vital character of the 
1 The Lancet, 11th March, 1882, p. 421. 32 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
circulating fluid, influencing to a corresponding degree the nutrition and functional 
activity of the various tissues and organs of the body. Beyond this it does not appear 
to have any specific action in any disease. 
I have already referred to the experience of Simpson and others to its effect in pre- 
venting abortion when threatened from placental inadequacy. Its influence on the 
foetus itself directly is no less remarkable. I have accumulated a mass of evidence in 
my own practice showing that its continuous exhibition during pregnancy-even when 
abortion or premature delivery has not been imminent-has an extraordinary effect in 
increasing the weight and development of the infant. In the case of a lady who has 
been under my care during eleven out of twelve confinements, the facts amount to a 
demonstration. Three out of her first six children were so feeble at birth that they 
barely survived the ordeal-the others being very small-the seventh child, a boy, was 
prematurely delivered at the eighth month, did not weigh quite five pounds, and was with 
the greatest difficulty reared. In this case the chlorate, which had been commenced at the 
beginning of the pregnancy, was suspended, by other advice, at the third month, when 
the patient passed temporarily from under my care. The effect of the suspension of the 
chlorate on the mother was almost equally disastrous. In five subsequent pregnancies 
the patient was placed, from the missing of the first period, on the salt, with the result 
that excellent health was enjoyed by the mother, that all the children were bom at full 
time, and weighed from 11 to 111 pounds. They are in striking contrast, as regards 
size, to the child I have referred to as bom at the eighth month. Many mothers, in my 
experience, have objected to take the chlorate in subsequent pregnancies, from their recog- 
nition of its effect on the size of their children in previous confinements, and so adding 
to their sufferings. The mother is usually conscious within two minutes of its ingestion, 
of the effect of the salt on the foetus, from the increased activity and strength of its 
movements. The mother also experiences a feeling of exhilaration and bien aise at the 
same time, which often creates quite a craving for the chlorate, under the use of which 
appetite is greatly stimulated. 
I have also for many years employed this salt in all cases of pulmonary insuffi- 
ciency; in arrested phthisis, where there is excavation; in chronic pneumonic consolida- 
tion; in bronchitis where due aeration of the blood is impeded either from emphysema 
or thickening of the tubes; and in pleurisy with effusion, or empyema, where the lung 
is more or less compressed. I have also seen it help to tide over the crisis successfully 
in pneumothorax. When administered steadily and judiciously in such conditions, it 
has the effect of rapidly alleviating the symptoms of dyspnoea and cyanosis, and at the 
same time improving the general state and removing the accompanying feeling of 
distress. 
In all cases of cardiac disability, either organic or functional, its action as a tonic 
and stimulant to the organ is very marked. It probably thus acts through the 
improved condition of the circulating fluid itself, which also exerts a potent influence 
on the nutrition of the tissues generally. 
In all states of the system where the blood is impoverished either in amount or 
quality after hemorrhages; in convalescence from acute diseases, more especially where 
mucous surfaces have been involved; in anæmia; in chlorosis; and particularly in the 
peculiar deterioration of the blood which results from the various forms of malarious 
poisoning, the chlorate of potash is strongly indicated, either alone or in such combina- 
tions as the complexity of the morbid conditions present may demand. I have seen 
many cases, both of anæmia and chlorosis, that had resisted all the usual preparations 
of iron, yield rapidly to the tincture of the sesquichloride of iron in an effervescing 
solution of twenty-five grains of chlorate of potash thrice daily, after food-the base, 
no doubt, aiding greatly in producing the good result. Quinine, digitalis or nux 
vomica may be added, as the symptoms indicate. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
33 
Chlorate of potash should, if possible, be given in aerated solution. I order it in 
syphons, each containing 3 j or 3 ij-marking the limits of daily doses for an adult. In 
this form it is more palatable and better tolerated by the stomach. It is very readily 
taken in milk, and also with wines or spirits, when such form part of the regimen. It 
should never be given in full doses except with or after food. The amount taken 
should be spread out over the day as much as possible. In moderate doses it is diuretic, 
partly, in all probability, from its stimulating effect on the heart, but as the kidneys 
are the main channel of its discharge from the system, it should be given with caution 
or withheld entirely where there is renal inadequacy and consequent accumulation 
of effete materials in the blood. 
Its action as an antiseptic is peculiar and valuable. While it effectually retards 
chemical decomposition in organic fluids, such as the urine, even when loaded with pus, 
it does not prevent bacterial evolution. In all cases where there is suppuration, either 
simple or specific, of the genito-urinary tract; where the urine is phosphatic, purulent 
or offensive from any other cause, the chlorate, well diluted and administered continu- 
ously as a diet drink, either alone or in milk or barley water, will give most satisfactory 
results. I was much impressed with its effect in a case of prostatic abscess in a young 
gentleman resulting from a local inflammation caused by sitting, while heated, at a foot- 
ball match, on damp grass. It had passed into the chronic stage when I saw the case. 
There was a large proportion of offensive pus passed with each voidance of urine, and 
there was great pain and irritability of the bladder. The general health had suffered 
greatly from the long suppurative process and accompanying irritation. It had resisted 
all treatment, and up to the time I saw the patient, every variety of treatment had 
been tried, including washing out the bladder twice a day with various antiseptic solu- 
tions-latterly, Condy's fluid. I at once put the patient on a milk, farinaceous dietary, 
and gave chlorate of potash to the extent of 3 ij per diem, at first alone and latterly 
with the tincture of the ferric sesquichloride. Relief began almost at once, and the 
cure ultimately complete within six weeks. 
In chronic pharyngeal folliculitis or so-called clergyman's sore throat, I do not think 
its singular efficacy in combination with liquor arsenicalis is sufficiently recognized. 
Steadily persevered in and the arsenic pushed occasionally to its full effect, with the 
throat kept constantly day and night bathed in a solution of the chlorate in the form 
of the milder (grs. iiss) lozenge I have previously described, no treatment in my hands 
has been found so effectual in this troublesome and obstinate malady. 
I need not again refer to the action of chlorate of potash as a purely local remedy 
in non-parasitic affections of the buccal and pharyngeal mucous membranes, it is so 
generally conceded. 
If I have succeeded, even to a limited extent, in restoring to professional favor this 
once much-lauded remedy, the object with which this paper has been written will 
have been accomplished. 
DISCUSSION. 
Dr. H. A. Hare, of Philadelphia.-It should never be forgotten that chlorate of 
potash does not part with its oxygen at the temperature of the body ; and even if it 
did do so, a sufficient quantity of oxygen could not be given off by the small quantity 
of the drug necessarily administered to do any good as an oxidizer in the body. 
Again, chlorate of potash should never be given internally in diphtheria, on account 
of its irritant action on the kidneys, which, in this disease, are already crowded with 
bacilli and greatly inflamed. As the object in this case is to locally affect the lesions 
in the pharynx, which is done by the elimination of the drug by the salivary glands, 
it is evident that the topical applications will do so as well, without danger of involv- 
ing the kidneys. If chlorate of potash ever produces any changes in the organism, 
Vol. Ill-3 34 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
it probably acts as do all potash salts, viz., as depressants, and not owing to its oxygen. 
Another objection to the use of chlorate of potash internally, particularly in diph- 
theria, is its depressing action on all the tissues, particularly the heart. 
Dr. J. Solis-Cohen, of Philadelphia.-In diphtheria, chlorate of potash lozen- 
ges are very useful adjuvants to the treatment ; there is nothing that gives as good 
results as chlorate of potash. It must not be pushed to the extent of injuring the 
kidneys, and as soon as there is evidence of such irritation, the dose must be reduced. 
In all inflammatory affections of the mouth, pharynx and air passages, the results 
are good. It is a fact that I previously have noted, that in diphtheria all the chlo- 
rine compounds have been found to be useful. 
Dr. Traill Green.-The sodium salt is preferable to the potassium chlorate, as 
it is more soluble and less irritating. I first became acquainted with the salt in 
1846, and generally give it in place of the other. Since the introduction of these 
salts the treatment of diphtheria has undergone a complete change ; caustics are no 
longer used. 
Dr. G. L. Magruder, of Washington.-In dispensary service I have remarkably 
satisfactory results in the treatment of catarrhal conditions of the bowels, especially 
in young children during hot weather. In catarrhal states of the air passages, also, 
potassium chlorate is very useful. 
Dr. F. E. Stewart.-In cases of fetid breath I have seen benefit from the 
chlorate of potash. 
Dr. Wm. Murrell.-The chlorate of sodium has been largely used in London 
since the publication, some time ago, of Dr. Sainsbury's paper in the Lancet on 
"Chlorate of Potash.'' 
Dr. Frank Woodbury.-It is not necessary that chlorate of potassium shall be 
decomposed in the blood in order to be therapeutically active ; sodium chloride is an 
important article of food, but no one claims that it is unstable ; on the contrary, 
after being disseminated all over the body, it is excreted in the same form in which it 
was administered. Too much attention should not be given to the mere analogies of 
chemical composition ; oxalic acid and starch contain the same elements, but differ 
widely in their effects. The question of solubility, however, is of much import- 
ance. As the chlorate of potassium is not very soluble, it is liable to crystallize from 
the blood in the kidneys, and give rise to irritation or inflammation. As it is quite 
depressing in its effects, it should be given with caution to children ; and a very color- 
able imitation of diphtheria can be obtained by administering the agent in relatively 
large doses to children with sore throat. 
Dr. Carter.-I use chlorate of potash very frequently in inflammation of the 
throat and nose with very good effect. I have been led to believe that the chlorate 
of potassium and all other chemical drugs, have an action, perse, as chemical com- 
pounds and not as potassium or chlorine would have if uncombined. 
Dr. Pollock, of Glasgow, Scotland.-All oxygen-bearing substances give up 
some oxygen in the body. Perhaps the marked benefit derived from the use of such 
agents is due to the fact that the oxygen that is given off is in a more than usually 
active condition. This may explain the discrepancy, to some extent, between the 
quantity of the drug used and the amount of actual benefit. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
35 
ON THE ACTION OF CERTAIN DRUGS ON THE CIRCULATION AND 
SECRETION OF THE KIDNEY. 
DE L'ACTION DE CERTAINES DROGUES SUR LA CIRCULATION ET LA 
SECRETION DES REINS. 
ÜBER DIE WIRKUNG GEWISSER ARZNEIMITTEL AUF DIE CIRCULATION UND SEKRETION 
DER NIERE. 
C. D. F. PHILLIPS, M. D., F. R. S. E. 
Mr. President and Gentlemen:-The paper I have the honor of presenting to 
you for this afternoon, is founded on experiments undertaken by me in conjunction 
■with Mr. Rose Bradford, in the Pharmacological Laboratory of University College, 
London. 
There is probably no single class of drugs that the physician requires to use more 
frequently than those known as diuretics, or supposed to have a diuretic action ; at the 
same time these drugs are required for a large number of very different diseased condi- 
tions. 
Further, the secretion of the kidney is so intimately connected with the vasomotor 
phenomena of the gland and of the body at large, or rather, with the differences existing 
at any given time between the local circulation in the kidney and the general circula- 
tion, that the action of any given drug or diseased condition on the renal secretion is 
an exceedingly complicated one. It would therefore obviously be useful to know the 
precise action of any given drug on the renal circulation, particularly as, when in doubt 
concerning the therapeutical value of a drug, we frequently turn to experimental 
pharmacology in order to throw light on the question. 
With regard to diuretics, the evidence at present obtainable from pharmacology is 
by no means satisfactory, owing to a variety of circumstances into which we need not 
here enter, the principal one being, however, that either a very few observations have 
been made, or, what is worse, that these observations have not been conducted under 
precisely similar conditions as to animal, anaesthetic, etc. The majority of observers 
have contented themselves with simply investigating the flow of urine before and after 
the administration of a given drug ; others have observed the blood pressure, and a very 
few have carried on simultaneous observations on both blood pressure and urinary flow. 
That this last method is much better than the first, becomes obvious when we remem- 
ber how complicated a mechanism the secretion of urine is, and how largely, though 
not entirely, it is dependent on the vasomotor system. But even when the action of 
drugs on the kidney is investigated in this manner, and their action both on the general 
vascular system and on the amount of urine is determined, yet one very important 
factor is left out, viz., the effect of the drug on the renal blood vessels. 
It may be said that the effect of the drug on these vessels can be deduced from the 
observed effects on the blood pressure and on the urinary flow ; but that is not a scien- 
tific method of procedure, and further, it is, as will be seen below, a very fallacious one. 
It does not necessarily follow that a drug has the same action on all peripheral vessels, 
and it is quite conceivable that it may constrict those of one area and dilate those of 
another. This is particularly true of the kidney vessels, where the flow of urine is not 
so much dependent on the general blood pressure, on the difference between the renal 
vessels and the vessels of the body at large. Thus an ideal diuretic would be one that 
dilated the blood vessels in the kidney, but constricted all others in the body. 
Now, by the observations mentioned above, such an action as this could not well be 
demonstrated with any approach to scientific accuracy ; so it occurred to us that it 
might be well to re-investigate drug action on the kidney from a rather different stand- 36 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
point to that usually adopted. It is well-known that Mosso and others have inves- 
tigated the peripheral circulation by enclosing a portion of the body, such as the arm 
or leg, in a rigid vessel filled with fluid, and communicating with a delicate registering 
apparatus, so that any expansion of the limb would, by causing an outflow of fluid, 
produce a movement of the registering apparatus, which could be recorded graphically 
on the blackened surface of a revolving drum. Dr. Roy, of Cambridge, has extended 
this method to other organs, such as the heart, spleen, and kidney. In this method 
the kidney is enclosed in a metal box filled with warm oil, the box being of such con- 
struction that no oil is allowed to leak out, and at the same time the structures at the 
hilus of the organ, vessels, ureter and nerves, are not injuriously pressed on. This is 
effected by the box or oncometer being made in two similar halves, and each half 
having a piece of peritoneum (specially prepared) applied to it in such a manner that 
the space between the membrane and wall of the oncometer can be filled with oil. The 
two halves of the instrument are hinged together, and the kidney placed between the 
corresponding membranes of opposite halves. This membrane being very flexible, 
applies itself accurately to the kidney ; so that, to use a simile, the kidney placed in 
the oncometer resembles, for instance, the heart enclosed in the pericardium full of 
fluid. The heart would represent the kidney, and the visceral layer of the pericardium 
the delicate membrane of the oncometer, the pericardial sac finding its equivalent in 
the oncometer, and the pericardial fluid in the oil filling the instrument. 
It is obvious, then, that if the oil in the oncometer be placed in communication with 
a recording apparatus, any expansion of the kidney can be readily detected, and 
recorded graphically in the usual manner. The recording instrument is called by Dr. 
Roy the oncograph, to distinguish it from the oncometer. Its exceeding delicacy is 
shown by the fact that the tracing obtained in this manner from the kidney, say of the 
dog, is practically identical with a simultaneous tracing of the carotid blood pressure; 
the slight expansions of the kidney caused by each heart beat, as well as those caused 
by the respiratory undulations of the blood pressure, being perfectly recorded by this 
instrument. 
If, now, in the same animal, we record simultaneously the general blood pressure, 
the expansion and contraction of the kidney, and the excretion of every drop of urine, 
we can determine the action of any given drug much more completely than before. 
Our method of experimentation was shortly as follows: The animal (cat or dog) 
having been anæsthetised with chloroform, or with chloroform and morphia, a cannula 
was placed in the usual manner in the carotid. The kidney was then exposed, carefully 
separated from surrounding structures, and placed in the oncometer, this having previously 
been filled to the required extent with warm oil. A cannula was then placed in the ureter, 
and each drop of urine falling from it was made to break a circuit through an electro- 
magnetic arrangement, so as to make a mark on the recording surface for each drop, 
Before commencing the actual experiment the animal was curarized, and artificial res- 
piration maintained, as any movements on the part of the animal might seriously 
damage the oncometer. Finally a cannula was placed in the external j ugular vein, for 
injection of the drugs experimented with. 
It is essential for success to handle the kidney as little as possible, as otherwise the 
flow of urine is much lessened ; but incredible as it may seem, if due care be taken, 
the kidney will go on secreting (as pointed out by Dr, Roy) for many hours perfectly 
regularly, although placed under the abnormal circumstances of being enclosed in a 
box of warm oil. 
In an experiment performed as j ust described, it will be found that the blood pres- 
sure curve and the kidney curve remain perfectly constant for several hours. The flow 
of urine is also very constant in its rate, although this varies considerably in different 
animals, owing to a variety of circumstances ; but in the same animal, the rate of flow SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
37 
does not sensibly alter unless some drug is injected, or the amount of chloroform 
administered is altered. This latter factor was maintained constant by blowing the 
air from the artificial respiration apparatus through a bottle containing chloroform. 
We will now, having described our method, pass on to the consideration of the 
action of the various drugs experimented upon by us, beginning with citrate of caffein, 
as this is deservedly one of the most popular of diuretics. When a solution of citrate 
of caffein is injected into the external jugular vein, in doses of half to one grain of the 
salt, the following changes are seen to occur: The blood pressure is at first lowered, 
and afterward slightly raised : the rise, however, is not so great as the fall, and is 
generally of shorter duration. Both effects are, with these small doses, slight and 
transitory in nature. The fall is due to a diminution in the force of the cardiac beats, 
and also, perhaps, to the heart becoming contracted, so that less blood is pumped out 
during each systole ; but whether this be so or not, the amplitude of the cardiac beats 
is markedly diminished. This period of diminished force is followed by one during 
which the heart is slowed in rhythm, and the individual beats increased markedly in 
force, and then the blood-pressure returns to the normal, and frequently rises slightly 
above it. This period of inhibition often persists for a minute or two, or longer if 
larger doses are used. Occasionally, and for a short time only, there is a period of 
marked acceleration; but this is not always observed, and is of the nature of an after- 
effect, not being so characteristic of caffein as the strong slow cardiac beat mentioned 
above. 
The effects of caffein on the kidney, however, are much more marked. Immediately 
after the injection the kidney contracts, and this contraction may last for two or even 
three minutes, whereas the fall of the general blood pressure lasts only some twenty or 
thirty seconds, This marked contraction of the kidney (frequently too large to be 
completely registered), which is due to a constriction of the renal vessels, is followed 
by a large expansion: that is to say, the kidney not only rapidly returns to its former 
bulk, but expands considerably beyond, and to a much greater extent than the previous 
contraction. This expansion of the kidney is not only much greater in amount than 
the previous contraction, but also lasts a much longer time; a single dose of 
caffein citrate, e. g., one grain, producing an expansion frequently lasting twenty or 
thirty minutes. 
It will thus be seen that the effects of this drug on the circulation of the kidney, 
and on the general blood pressure, are by no means similar; since the peripheral action 
on the kidney would, per se, tend to cause an initial heightening of the blood pressure, 
instead of the observed fall. It might be urged that the contraction of the kidney was 
really due to the fall of blood pressure ; but that this is not the case is shown by 
the fact that the two phenomena do not occur simultaneously, and do not, as mentioned 
above, persist for the same length of time, the kidney contraction lasting some minutes, 
the fall of blood pressure some seconds only. Further, if very small doses of 
caffein be used, the contraction of the kidney will follow, but not the fall of general 
blood pressure. This fall is undoubtedly a cardiac effect, as can readily be seen by 
inspection of the curves. 
The effect on the urinary flow is also very marked. During the period of contrac- 
tion of the kidney the flow of urine is either greatly diminished, or may even be 
totally arrested. During the subsequent expansion the rate of flow is frequently trebled, 
and this effect persists as long as the expansion. Thus, the effect of caffein citrate is a 
twofold one': during the first stage of its action there is a fall of general blood pressure, 
and great constriction of the renal vessels; during the second stage the blood pressure 
returns to its normal height, and the kidney undergoes great expansion; but this latter 
effect has a longer latent period, and persists longer than the former. Both the con- 
striction of the renal vessels and the fall of blood pressure would cause less blood to 38 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
enter the kidney; and so it is not surprising that during this stage the actual secretion 
of the kidney is frequently temporarily arrested, to be succeeded by a marked increase 
during the second stage of the action of this drug. There are many drugs that will 
produce constriction of the kidney vessels, but as far as we have seen, caffein is the only 
one that will actually arrest the flow of urine. 
As another example of a drug that will produce expansion of the kidney and marked 
diuresis, we may cite ulexin, a new alkaloid that has recently been obtained from the 
seeds of the common gorse, Ulex Europæus. Although the principal action of this 
drug is on the respiratory system, it is also a powerful diuretic; but it has the objection 
that, at any rate in animals, the diuretic action is only maintained with doses that 
would either kill through the respiration, or would produce violent convulsions. The 
action of ulexin on the kidney is as powerful, or even more so, than that of caffein ; but 
it is much more transitory in its action. A dose of one-sixth of a grain injected into 
the external j ugular vein will produce great heightening of the general blood pressure, 
accompanied by a contraction of short duration, followed by a very large expansion, 
during which the rate of the urinary flow may be quadrupled. 
There is, however, this great difference between the two drugs, that whereas the 
caffein effect may last for half, or even three-quarters of an hour, the diuretic action of 
ulexin passes off in about ten minutes from the moment of its injection. There is 
another point of difference between caffein and ulexin, which is of some interest. They 
both cause constriction of the kidney, followed by expansion, although the effects pro- 
duced by the latter do not last so long as those produced by caffein; but if the dose be 
frequently repeated, the following differences come out. 
With caffein, if several doses of one grain be injected rapidly, one after another, 
into the external jugular vein, we soon arrive at a point when each injection only pro- 
duces contraction of the kidney-there being no subsequent expansion and diuresis; in 
other words, the caffein ceases to have any diuretic action. 
With ulexin it is different. Repeated doses, or single large doses, produce only a 
moderate degree of expansion, instead of the much larger double effect produced by 
small initial doses. Hence, although both drugs produce, in small doses, a double 
effect, the second portion of which-i. e., the expansion-is not only the larger, but 
also the most important; practically, excess of caffein produces only the first phase, and 
excess of ulexin only the second phase of this double effect. With regard to caffein, this 
may be a point of some importance, since at this stage of its action it not only ceases to 
be a diuretic, but its action rather tends to arrest what flow there is. 
Among other substances causing expansion of the kidney, we may cite dextrose. 
The injection of one cubic centimetre of a strong solution-twenty per cent, or fifty per 
cent.-produces a continuous expansion, remarkable for its extreme slowness and 
persistence. This expansion, although very persistent in its duration, is not great in 
amount, being much less than that produced by either caffein or ulexin. 
Many other substances produce expansion of the kidney vessels, such as urea (deter- 
mined by Dr. Roy), acetate and chloride of sodium, etc.; and it is very probable, 
although we have not yet determined this point, that all the constituents of the urine 
have a similar action, causing dilatation of the renal vessels to a varying extent in dif- 
ferent cases. 
The drugs investigated by us that produce only constriction of the kidney form 
a much more numerous group, including several that are usually considered good 
diuretics, and prominent among these is digitalin, which is further interesting from the 
fact that it is so much used as a diuretic clinically. 
Digitalin, in doses of grain, produces marked contraction of the kidney. The 
peculiarity of this contraction is its extreme persistence, lasting for as much as half 
an hour, and sometimes, if large or repeated doees are used, the kidney does not SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
39 
return to its previous volume throughout the duration of an experiment. It is need- 
less to discuss here the effect of the drug on the blood pressure and on the heart, as 
they are both so well known ; but observers are rather divided in opinion as to the 
action of digitalin on the kidney, some maintaining that such action is purely indirect 
-i. e., due to its effects on the heart, etc. ; others, that the drug is a true diuretic, and 
that the observed increase in the urine during its administration is not solely due to 
the improvement of the general circulation. It is not easy to decide between these two 
views, but it is interesting to observe that although, like caffein, it produces contrac- 
tion of the renal vessels, yet, contrary to results with caffein, during this contraction 
the flow of urine is not diminished, but is generally slightly increased. This is a 
point to which we will return later ; but it appears to us that the probable explanation 
is that, although both drugs produce contraction of the kidney, the one raises the 
general blood pressure while the other depresses it. 
Spartein, a drug that has attracted considerable attention of late, has an action 
very similar to that of digitalin on the kidney vessels and on the general blood 
pressure; this being slightly raised, the cardiac beats increased markedly in force and 
diminished in frequency, and the kidney vessels constricted. The action of the two 
drugs on the flow of the urine is, however, very different. Thus, with spartein, in 
one case the rate of secretion prior to the injection was one drop in ten seconds; during 
the contraction of the kidney vessels caused by the drug, the rate fell to one drop in 
twenty-eight seconds, and after the kidney contraction had passed off the rate only 
rose to one drop in eighteen seconds. Hence it can scarcely be said that spartein is a 
diuretic, since its action on the renal vessels is accompanied by a marked diminution 
in the rate of the urinary secretion. On the other hand, spartein, like digitalin, Stro- 
phanthin, etc., increases notably the force of the cardiac beats, although markedly 
slowing the rate, so that it is quite possible that in disease it will increase the urinary 
flow, not from any action on the kidney (since, as shown above, this kidney action is 
in the opposite direction), but simply because it improves the general circulation. It 
seems to us incorrect to class such drugs as spartein with diuretics, for although in 
disease an increase in the amount of urine is observed under their action, this is not 
from any specific local effect, but is rather from the improved condition of the systemic 
circulation. This is still more the case with regard to the kidney, since the action of 
many of these drugs on the healthy kidney is rather of a nature to diminish than to 
increase the amount of fluid excreted. 
Further light is thrown on this question by the action of Strophanthin, and also by 
the action of the glucoside apocynëin, obtainable from the Apocynum cannabinum 
(Canadian hemp). Strophanthin, as is well known from the work of Professor Fraser, 
acts mainly, if not entirely, on the heart muscle-that is to say, as far as its action on 
the general circulation is concerned; the heightening of arterial pressure produced by 
it being practically entirely due to the increase in the force of the cardiac beats. 
Thus, in this respect, it differs considerably from digitalin and spartein, where the 
cardiac action is accompanied by a constriction of the muscular coat of the peripheral 
vessels. 
When the action of Strophanthin on the kidney is investigated, it is found that the 
drug only causes a slight temporary contraction of the organ, which soon returns to 
nearly, though not quite, its previous volume. Thus, whereas digitalin will produce a 
contraction of the kidney, lasting half an hour, Strophanthin, on the other hand, produces 
a much slighter contraction, lasting only twenty or thirty seconds. Further, it does not 
produce any marked increase in the rate of the urinary flow, althoug, a priori it might 
have been expected to do so. 
We have made many observations on the Apocynum cannabinum-a drug that has, 40 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
we believe, a considerable reputation among some observers as a diuretic in certain 
conditions. The glucoside apocynëin was obtained by Mr. Gerrard for us from the 
dried plant, and this we have found to be a very powerful drug, resembling in many 
points Strophanthin. The injection of grain of the glucoside (not quite free from 
adventitious matter) causes a contraction of the kidney very like that produced by a 
fortieth of a grain of Strophanthin, lasting about fifteen to twenty seconds, after which 
the kidney trace returns to its normal level. The amplitude of the cardiac beats is 
greatly increased, the rhythm much slowed, and the blood pressure slightly raised. In 
many cases the rhythm is even more slowed than by Strophanthin ; for instance, in one 
dog, the rate was reduced from 100 per minute to forty per minute, after about one-sixth 
of a grain had been injected, in four doses of grain each, at intervals of fifteen 
minutes. In these respects this drug resembles Strophanthin, as also in its not increas- 
ing the flow of urine; thus, in one case the rate of flow prior to the injection was one 
drop in twenty seconds, and subsequently to it, remained constant at the rate of one 
drop in twenty-two seconds, notwithstanding the fact that the drug had greatly 
increased the force of the cardiac beats. 
Turpentine and adonidin produce marked contraction of the kidney, the effects of 
the former being very marked and persistent, and that of the latter resembling the con- 
traction produced by digitalin, except that it is not of such long duration. Finally, 
barium chloride produces great contraction of the kidney, as well as great rise of blood 
pressure. The effects produced by this salt also resemble, to a certain extent, those 
produced by digitalin, but the rise of blood pressure after barium is much greater than 
that caused by digitalis. 
In summing up the results obtained by us, we see that, on the whole, it is more com- 
mon for drugs reputed diuretics to produce a contraction of the renal vessels than an 
expansion. Further, that the expansion is either slight-e. y., as by acetate of soda, 
or, if large-e. g., as by citrate of caffein, it is only produced by small and initial doses, 
and that if the dose be too frequently repeated no expansion is obtained. Ulexin possi- 
bly may be useful as a diuretic in small doses, but its powerful action on the respiratory 
mechanism is a great drawback. Thus, in the case mentioned above, one-sixth of a 
grain was used, but half this dose would completely arrest the respirations. In all 
cases this renal expansion is accompanied by a copious flow of urine (more persistent in 
the case of caffein than in the case of ulexin). 
Then if we consider the drugs that produce contraction of the kidney, such as digi- 
talin, spartein, adonidin, etc., it is obvious that they cannot all be bracketed together, 
since although they all produce a similar effect on the general blood pressure, and on 
the renal circulation, yet it is only the first that has any very obvious diuretic action. 
Again, we might expect such drugs as Strophanthin and apocynëin to have a diuretic 
action, if anything, greater than that of digitalin, but experimentally it is found that 
such is not the case. 
From all these considerations, we see further evidence of the truth, that the flow of 
urine is not so much dependent on the blood pressure as on the rate of flow of the blood 
in the renal vessels. With regard to this point, it is necessary to remember, that although 
such drugs as Strophanthin produce a great increase in the force of the cardiac beats, yet 
these are very much slowed, so that it is quite possible that although the heart's action 
is stronger, yet the total amount of blood sent through any given organ, such as the 
kidney, in a given time, may remain the same. Whereas such a drug as digitalis, 
producing, as it does, a rise of blood pressure and a contraction of the kidney vessels, 
may cause an increased quantity of blood to pass through the renal vessels. On this 
view one could find the explanation of digitalin being a diuretic, and Strophanthin not 
being one. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
41 
Inasmuch, however, as spartein has not so marked diuretic action, we must also 
assume that digitalin must have some peripheral action on the secretory apparatus of 
the kidney. 
Our results may be tabulated briefly as follows, in three divisions :- 
(a) DRUGS THAT FIRST CONTRACT, AND AFTERWARD DILATE THE KIDNEY. 
1. Caffein-in small doses-induces in the stage of contraction, a fall of blood pres- 
sure-in that of expansion, a slight rise : during the former, the flow of urine may be 
arrested ; during the latter it is always increased, such increase depending on dilata- 
tion of the renal vessels. 
(The possible arrest of secretion during the first stage is special to caffein, and may 
be induced by large or repeated doses. ) 
2 Ulexin-One-sixth grain greatly raises blood pressure during the first stage (that 
of contraction): in the second, expansion is much greater in degree but shorter in dura- 
tion than under caffein, and is accompanied by brief but marked increase in urinary 
flow : the effective dose is limited by its toxic action on respiratory centres. Practically, 
excess of caffein induces only the first stage-excess of ulexin only the second. 
(B) SUBSTANCES THAT DILATE THE KIDNEY, BUT TO LESS EXTENT AND MORE 
SLOWLY THAN CAFFEIN AND ULEXIN, 
Are dextrose, urea, sodium, chloride and acetate, and probably all constituents of the 
urine. 
(c) DRUGS THAT CONTRACT THE KIDNEY WITHOUT SUBSEQUENT EXPANSION. 
1. Digitalin, with increased secretion of urine (probably resulting from general 
heightened blood pressure). 
2. Spartein, with diminished secretion (in health at least). 
3. Strophanthin causes slight temporary contraction, with no marked increase of 
secretion. 
4. Apocynëin; similar temporary contraction, and no definite increase of secretion. 
5. Turpentine ; 6, adonidin ; and 7, barium chloride give similar results. 
In conclusion, it seems to us that the plethysmographic method of experimentation 
is a valuable one for determining the exact action of drugs on the circulation, and one 
that deserves more attention than it has hitherto attracted. 
DISCUSSION. 
Dr. Ralph Stockman.-Have you tested the action of nitrites upon the kidneys? 
Dr. Phillips.-No. 
Dr. Stewart.-Was the blood pressure measured with a manometer? 
Dr. Phillips.-Yes. 
Dr. Murrell.-The subject is such a technical one that it is no wonder that 
there is some reluctance to discuss it without previous preparation. The subject of 
the action of diuretics is a very interesting one, and it is a field that needs to be 
investigated. We can make a man perspire very promptly, but we often find diffi- 
culty in getting the kidneys to work. I cannot see, exactly, why the instrument 
used is better than Marcy's tympanum for the purpose. It would be advantageous 
to use patients who have lost the anterior wall of their bladder, in order to study the 
action of diuretics, and to check the results of studies upon animals. 
Dr. Phillips.-I consider the oncometer as much more convenient to use and 
more readily seen. It is one of the simplest things possible when once in action, 42 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and works by entirely different mechanism from Marcy's instrument. The true 
diuretic is one which directly causes expansion of the kidney by increasing the blood 
supply of the organ. We do not find this to be the case with digitalis, which acts 
upon the heart and forces more blood through the kidney within a given time, thus 
increasing the proportion of water in the urine. It is not a true diuretic. 
Dr. Woodbury.-Having been impressed by the interesting character of the 
experiments which have been reported, and realizing the importance of the subject, 
I would ask if the chemical analysis of the urine was systematically conducted in 
connection with the physical examination ? It seems that this is very necessary in 
collecting the data for a comparative estimate of the value of diuretics. Water forms 
the bulk of the urinary secretion in mammals, and may vary in quantity within rather 
large limits, without indicating anything more serious than the state of supplemen- 
tal activity of the skin. In fact, it may be influenced by meteorological conditions. 
In a case of diabetes mellitus, seen some years ago while Resident Physician to the 
Pennsylvania Hospital, there were sudden fluctuations in the quantity of urine 
voided, which for a time seemed unaccountable, until it was noticed, by comparison 
with the weather record, that the exacerbations preceded a snow or rain storm, and 
that they gradually passed off when the storm actually appeared. 
Water is only incidental to the urinary secretion ; snakes' urine is solid, birds' 
urine is nearly so. The characteristic and essential ingredients are the nitrogen- 
containing salts, such as urea, the urates, creatin, etc. A true diurectic, therefore, 
would be one that influenced the separation of such excrementitious waste from the 
blood by the parenchyma of the kidney. The testimony with regard to the influence 
of digitalis upon the excretion of urea is conflicting; at times and under some 
circumstances it is claimed that it increases the discharge of urea, and may, there- 
fore, be considered as a true diuretic. Have such determinations been made in the 
present series of experiments ? 
Dr. Phillips.-These experiments have been under way for three years and a 
half, but they are not yet concluded ; the chemical analyses have been made in some 
cases, but not yet in sufficient number to report. It was found that all diuretics 
increase the amount of circulation in the kidney. This investigation is only as yet 
in its infancy, but it is believed that in the course of time the results from this line 
of work will give more information of the action of diuretics and their relative value. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
43 
THIRD DAY. 
The President in the chair. 
Dr. John E. Brackett, of Washington, D. C., read a paper on- 
CASCARA SAGRADA (RHAMNUS PURSHIANA). 
BY JOHN ELY BRACKETT, M. D. 
RHAMNUS PURSHIANUS. 
Synonym.-Cascara Sagrada, cascara (bark), sagrada (sacred), is the common Spanish 
name, and means simply sacred bark. 
Part Employed.-The bark. • 
Natural Order.-Rhamnaceæ. 
ITaôîïaL-California and Oregon. 
Properties.-Laxative, cathartic and intestinal tonic. 
In its botanical origin, this plant belongs to the natural order of Rhamnaceæ and 
the tribe Rhamneæ, and is indigenous to the Pacific slope of North America, noticeably, 
'to the States of California and Oregon. It is a small tree, and its name was given in 
honor of the Prussian botanist, Frederick Pursch, who, in 1814, gave it a fixed place in 
botany. 
The plant rarely exceeds twenty feet in height, averaging from ten to fifteen feet, 
and measuring through the trunk from six to nine inches. The leaves are elliptical, 
from three to five inches in length, by one and a half to two inches in their greatest 
width. The flowers are small and white, and appear after the leaves have matured. 
The fruit is a plain, round, black, berry about a quarter of an inch in diameter, and 
contains three seeds. Both the tree and the fruit, it will be seen, are much larger than 
other species of the Rhamnus group. 
In its microscopical structure, the outer bark consists of dark-brown, withered cells, 
then several rows of cells filled with a dark-red coloring matter, and in newly-gathered 
bark, a couple of rows of cells containing chlorophyll. The middle bark is made of 
parenchymatous cells, which are filled with small starch grains. In a transverse sec- 
tion may be seen several groups of cubical crystals, and in a longitudinal section groups 
of very thick-walled yellow cells. The inner bark consists mainly of yellow medul- 
lary rays, separated by bast parenchyma, through which are scattered numerous yellow 
bast fibres. In longitudinal sections these same fibres are frequently surrounded by 
cubical crystals. 
In its cÄemrcaZ composition, there is 1st a brown resin of strong, bitter taste, con- 
tained mostly in the middle and inner layers of the bark; this is sparingly soluble in 
water, freely soluble in alcohol and dilute alcohol, scarcely soluble at all in absolute 
ether, but quite soluble in chloroform. Caustic alkali solutions dissolve it with a beau- 44 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tiful purple red color, which may he precipitated by acids. Animal charcoal will 
remove it from alcohol solutions. 
2d. There is a red resin which is nearly tasteless and which is soluble in water, freely 
soluble in alcohol and dilute alcohol, only sparingly soluble in ether and chloroform, 
quite soluble in caustic alkali solutions, to which it imparts a rich brown color, and 
may be precipitated by acids. This resin is not removed from alcohol solution by 
animal charcoal, and is found in the outer layer of the bark. 
3d. There is a light yellow resin, or natural body, tasteless, insoluble in water, 
soluble in hot alcohol and in chloroform. In concentrated solution it deposits granules 
of a pale orange color. It gives negative results with the general tests for alkaloids. 
4th. From an absolute alcohol solution a crystallizable body is obtained, occurring 
in white, double pyramids and in some other forms of the dimetric system. At a tem- 
perature a little above the water bath, the crystals first melt and then sublime, the sub- 
limate being partly crystalline. This crystalline substance is not noticeably soluble in 
chloroform or ether, is slowly soluble in absolute alcohol and slightly so in dilute alco- 
hol. The acids do not dissolve it, neither is it colored by any of the ordinary tests, 
and test paper gives neutral results. The general tests for alkaloids, in alcohol solu- 
tions, give negative results. 
5th. Tannic acid is found, of the variety which gives a brownish-green precipitate 
with the salts of iron. 
6th. Oxalic Acid. 
7th. Malic Acid. 
7th. A yellow-colored fat oil. 
9th. A volatile oil not very abundant, having the odor of the bark. 
10th. Wax. 
11th. A considerable quantity of starch. 
Within the past few years the chemistry of the Rhamnaceæ has considerably in- 
creased in interest. The European buckthorn or Rhamnus Frangula was reported in 
1876, by both Liebermann and Waldstein, to contain emodin, a well determined con- 
stituent of Rhubarb, allied to chrysophane, and chemically a derivative of anthracene. 
These same investigators further find it nearly certain that frangula is capable of 
ready change into emodin by the glucosic fermentation. We know that Rhamnus 
Frangula is both purgative and emetic when first gathered, and may retain these double 
properties for some considerable time ; but after two years storing only the purgative 
property remains. Emodin is a constituent of rhubarb. The glucosic fermentation 
which changes frangulin into emodin doubtless gives a chemical explanation of the 
medicinal powers of the bark. The Rhamnus Purshiana, though not identical with 
the Rhamnus Frangula, yet show certain chemical reactions which are quite similar. 
The different species of the Rhamnaceæ doubtless contain bodies closely allied, but the 
medicinal qualities seem quite distinct ; these qualities may be determined only by 
physiological investigation and therapeutic trial. 
In its therapeutic application, Rhamnus Purshiana belongs to the tonic astringent 
and resin-bearing purgative class of évacuants. The taste is nauseous, bitter, and with 
rather a disagreeable odor; produces in the stomach a sense of warmth, with, perhaps, 
in some cases, flatulence and griping pains, these latter conditions not altogether com- 
mon, and may be prevented by combination with aromatics. In very small doses I 
have known it to excite the appetite and promote digestion, the tannic acid it contains 
acting as an astringent, diminishing peristalsis. In sufficient doses a laxative; if the 
dose be increased a purgative effect will follow its administration, producing stools of 
an almost invariable brownish yellow, shading off into a light orange. From this 
unvarying color we may reasonably assume that the drug possesses the power of increas- 
ing the flow of bile, and therefore may be placed among the cholagogue medicines, SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
45 
although investigators thus far do not fully concur in this. That the intestinal secre- 
tions are promoted, the glandular appendages of the mucous membrane stimulated, 
and the tone of the muscular coat raised, there can be no question; as all resin-bearing 
purgatives produce these effects, and in the case of the medicine under consideration, 
is doubtless due to one or more of the already enumerated resins. 
As a gentle laxative I have found this an excellent medicine, and when given in 
small doses, seems to stimulate the intestinal movement without noticeably augmenting 
its secretions, other than a natural increase of the proper secretion of the glands, and not 
merely an osmosis of fluid from the vessels. In larger doses the effects following its 
administration are decidedly purgative, as is evinced by the hastened peristaltic action, 
increased secretion, and loose and watery stools. 
It is in chronic or habitual constipation, however, that the medicine proved most 
useful in my hands ; and for overcoming this most obstinate and troublesome disorder, 
to my mind, few medicines equal it. The fluid extract is the most eligible, as well as 
the most reliable preparation of the drug. Of this, I usually give from five to fifteen 
minims night and morning ; al ways commencing with the minimum dose, and gradually 
increasing until the stools are softened, when the dose may slowly be diminished ; 
strongly impressing upon the mind the necessity for perseverance in the use of the 
medicine, even though a period of months may be requisite in order to produce a cure. 
I may be permitted to strengthen my own conclusions by quoting from the following 
reports: Dr. Russell, Professor of Materia Medica, Yale Medical College, says: "I 
do not think that its effects are diminished by constant use. I believe that in doses of 
from fifteen to thirty drops (fluid extract) given three times daily, it is an admirable 
remedy for habitual constipation. The stools produced by moderate doses of it are so 
copious, soft and unirritating, that it must be well suited to cases afflicted by constipa- 
tion with hemorrhoids, fissure of the anus, etc. It is a remedy of great value, and 
should occupy a prominent position in our Materia Medica. ' ' 
In the British Medical Journal of April 11th, 1885, is published an analysis of thirty- 
three cases of habitual constipation treated by Rhamnus Purshiana, being a paper read 
before the British Medical Association by Dr. Reid, of London. The conclusions arrived 
at were as follows : "1st. Cascara Sagrada, or Rhamnus Purshiana, was a most use- 
ful remedy, both regarding its immediate effects and after results in obstinate and 
chronic cases of constipation. 2d. It was better to prescribe it in continuous small 
doses, rather than in occasional large ones. 3d. Cases were met with in which, even in 
large doses, at any rate in the form of the fluid extract, the drug had not been of ser- 
vice. 4th. No rule could be laid down by which one could ascertain previously 
whether the drug would suit or not ; but when pain was produced, in all probability it 
was owing to too large a dose being given. 5th. It was of great service when other 
aperients failed." 
Prof. H. Senator, in the Berliner Klinische Wochenschrift, January 5th, 1885, 
says : ' ' Its action is prompt and harmless, even after a protracted use. It is scarcely 
sufficiently bitter to call for a flavoring vehicle. Its proper place in the pharmacopoeia 
is between rhubarb and senna, but it has the advantage of acting in smaller doses than 
either of them." 
It is, perhaps, needless for me to say that chronic or habitual constipation is pro- 
duced by a great variety of causes. The diet may be largely at fault ; there may be a 
deficiency or a faulty composition of the intestinal juices ; the glands which pour out 
their secretion into the intestines may be impaired ; there may be some nervous influ- 
ence, or some mechanical pressure, or possibly, the presence of poisonous bodies, such 
as lead, for example, any one of which may impair the bowel to such an extent as to 
interfere with its requisite propelling power. Absence of or insufficient physical exer- 
cise ; impoverished blood, anaemia, and general nervous debility ; absorbing mental 46 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
occupation ; a neglect to respond to the calls of nature ; excessive urination ; profuse 
perspiration, or other discharges of the fluids of the body in undue amount ; atonic 
dyspepsia, or various organic diseases of the stomach and bowels. Now, to say that 
any one medicine is going to relieve constipation due to all these several causes, with- 
out in the least attempting the removal of the cause, is simply absurd. A proper atten- 
tion must, as a matter of course, be directed to the cause, and its removal insisted upon 
whenever possible, or when that is impossible, to be alleviated with other remedies in 
so far as we may be able. 
The pharmaceutical preparations are- 
1. An extract; Extractum Rhamni Purshianæ, is a solid or inspissated extract, and 
represents in three grains of the extract ten grains of the drug. The dose of this as a 
laxative is one to three grains ; as a purgative three to eight grains ; and is best given 
in the-form of a pill or in capsules. 
2. A powdered extract is prepared of the same strength as the solid or inspissated 
extract. It is nothing more than the solid extract evaporated, at a low temperature, to 
dryness ; is then powdered, and the quantity of moisture lost by evaporation is replaced 
by its weight of powdered bark. The dose is the same as the solid extract, and may 
be given either in the powder itself, or in pill or capsule. 
3. Pills, or Pilulæ Rhamni Purshianæ ; each pill contains two grains of the solid 
extract, with sufficient dry excipient to obtain a pill mass of proper consistency. About 
seven grains of the true bark are represented in each pill. 
4. Capsules, or Capsulæ Rhamni Purshianæ, contain each three grains of the solid 
extract evaporated down to dryness, and mixed with sufficient castor oil to make ten 
minims. The castor oil has been added for the purpose of preventing the powdered 
extract from absorbing moisture from the capsule hull and from caking together. The 
inspissated extract cannot be encapsuled, because it contains moisture which would 
attack the hull of the capsule and cause it to collapse or to leak. Only oily substances 
are encapsuled in soluble elastic capsules, or are used as a vehicle in which to incor- 
porate medicinal substances. 
5. A fluid extract, Extractum Rhamni Purshianæ Fluidum, represents in one cubic 
centimeter of the extract one gram of the drug. It has an average of from twenty to 
twenty-two per cent, of extractive, and contains in a hundred parts thirty-three and a 
third parts alcohol. The dose, as a laxative, is from three to fifteen minims, two or 
three times a day ; as a purgative, from twenty to forty-five minims. 
6. Elixir Rhamni Purshianæ, or as commonly known, Cascara Cordial, is prepared 
by Parke, Davis and Co., of Detroit, Michigan, and is an agreeable and pleasant com- 
bination of cascara and berberis aquifolium barks, together with solvents and aromatics. 
This preparation I have used to some extent and have usually found it quite reliable 
and always palatable. The dose is from half a teaspoonful to a teaspoonful, two or 
three times a day. 
For the microscopical structure of the bark, and its chemical composition, I am 
largely indebted to Dr. Prescott, Professor of Organic and applied Chemistry in the 
University of Michigan. 
DISCUSSION. 
Dr. Murrell.-These preparations are familiar to us in England, where this 
bark is officinal. I do not think that there is any special virtue in it over Buckthorn. 
It used to be given as a cathartic to dogs. 
Dr. Phillips.-I have used it in treating constipation, and consider that it has 
great and many advantages over senna and rhubarb. It differs from senna in having 
a more powerful cholagogue effect ; and, secondly, it causes less watery secretion to 
be poured out into the small intestine, and is less griping. It is effective and reliable. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
47 
It differs from rhubarb in being more stimulating to the hepatic cells, and not so 
astringent, and, therefore, less liable to produce secondary constipation. From my 
experience, I am much pleased with it. 
Dr. Woodbury.-In cases of hemorrhoids with constipation, I have noticed that 
with the correction of the torpid condition of the intestinal walls, the hemorrhoids 
gave no further trouble. This is a great boon to women who frequently suffer in this 
way. 
Dr. Ralph Stockman read a paper- 
ON THE PHARMACOLOGY OF SOME BODIES DERIVED FROM 
MORPHIA. 
SUR LA PHARMACOLOGIE DE QUELQUES CORPS DERIVES DE LA MORPHINE. 
ÜBER DIE PHARMAKOLOGIE EINIGER DERIVATE DES MORPHINS. 
BY D. B. DOTT, F.R.S.E., AND RALPH STOCKMAN, M.D. 
The relationship between chemical constitution and physiological action must 
always be a subject of deep interest and importance to the pharmacologist. In this 
short paper I propose to lay before you, in a very brief manner, the results of an inves- 
tigation which has been made into the action of a few of the substitution products of 
morphia. Owing to the very large number of such bodies which it is possible to pro- 
duce, the present communication partakes more of the nature of a preliminary note 
than of a completed investigation. 
In 1854, How, by acting on morphia with iodide of ethyl, obtained a body 
which he named hydriodate of ethylmorphia 
(C1"'Ä5NO,hi), 
and which he regarded as a substitution product, the ethyl being supposed to replace 
one atom of hydrogen in morphia. He also formed iodide of methylmorphia, and both 
these bodies he took to be substitution products. In the light of our present chemical 
knowledge we regard them as addition, and not as substitution, compounds. 
In 1869 Crum, Brown and Fraser published a research on the physiological action 
of these substances, in which they showed that the original action of the alkaloid is 
quite lost, and a curara-like action substituted in its place. From the nomenclature 
which these observers have adopted they make it clear that they regard such bodies as 
addition products-that, in fact, the iodide of methyl is simply added to the morphia 
molecule and does not replace a hydrogen atom in it. Notwithstanding this, we find 
that, in all text-books and reference books which treat of the subject, the bodies which 
these investigators used are universally regarded as substitution products, and it is at 
present generally held that the substitution of a hydrogen atom in an alkaloid by such 
a body as methyl causes a curara-like action, no matter what the original action of the 
pure alkaloid may be. 
It appears to us, indeed, that morphia methyliodide and similar bodies are not to 
be regarded as morphine compounds, but rather as salts of a new base. That such 
bodies frequently give the same color reactions as the alkaloids themselves proves 
nothing more than that both contain some common nucleus. They are, therefore, 
entirely different from the bodies formed by replacing one or more hydrogen atoms in 
an alkaloid by radicals such as methyl (CH3), ethyl (C2H5) or acetyl (C2H3O). 
The formula of morphia is CnH19NO3, or, as it is more frequently written now, 48 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
C17H17NO(OH)2, containing, therefore, two molecules of hydroxyl. It has been repeat- 
edly shown that it is the hydroxyl hydrogen atoms which are most easily replaced by 
different radicals. 
With regard to the action of morphia, it may be regarded as causing symptoms 
readily divisible into two stages. In frogs, when 0.030-0.050 grm. are given, there is 
produced a condition of narcosis which is soon followed by greatly increased reflex 
excitability. 
In mammalia the same symptoms may be observed with appropriate doses, but the 
narcotic effects are much more pronounced than the tetanic. 
The first body which we shall consider is methylmorphia (codeine) C17H18(CH3)- 
NO3. It has been known for many years that codeine extracted from opium is to be 
regarded chemically as methylmorphia, but, in spite of several attempts to prepare it 
artificially from morphia, success was only obtained by Grimaux, in 1881. By acting 
on morphiuate of sodium with methylchloride he obtained a body which he showed to 
be chemically identical with codeine. We prepared methylmorphia in practically the 
same manner as Grimaux, and found that its action is similar to that of natural codeine 
obtained directly from opium. Thus, frogs, with a small dose, such as 0.005-0.025 
grm. given hypodermically in solution, show symptoms of narcosis, passing, after a vary- 
ing but always comparatively short time, into a condition of greatly increased reflex 
excitability. With larger doses the narcotic period was much shortened, and tetanus 
supervened in a few minutes. The central nervous system only is affected. 
In rabbits 0.01-0.02 grm. caused well-marked but not very deep narcosis. On 
increasing the dose the reflexes were found to become greatly exaggerated, while with 
a further increase tetanus was speedily induced, and death, in convulsions. In dogs, 
while narcosis was readily enough induced by small doses, the accompanying disagree- 
able symptoms which are so often seen with morphia-salivation, vomiting and diar- 
rhoea-are much more marked than in the case of the latter alkaloid. 
Ethylmorphia, C17H18(C2H5)NO3. The action of this body has been briefly described 
by Bochefontaine (Compt. Rend., 1881). Owing, however, to his having used too large 
doses, he has failed to observe that, like codeine, it produces a preliminary narcotic 
effect. He describes its action as purely tetanic. Our observations show, however, that 
its action on animals is similar in every respect to that of methylmorphia, and so far as 
physiological effect is concerned it is immaterial whether methyl or ethyl replace the 
hydrogen atom in morphine. 
For the sake of brevity we omit the details of our experiments at present. 
As regards the preparation of this body, the method was analogous to that used for 
the preparation of methylmorphia, and we ascertained by analysis that it was pure. 
In our experiments we used the hydrochlorate, a crystalline salt. 
Acetylmorphia C7 7H7g(C2H3O)NO3. This body was first prepared by Wright, 
and we prepared in the same manner as he has done, satisfying ourselves as to the 
purity of the body which we obtained. The introduction of æthyl into morphia 
alters its action very slightly qualitatively, but quantitatively both the narcotic and 
tetauizing actions are induced by smaller doses than is the case with morphia. Thus, 
with 0.010-0.015 grm. frogs exhibit perfectly the two stages, a similar dose of morphia 
being quite insufficient to produce characteristic effects, beyond slight drowsiness. 
With 0.020 grm. tetanus supervenes in a few minutes, and this always proves a fatal 
dose. In rabbits 0.001 grm. is sufficient to produce slight lethargy, lasting for two or 
three hours. With such a dose the rate of respiration falls from about 120 per minute 
to 12-36 per minute, the heart remaining unaffected. Larger doses deepen and prolong 
the narcosis. 0.10 grm. causes very great increase in the reflexes, while a slightly 
larger dose produces convulsions and death. In dogs, as with methylmorphia, a good 
deal of distress is seen along with the narcosis. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
49 
Diacetylmorphia, C17H17(C2H3O)2 NO3, was first prepared and described by- 
Wright. In it two atoms of hydroxyl hydrogen are replaced by two molecules of acetyl. 
An account of its action would simply be a repetition of what we have said about 
acetylmorphia. In this case, therefore, the action remains the same whether one or 
both hydrogen atoms are replaced. 
Dimethylmorphia 7Hj7(C2H3)2NO3. This base was prepared by warming 
together in alcohol equivalent quantities of morphia, soda, and methyliodide; then 
on cooling additional equivalents of soda and methyliodide were introduced and the 
solution again digested on the water bath. The moisture was evaporated to get rid 
of the alcohol, and the alkaloid extracted with chloroform. The hydrochlorate was the 
salt used for experiment. 
The preparation, purification and analysis of these substitution compounds presents 
peculiar difficulties, as one has to deal not only with ordinary impurities, but with the 
risk of the presence of isomers. For instance, methylmorphia methochloride, dimethyl- 
morphia hydrochloride and methylmorphineëthine hydrochloride, have all the same 
molecular weight. It is impossible, therefore, to distinguish one from the other by ulti- 
mate analysis or by forming platinum or silver compounds. We took, in this case, 
special pains to ensure the purity of our salt, but for the present we are hardly in a 
position to state definitely which hydrogen atom in morphia is replaced by the second 
molecule of methyl introduced-whether it is one of the hydroxyl hydrogens, or one of 
the hydrogen atoms in the morphine nucleus. We have named it at present dimethyl- 
morphia. Its action differs so materially from that of diacetylmorphia, that it arouses 
the suspicion very thoroughly that the same atoms of hydrogen are not replaced in 
both cases. 
With this body, the symptoms which characterize the morphia action are pro- 
foundly altered, so much so that points of similarity are difficult to find. In frogs, five 
milligrams caused slight depression, which soon passed off, the animal passing again 
into its normal condition. When 0.010-0.025 grm. were given, the animal showed 
symptoms of extreme depression, lost its power of jumping, and ceased to respond to 
external stimuli. The motor nerves remain unaffected, but the brain and spinal cord 
are much depressed. The most prominent effect, however, was poisoning of the 
muscles. At the point of injection the muscles passed into a state of rigor mortis 
almost at once, and this condition gradually extends all over the body, death resulting 
from poisoning of the whole muscular system. The action of this body, however, is 
not comparable to that of digitalin, but rather to that of saponin. The heart is 
slowed and depressed, and does not pass through the characteristic stages of the 
digitalis heart. 
In rabbits, no narcosis was produced even with large doses. In one case, 0.05 grm. 
caused only slight depression and slowing of the respiration. 
In another case, 0.5 grm. caused great depression and death in eighteen minutes. 
The cause of death was failure of respiration, due to poisoning of the thoracic muscles, 
the substance having been injected hypodermically over the thoracic region. 
In conclusion, I must express my regrets that we are able to report on so few of 
these bodies. We have now a large number prepared, but owing to the great difficulty 
of obtaining them quite pure, we have not yet made experiments as regards their 
action. It will be inferred from our description that none of these bodies are to be 
preferred in practice to morphia itself. They are all (with the exception of dimethyl- 
morphia) more poisonous than morphia, and possess in a much higher degree the 
power of causing disagreeable symptoms. As regards dimethylmorphia there seem to 
be no indications for its use clinically. 
Vol. Ill-4 50 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. Hull.-Is there any assignable cause to explain why the acetyl morphine 
is so much more active than the methyl compound ? 
Dr. Stockman.-The present investigation may throw some light upon this 
point hereafter ; but at present I am unable to answer this question. 
Dr. William Murrell.-There are only two members of this group that I have 
had any experience with, apocodeine and apomorphine. The latter was discovered 
by Malthison, and its action was investigated by Dr. Lee, of London, who recom- 
mended it as the safest and best agent for an emetic. It did not come into use as a 
therapeutic agent in England until about five years ago ; since then it has been exten- 
sively employed, and was introduced into the British Pharmacopoeia at the last 
revision. A special two per cent, solution was recommended for hypodermic use. The 
preparation is a very good one for this purpose, but the directions for the extempo- 
raneous preparation of the solution, given in the British Pharmacopoeia, to have 
it freshly prepared, are simply puerile. It gets darker in color on standing, but the 
physical change does not interfere with its physiological effects. I have kept a 
solution on hand for months, and have been unable to detect any difference in its 
activity ; it acts the same in identical doses as the fresh solution does. I have had 
the same preparation in my poison antidote-bag for four years, and nearly every case 
of opium poisoning gets some of it, and it acts very satisfactory yet. 
The other agent I have used is apocodeine, but I have not been satisfied with it. 
It is much slower than apomorphine. I therefore went back to the apomorphine. 
I do not regard them as identical in their action, although they are in preparation. 
Apocodeine is commonly made from morphine, and apomorphine from ethyl- 
morphine or codeine. There is much difference of opinion as to the value of codeine 
as a therapeutic agent. On the Continent codeine is much used in diabetes. I am 
not satisfied that it possesses advantages over morphine in this disease. 
Dr. Stockman.-Codeine is given in doses as high as three grains in diabetes, 
and in smaller doses in cough mixtures. Morphine is usually given in smaller doses. 
Theoretically, the conditions should be reversed : codeine is more poisonous, and, there- 
fore, should be given in smaller doses. It is my opinion that none of these substitutes 
for morphine should be used. In former times morphine was given in diabetes, now 
it is the fashion to give codeine. Morphine is much better in cough mixtures, and 
from the pharmacology of these compounds, I would say that morphine is better in 
every way than its derivatives. 
Dr. Brackett.-I found that, clinically, the codeine is better accepted by the 
stomach than morphine. I was surprised to hear that codeine is more violent in its 
action ; and especially, to learn that it produces vomiting. My own preference is for 
the hydrochlorate of codeine for all the purposes to which this drug has been 
applied. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
51 
THE ANTISEPTIC ACTION OF CALOMEL IN LARGE DOSES. 
L'ACTION ANTISEPTIQUE DU CALOMEL À GRANDES DOSES. 
BY GEORGE S. HULL, M. D., 
Chambersburg, Pa. 
The gradual return to the use of large doses of calomel in the treatment of diseases 
of the alimentary canal which are peculiar to the hot weather of summer and mostly 
due to fermentation, seems to warrant a study into the special action of this favorite 
salt of mercury in these disorders. 
Years ago heroic doses of calomel were lauded in the treatment of cholera, dysen- 
tery and like affections, but the dread of these large doses led to a reaction in favor of 
small and frequently repeated ones; and to such an extent has this been carried, that 
many physicians of the present day make use of granules of from one hundredth to 
one-tenth of a grain, and think a ten-grain dose a relic of barbarism. 
Lately, however, the great advance in the study of bacteriology, and the consequent 
search for germicides among medicines, has led to a renewed interest in the salts of mer- 
cury, among which stands the most powerful germicide yet discovered, the corrosive 
chloride, the merits and uses of which are so well known. 
In this examination of the mercurials, the mild chloride has not been neglected, 
and as a result we are beginning to hear again of doses of calomel ranging from a 
scruple to a drachm, being given in summer diseases of the intestinal canal; and the 
claim is that it cures them by virtue of its antiseptic action. 
The object of this paper is to inquire into the so-called antiseptic action of large 
doses of calomel-the considerable and successful use of it in such doses in an epidemic 
of dysentery having aroused a personal interest in the matter. 
Does calomel act as an antiseptic per se, or by virtue of its power, in disease, of caus- 
ing a large flow of bile, which fluid exerts the antiseptic action ? I shall not consume 
time in a discussion of the manner in which calomel brings about its peculiar effects 
upon the system, but only glance at several theories as bearing upon the question of its 
antiseptic action. Almost forty years ago, Sir Henry Holland said, in a lecture, that 
any remarks "on the principle or method of using calomel must be trite and altogether 
needless;" and to-day there is but little ground for anything novel in this direction, as 
we can boast of but little additional knowledge of the precise way in which calomel 
acts upon the liver in disease-I say disease, as it is even claimed that calomel dimin- 
ishes the flow of bile in health. 
The most likely theories of the action of calomel are those of Mailhe and Jeannel. 
The former claimed that calomel is converted into corrosive sublimate by the chlorides 
in the stomach, and, as such, absorbed and made active. Against this we have the 
fact that calomel, to be acted upon by the chlorides in the gastric juice, must have a 
much higher temperature than the stomach affords, and much more time than is occu- 
pied in digestion to form even minute quantities of corrosive sublimate. Also, the 
action of calomel upon the system is quite different from that of the corrosive chloride, 
resembling more the action of blue mass. And yet when chlorides are abundant in the 
stomach, as when salt meats are freely used, or when brackish water is drunk, as is 
sometimes the case on the sea coast, there is, undoubtedly, increased danger of saliva- 
tion. The theory advanced by Jeannel, and spoken of favorably by some authorities, 
seems to be the most plausible. The mercurous chloride, in the presence of an alkaline 
carbonate, is decomposed and mercurous oxide formed. This gray oxide is somewhat 
soluble in water, but if a fatty oil be present, the solubility is very much increased. 
DIE ANTISEPTISCHE WIRKUNG DES KALOMEL IN GROSSEN GABEN. 52 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Now, as the juices of the intestine are alkaline, and as fatty matters are always present, 
it is supposed that the calomel, after passing through the stomach unchanged, is decom- 
posed and dissolved to a sufficient extent by the intestinal juice. However, as Prof. 
H. C. Wood says: " The varying constitution of the alimentary juices and the complex 
chemical relations of calomel, would indicate that its solution in the alimentary canal 
is accomplished in more ways than one." The excess of chlorides may cause a slight 
portion of the calomel to be converted into corrosive sublimate, and the presence of 
sulphureted hydrogen may lead to the formation of a soluble sulphide. Certain it is 
that it is not judicious to administer large doses of calomel where salt foods are con- 
sumed largely, and may it not be probable that the reason calomel acts so promptly, and 
often violently, when the contents of the bowels are in a fermented state and charged 
with sulphureted hydrogen, is that the mercurous chloride reacts with the hydrogen 
sulphide, forming the soluble mercurous sulphide, which is readily absorbed ? I have 
noticed that calomel is apt to act very promptly and effectively when there w'ere eruc- 
tations of this offensive gas, but have always reasoned that this state of affairs showed 
a badly engorged state of the liver, and that the calomel found a large amount of bile 
to be liberated, and hence the free purgation. May not the very presence of the sulphur 
eted hydrogen be the reason why the mercurial is so promptly absorbed and its effects 
so quickly manifested ? 
Then we have the additional and important fact that calomel is soluble in the bile, 
pointed out by no less an authority than Headland ; and this may assist in accounting 
for the reason why calomel purges most powerfully when the dose is repeated at short, 
intervals ; the first dose releases some of the bile, and the following ones, being the 
more readily dissolved, owing to the presence of the bile, are quickly absorbed, thus 
keeping up and intensifying the purgative action. It is the practice of many physi- 
cians, in order to increase the purgative effect, to associate a fair amount of sodium 
bicarbonate with calomel, and here we have the alkaline carbonate ready to reduce the 
mercurous chloride and permit of its being dissolved, even in the stomach, providing 
its contents are not too acid, and contain fatty matter. The familiar and useful com- 
pound cathartic pill of our Pharmacopœia contains, with the calomel, alkaline mat- 
ter, in the form of soap; so do other cathartic mercurial pills. Before proceeding further 
and attempting to show in just what manner calomel may act as an antiseptic, it may 
be well to introduce some clinical evidence in support of this claim. Accordingly, I 
will relate briefly several cases, chosen from a number in a recent epidemic of dysen- 
tery at Chambersburg, Pa. ; and also will supplement them with extracts from reported 
cases of this and allied diseases, in which calomel was given in large doses. 
During the summer of 1886, dysentery became epidemic in Chambersburg ' and 
vicinity, the total number of cases being estimated at about 800. After but indifferent 
success with the usual modes of treatment, I became very much impressed with the 
treatment by calomel in large doses. The very first case in which it was given was 
such a surprise to me that I determined to give it a faithful trial thereafter, and have 
done so. The case just mentioned was briefly as follows: Henry H., a lad of eighteen 
years, had been ill for several days before being seen; his dysenteric symptoms were 
unusually severe, and in spite of the usual treatment (castor oil, followed by opiates 
and astringents by mouth and rectum,) he grew worse. On the seventh night he had 
between twenty and thirty passages of bloody, gelatinous matter, the tormina being 
very severe and uncontrollable. In the morning he was in a decided typhoid condition; 
pulse 130, temperature 104°, tongue dry, hard and brown, limbs drawn up in bed, body 
already very much emaciated, face sunken, intellect dull. In this emergency I deter- 
mined to give the calomel treatment a test, so emptied the contents of the vial in my 
pocket case (containing nearly a drachm) upon his tongue and gave him frequent small 
amounts of water until it bail completely disappeared. In about six hours I returned SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
53 
and found the vessel about half full of an olive-green fluid, about the consistence of 
thick paint. His tormina had left him and he was disposed to sleep; his bowels were 
quiet and there seemed a marked change for the better in every respect. He made a 
good recovery after this, without the use of either opiates or astringents. 
In another case, a lady of thirty-five years, who had been ill for several weeks before 
I saw her, and was delirious, and as I thought, uear death, a similar dose was given. 
A large amount of the olive-green fluid was discharged from her, after which the blood 
disappeared from the passages and signs of betterment set in, although the irritated 
condition of the bowels demanded the use of opiates for a few days. 
In quite a number of cases seen very early in the disease, and in which twenty 
grains of calomel were given at once, the symptoms were very much modified, and in 
some cases the disease terminated abruptly. 
After some experience with this mode of treatment I became confident of a recovery 
when calomel brought away the characteristic bilious discharge, and very rarely did it 
fail to do so ; never, to my recollection, in adults. In several cases where there was a 
tendency to relapse, the dose was repeated, with good results. 
Numerous similar cases could be quoted from the experience of others, but I will 
only refer to one; that of Dr. James Johnson, who, in his day, strongly advocated the 
use of these large doses. His description of his own symptoms, showing the relief he 
obtained from scruple doses of calomel, is indeed graphic. He contracted dysentery 
while hunting on the banks of the Ganges. He was taking, under advice, small, 
repeated doses of calomel, with the hope that ptyalism would alleviate his sufferings. 
Growing worse and fearing a fatal termination, he took, on his own responsibility, one 
scruple of calomel, and fancying it rather lulled the tormina, he, after a number of 
hours, repeated the dose. He then fell asleep, and on awaking was so free from pain 
that he feared it was a dream. To quote his own language, he says: "My skin was 
covered with a warm moisture, and I lay for some considerable time without moving 
a voluntary muscle, doubtful whether my feelings and senses did not deceive me. I 
now felt an uneasiness in my bowels and a call to stool. Alas, thought I, my miseries 
are not yet over ! I wrapped myself up, to prevent a chill, and was most agreeably sur- 
prised to find that, with little or no griping, I passed a copious, feculent, bilious stool, 
succeeded by such agreeable sensations-acquisition of strength and elevation of spirits 
-that I ejaculated aloud the most sincere and heartfelt tribute of gratitude to Heaven 
for my deliverance. ' ' 
To add still more weight to the prognostic value of the appearance of bile in the 
stools of dysenteric patients, I might quote from Dujardin Beaumetz, who in one of his 
lectures says : "You may regard your patient as cured when once bile appears anew in 
the stools. ' ' 
In looking over the modes of action of the drugs which are the most successful in 
the treatment of dysentery, it is noticeable that they all either aim at releasing the bile 
or at depleting the portal circulation by causing a flow of serum from the numerous 
veins composing it. Of the former, calomel and ipecac are examples; of the latter, the 
salines. 
The rationale of the calomel treatment in dysentery, where we have a loaded portal 
circulation, brought about by some specific poison, and followed by discharges of mucus 
from the irritated bowel, which irritation increases until blood tinges the stools and 
finally tissue breaks down and ulceration results-the rationale of this treatment seems 
to be that it unloads promptly this congested circulation, by removing the obstruction; 
i. e., by relieving the engorged liver of its bile; and the reason for giving a large dose 
in preference to small repeated doses, would seem to be as follows : So much of the large 
dose reaches the alkaline small intestine, that after sufficient of it is dissolved to excite 
the flow of bile, there still remains a quantity of it to be dissolved by the bile, and this 54 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
solution, which has increased antiseptic powers, flowing down the canal, after having 
led to a depletion of the engorged portal circulation and thus given relief to the con- 
gested mucous membrane, has a twofold action : First, by virtue of its purgative action 
it sweeps from the bowels offending matter, and in the second place, and where it 
excells other cholagogues and purgatives, it directly (by virtue of its antiseptic proper- 
ties, due, in a large measure, to the mercury salt in solution.) destroys the infectious 
matter, i. e., acts as a germicide. 
In the ordinary summer diarrhoeas, where fermentation plays a part, this happy 
action is manifested to a great advantage; even in cholera I can well believe it is cap- 
able of doing good, and possibly, when given early, is able to cut short, or at least to 
mitigate the disease, by virtue of this antiseptic action. 
We have on record various and opposed opinions concerning its use in cholera, as it 
has been given in the smallest doses, and in such enormous quantities that one pound 
has been administered in a single case. In this rapid and formidable disease there is 
not the same latitude for giving it as in dysentery, and unless its action is manifested 
in time to destroy and eliminate from the intestinal canal the bacillus of this disease, 
we cannot place much reliance upon the administration of it, as the absorbed poison is 
hardly likely to be influenced by any remedial property calomel possesses. 
Dr. Vandeveer, in his report of the Franklin Street Cholera Hospital, in the 
epidemic of 1854, states that he gave thirty-five to forty grains of calomel in the first 
stages of confirmed cholera, which, if rejected by the stomach, was repeated every five 
minutes until sufficient was retained. Even in the stage of collapse he gave as much 
as sixty grains in the same manner. 
With reference to purgation being brought about by its use, he says : "I have never 
met a case of cholera treated as above stated where hypercatharsis ensued; on the 
contrary, it has frequently occurred that patients, both in hospital and private practice, 
have been seized with violent vomiting, purging and cramps, which had, from their 
own statement, been kept up, every ten minutes, for one, two, or three hours, and, upon 
taking sixty grains of calomel have not vomited for six, ten, or twelve hours after; and 
in two or three instances, in the hospital, after waiting twelve hours, mild enemata 
were resorted to in order to open the bowels." His success was such, that even one- 
third of those cases described as in *4 profound collapse ' ' when admitted were saved. 
Dr. Ayre gave in three days 580 grains, without producing any soreness of the gums, 
and his patient recovered. Dr. Sternberg says that calomel given with a view to the 
formation of corrosive sublimate in the stomach and its germicidal action upon the 
bacillus, is a very unscientific procedure, because of the uncertainty of the formation 
of the corrosive sublimate, and if any should be accidentally formed, the smallness of 
the amount would be of little avail. This may be readily granted, as there is, under 
any circumstances, but small likelihood of the formation of a sufficient amount of 
corrosive sublimate in the stomach to disinfect the whole intestinal canal without pre- 
viously doing much, and perhaps greater, damage by virtue of its own poisonous action. 
Now, if calomel, after some decomposition, is dissolved in the bile, as stated by Head- 
land, may not the early use of large doses of this tasteless powder, which is far 
more likely than any other cholagogue to remain in a sensitive stomach, may 
not the administration of it before collapse has set in, and while the liver can 
respond to its action, cause a flow of bile which will dissolve some of the excess, 
and passing through the intestine act as a germicide by virtue of the mercurial salt 
held in solution? I put this as a question which has constantly come up 
before my mind, and it seems to me an answer in the affirmative could be 
reasonably hoped for. Certainly, but little objection can be urged against the use 
of these large doses, when it has been the experience of all who have used them 
that the danger of salivation is almost nothing. And as regards the poisonous action SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
55 
of calomel, it does not seem to be actively poisonous in any single doses. And besides 
its probable germicidal action, it possesses, as claimed for it by several writers, a 
decidedly sedative action, frequently bringing on sleep and even quieting pain. This 
sedative effect, which I have seen decidedly manifested in some cases, is spoken highly 
of by Vandeveer; also in the case of Dr. Johnson, as related above, he emphasizes this 
result of its action; and in an excellent paper by Dr. T. D. Lente, in the JVew York 
Medical Journal, on the "Sedative Action of Calomel," he speaks enthusiastically of its 
action in this respect, even in such diseases as croup and pneumonia. To sum up the 
matter in a few words, if we can both promote the flow of bile and increase its anti- 
septic properties by large doses of calomel, should we not give this matter our careful 
consideration, and see how it will stand in the light of clinical evidence. 
DISCUSSION. 
Dr. Julius Gnezda, of Berlin.-Has the lecturer used large doses of calomel in 
hepatitis, or commencing cirrhosis of the liver ? 
Dr. Hull.-I have never used large doses in such cases. I might add to what I 
have said, that in none of the cases treated did there follow abscess of the liver or 
any of the other troublesome and serious sequelæ of dysentery. This was probably 
averted by the prompt action of the calomel treatment. 
Dr. Green.-Large doses of calomel are not given as frequently by physicians as 
formerly ; and it is a question if the most of it does not pass through without pro- 
ducing any effect whatever. I prefer to give fractional doses. 
Dr. Brackett.-Large doses of calomel in the early stage of typhoid fever are 
used in Germany. From personal trial, I was not satisfied with the doses even as 
large as ten grains, and have gone back to small doses. 
Dr. Upshur.-I began many years ago to use calomel in large doses, but the 
tendency of late years has been to give small doses. When I desire action upon 
the liver I give one-fourth or one-fifth of a grain of calomel every hour or two, and 
after four or five doses I obtain copious bilious stools. The practice in Richmond 
to-day is averse to giving large doses in dystentery, and we get just as good results 
from other purgatives. The benefit from the calomel is not due to antiseptic action, 
but it relieves by removing irritating contents from the bowels. I believe that if the 
lecturer had given teaspoonful doses of sulphate of magnesia, and then followed up 
with small doses of morphine, he would have had equally good results. 
Dr. W. M. Ramsey.-Being from the same locality as the gentleman who read 
the paper, I am exceedingly anxious to hear this question of large doses of calomel 
in dysentery discussed by the Section. I have never used over ten or twelve grains 
at a dose. If the experience of those present confirms that of the reader of the 
paper, I am willing to test the treatment. Within a few days I have had a gentle- 
man prescribe for a patient of mine, in consultation, one-twentieth of a grain of 
calomel, and obtain from this small quantity bilious stools within twenty-four hours. 
You see the great difference in the dose, which gives rise to my dilemma which to 
use. 
Dr. A. M. Duncan, of Ohio.-I have for four years past been in the habit of 
using calomel in dysentery, in from one-half to one-tenth of a grain doses, with good 
results. I often associate with it, in small doses, ipecacuanha, or use the latter 
alone ; both remedies to be freely repeated as the case requires. 
Dr. J. Gnezda.-Calomel is not used in typhoid fever in the clinic of Prof. 
Leyden, in Berlin ; but it has been tried with more or less success in cases of hepatitis during the last two years. This treatment was recommended by Prof. Sacharin, of 
Moscow, Russia. 
Dr. Hull.-In my paper I reported the results of individual experience in the 
treatment of dysentery with large doses of calomel. Some of those who compli- 
mented me by discussing the paper must have misunderstood my position. I did 
not say it was the only treatment, nor the best treatment of this disorder ; nor did I 
say that it acted as an antiseptic only in such cases. The title of my paper is the 
" So-called Antiseptic Action of Calomel," and I should have been pleased, indeed, 
had the discussion been centred upon this point, or even upon the action and merit 
of large doses of calomel in the treatment of dysentery. 
56 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
57 
FOURTH DAY. 
A paper by Dr. George Armstrong Atkinson, of Edinburgh, Scotland, in 
the absence of the author, was read by Dr. Ralph Stockman, entitled- 
THE PHARMACOLOGY OF THE NITRITES AND OF 
NITROGLYCERINE. 
LA PHARMACOLOGIE DES NITRITES ET DE LA NITROGLYCÉRINE. 
DIE PHARMAKOLOGIE DER NITRITE UND DES NITRO-GLYCERINS. 
BY G. ARMSTRONG ATKINSON, M.D., 
Of Edinburgh, Scotland. 
The pharmacology of the nitrites and of nitroglycerine is most conveniently 
discussed by considering, in the first place, the Pharmacology of the Nitrites, and then 
the Pharmacology of Nitroglycerine. 
THE PHARMACOLOGY OF THE NITRITES. 
The essential basis of pharmacological action in this group of medicinal agents is 
nitrous acid, an acid which is remarkably unstable at ordinary temperatures, especially 
in the presence of water. By making a watery solution of about 1 in 3000 there is not 
very rapid deterioration, and such a freshly prepared solution may be used for a couple 
of days or so. The solution, however, has no advantage over a simple metallic nitrite 
solution, as of nitrite of sodium, and the experiments carried out with it on myself, on 
rabbits and frogs, showed its action to be identical with that of a solution of nitrite of 
sodium, in so far as the action of an acid can be considered identical with one of its 
salts. Our knowledge of the actions of the nitrite group has chiefly been derived from 
the effects produced by nitrite of amyl. Since here the base (amyl) has a decided 
action of its own, it is advisable, in order to ascertain the action of nitrous acid, in 
combination to form a salt, to select such a nitrite as nitrite of sodium, the base sodium 
possessing in its combinations no well marked pharmacological activity. 
THE PHARMACOLOGY OF NITRITE OF SODIUM. 
The literature pertaining to the action of this nitrite is not great. Gamgee, Lauder 
Brunton, Hay, Leech and others have all recorded their experience of a like similarity 
of action between this salt and amyl nitrite. Barth (Toxikologische Untersuch, über 
Chilisalpeter., Bonn, 1879) pointed out its highly poisonous qualities; Binz (Archiv f. 
Exper. Path, und Pharmak., XIII, 133) gave some experiments as to its general action 
on dogs, rabbits and frogs, showing that it produced death from a general paralysis, 
especially of the muscular system, no convulsions preceding the fatal issue. Reichert 
(American Journal of Medical Sciences, vol. 80, p. 158) states he found its action, so far 
as he investigated it, identical with that of nitrite of potassium, with which nitrite he 
made a long series of experiments, which will afterward be referred to. The nitrite of 58 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sodium used in the experiments I am about to detail was recrystallized by myself, from 
commercial specimens of the salt, and contained nitrous acid equal to from 99.2- 99.4 
per cent, of actual nitrite. 
General Action on Frogs.-Almost all the experiments were made on winter and 
summer specimens of the Rana Temporaria ; those made on the Rana Esculenta were 
merely check experiments and showed no difference. The general action on frogs is well 
seen in animals to which minimum lethal doses of the nitrite have been administered. 
For frogs of 25 to 30 grams .15 grain (.00972 gram) is a fatal dose, subcutaneously 
injected. Such a frog with such a dose, in about two minutes after injection, without 
any preliminary stage of excitement, leaps less readily and its reflex movements are 
less vigorous. In ten minutes after injection it jumps feebly and unwillingly, its cuta- 
neous vessels are dilated, their contents are darkened, and respiration is slower. After 
fifteen minutes the animal sits with its thorax only slightly raised from the table, its respi- 
rations are decidedly slowed, the pupils are as large as before the experiment commenced ; 
the lower eyelids are slightly closed. On pinching the legs a feeble reflex movement is 
produced and the animal crawls away with a kind of walking movement. It cannot 
jump and cannot turn off its back. In one hour, having gradually become feebler, with- 
out any twitchings or convulsive movements, respiration has ceased. The exposed 
ventricle of the heart is beating slowly, generally about 18 per minute, the auricles 
usually about twice as fast. The blood is markedly chocolate colored. The strongest 
stimulation of the exposed sciatics by a du Bois-Reymond induction coil with one 
Daniel's cell produces only feeble movements of the toes. All skeletal muscles iuex- 
citable except those on inferior aspect of thighs and of legs, which feebly respond to 
strongest current. Cord on strongest stimulation produces no movement. Ventricle 
beats for one and a half hours more, auricles for three hours, the heart stopping in full 
diastole and being quite inexcitable. Tissues aud blood (on dialysis) give nitrite reac- 
tions, and blood shows the spectroscopic appearances of methaemoglobin. Post-mortem 
rigidity comes on early; the pupils in it are contracted to pin points and the subcuta- 
neous tissues become somewhat œdematous. Similar doses to larger frogs produced 
severe symptoms in about 20 to 30 minutes, the symptoms being similar to the above 
but not proceeding to death. The frog gradually recovers and iu two or three hours is 
almost well. Smaller doses produce slighter but similar effects. With larger doses the 
various stages occur more rapidly but without any difference in phenomena. A frog 
weighing 22 grains received subcutaneously three grains of the nitrite. The animal 
rapidly became profoundly affected as described with the other frogs. Iu five minutes 
respiration ceased; in 15 the ventricle and in 18 the auricles stopped beating. The 
nitrite was ascertained to be readily absorbed from the stomach or the skin of the frog. 
Strong solutions painted over the legs rapidly killed. 
In Rabbits of about three pounds in weight, three grains was ibund to be a fatal dose. 
Larger rabbits recovered from this quantity. The phenomena are closely allied to those 
in the frog. A white rabbit weighing four pounds four ounces received subcutaneously 
four grains of nitrite of sodium. Animal almost immediately became very prostrate, 
lying down on its belly with its limbs extended ; respirations rapid and shallow, blood ves- 
sels dilated and blood of a chocolate color. Symptoms of muscular paralysis rapidly pro- 
gressed, and in half an hour the animal was very feeble and moribund. It now cried 
once or twice. Respiration, which had become slow, ceased; the rabbit made slight 
movements of a dyspnoeic character with its forepaws and died. 
Immediate post mortem: Venous system engorged; blood deeply chocolate colored; 
right ventricle in full diastole; left iu moderate systole; auricles occasionally feebly 
beating; sciatics and muscles inexcitable; all viscera congested. Intestines contracted 
somewhat less strongly to strong current than in normal rabbit. Dialysed blood gave 
nitrite reactions. Urine contained trace of nitrite but no sugar and no albumen. In SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
59 
rabbits more slowly poisoned gastric ecchymoses were present and there was a tendency 
to looseness of the bowel, but no diarrhoea was ever observed. Larger doses than the 
above produced death very rapidly ; from smaller doses recovery after development of 
the severe symptoms was comparatively rapid. 
In Dogs the phenomena are much as in rabbits, except that vomiting usually 
occurred shortly after exhibition of the poison, even subcutaneously. Large dogs, as 
of about fifty pounds, required about twenty grains, this dose being fatal in a little 
more than one hour. Post-mortem rigidity, both in dogs and rabbits, was early in its 
appearance. In dogs, nitrite reactions are very usually obtained early in the urine; 
in rabbits, not always, and only when present in very minute traces. 
In Man I am unaware of any fatal cases; in myself, after taking on an empty 
stomach eight grains of nitrite of sodium, in a few minutes I experienced a great ten- 
dency to faintness with considerable acceleration of pulse, and great lowering of arterial 
tension. No sickness occurred, but considerable eructation of oxides of nitrogen. No 
visible flushing of any part of the body was detectable. 
Action on the Individual Systems.-Action on the blood and on the circulatory system. 
The account given of the general action indicates an important action on the blood and 
circulatory system. Nitrite of sodium very readily produces methæmoglobin, and in 
dogs to which a dose of about four grains of nitrite of sodium has been given, methæ- 
moglobin is found for thirty to thirty-six hours. The red blood corpuscles are unaltered, 
the white are readily paralyzed-by a one per cent, solution in four or five minutes-by 
a one per mille in fifteen to twenty minutes. The excised heart of the frog is killed by 
being placed in normal saline containing nitrite of sodium in eight to nine minutes, if 
a one per cent, solution be used, in about three hours if a one per mille-no prelimin- 
ary stage of increased rapidity of beat occurs, the heart gradually beating more and 
more slowly, and finally stopping in full diastole. Directly applied to the heart in situ 
death was caused by strong solutions, as twenty per cent., in a few minutes ; by weak, as 
one per cent., in an hour or so. Subcutaneously injected the same phenomena occurred, 
no preliminary increase in rate being present. To ascertain the effect on the heart when 
the vascular dilatation is not present as a disturbing influence, Williams' well known 
heart apparatus was employed; with one in 1000 death of the heart in diastole occurred 
in 10 or 11 minutes without any preliminary rise; with one in 10,000, a slight rise for 
four or five minutes was observed, followed by a slow fall to death, which occurred in 
40 to 60 minutes; with one in 20,000 the rise lasted 10 to 15 minutes, and death did not 
occur for some hours. The slight rise in blood pressure seemed due to a slight quick- 
ening of the heart's action, rather than to an increase in the strength of the individual 
beat. From experiments with many variations of dose it was ascertained that no 
stimulating effect on the vagus terminations in the heart, and no paralyzing effect either 
was induced. Both arteries, veins and capillaries were widened by the drug, as ascer- 
tained by a micrometer. The solution of nitrite in normal saline was run through the 
vessels of a pithed frog, the pressure of the inflowing fluid being maintained at a con- 
stant level by means of reservoirs fitted with Mariotte's flasks. Dilatation occurred with 
all strengths from one in 10,000 to one in 200,000. In mammals great vascular dilata- 
tion and great acceleration of the heart beat occur. The ophthalmoscopic appearances 
are those of slight arterial and venous dilatation with small doses; with large doses this 
dilatation was rapidly followed by diminution in size. Blood pressure experiments on 
rabbits showed a steady fall ; with no dose was there any preliminary rise in blood 
pressure ever observed. The heart beat was markedly accelerated. The vagus termina- 
tions in the heart are unaffected. When the animal is fully under the nitrite, section of 
the vagi is still followed by some rise in blood pressure, although the rise is very much 
less than in the normal animal. Section of the depressor nerves was followed by a fall in 
blood pressure, probably due to loss of sensory impulses passing from the heart to the 60 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
accelerating centres in the medulla. When the free carotid was clamped, with the blood 
pressure very low, the rise was only small. The acceleration in heart beat seems, there- 
fore, to be due to depression of the medullary inhibitory centre, secondary to the fall in 
blood pressure, which is almost entirely due to vascular dilatation, the heart muscle 
being only affected in advanced poisoning. 
On Respiration the effects are to cause increased rapidity followed by slowing and 
finally by stoppage before the heart ceases. The nitrite, by producing methaemoglobin, 
and by lowering the blood pressure, causes the increase. The paralysis of respiration 
is due to the effect of the nitrite on the muscular system chiefly, but also in part to the 
effect on the medullary centre. 
The temperature falls, a slight rise occurs at the beginning, with the thermometer in 
the rectum, due to vascular dilatation. 
Striped muscle is rapidly paralyzed, non-striped more slowly ; in the rabbit non-striped, 
as of the intestine, is only paralyzed by a one per thousand solution in four hours ; by a 
one per hundred in about half an hour. 
Motor and Sensory nerves are almost, if not quite, unaffected, even with lethal doses, 
as to their peripheral terminations. Their trunks are also probably unaffected, unless 
the nitrite be directly applied. The brain and eord are both paralyzed without any 
previous excitation, unless saturated or very strong solutions be directly applied. Cer- 
tainly in the uninjured animal no such stimulation occurs. 
On the urine small doses slightly increase the flow; large always diminish it here if 
the arterial tension be previously raised by means of digitalis. The urea and uric acid 
are almost unaffected. Sugar appears in the urine of rabbits after some hours, if the 
animal be kept very decidedly under the influence of the drug, but rapidly disappears 
if the administration of the drug be stopped. The nitrite is largely destroyed in the 
system, being partly, however, excreted as nitrate, partly, probably, as urea. A portion 
of it is excreted as nitrite. 
THE PHARMACOLOGY OF THE OTHER NITRITES 
is briefly dismissed. 
Nitrite of Potassium is stated by Reichert (op. cit.) to produce restlessness and excite- 
ment in frogs, followed by depression and incoordination of voluntary movements, 
occasionally clonic convulsions or a tetanoid condition being present: Motor and sen- 
sory nerves are mentioned as being depressed, and the blood pressure is stated as being 
primarily increased and then diminished. According to this observer nitrite of sodium 
would markedly differ from nitrite of potassium in action, and I made, therefore, a pro- 
longed series of observations with the potassium salt. It was found to be practically 
absolutely identical in action. 
Nitrite of Ethyl was used mixed with an equal volume of absolute alcohol. This 
drug acted much as the sodium salt, but much more rapidly, death after subcutaneous 
injection occurring in a few minutes, and by inhalation in one or two. The blood is 
rendered markedly chocolate colored, from methaemoglobin production ; the muscles and 
sciatica are very little affected ; slight dyspnoeic convulsions occur, and death is appar- 
ently due largely to medullary paralysis. 
Nitrite of Amyl has been so largely written upon that it requires but little to be said 
of it. Death with it is partly due to the muscle paralysis, especially if the drug be 
subcutaneously exhibited, as then very slow absorption takes place, death not usually 
occurring for many hours. The fatal issue is principally, however, produced by similar 
causes to those acting with nitrite of ethyl. 
THE PHARMACOLOGY OF NITROGLYCERINE. 
This body, a trinitrate of glyceryl, as shown by Hay, breaks up in the system with 
the production of nitrites, hence, therapeutically, it has a nitrite-like action when given SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
61 
to man and mammals by the stomach, subcutaneously or by intra-peritoneal injection; 
occasionally, with very large doses to rabbits by the stomach, as live or six grams, tetanic 
convulsions occur. Watery solutions, usually of the strength of one per mille, when 
subcutaneously injected into frogs, produce a series of phenomena quite different from 
nitrite of sodium. A frog weighing 20 grams received subcutaneously 30 minims of a 1 per 
1000 watery solution of nitroglycerine. In one minute it began to walk slowly about and 
refused to jump unless strongly irritated. In two minutes it was unwilling to jump at 
all, and the movements were stiff, with a tendency for the animal to rotate on its 
haunches. Reflex movements much diminished in three minutes from time of injec- 
tion. Four minutes after injection it gave a sharp cry, and after a few seconds of very 
irregular movements pronounced tetanus occurred. The tetanus soon passed off, but was 
readily induced by stimulating skin until following morning. Animal feeble following 
day, and did not fully recover until third day after injection. 
If smaller doses be given, clonic but not tetanic movements occur. If larger, as 
100 minims of the 1 per 1000 solution, the animal dies from the exhaustion produced 
by the tetanus. After death the post-mortem appearances are like those of nitrite 
poisoning to some extent, and the blood, on dialysis, gives nitrite reactions. 
Portions of the brain were successively removed, and the clonic movements were 
localized in the medulla, the tonic in the spinal cord. The effects on the other systems 
of the body were similar to those of nitrite of sodium, being, indeed, due to the pro- 
duction of this salt. 
Administered to mammalia by the stomach, death occurred, due to nitrite poison- 
ing, but if intravenously injected, tetanus, preceded by clonic movements invariably, 
was very readily induced by the injection of a few cc. of a one per mille watery solu- 
tion into the jugular vein of rabbits. The cause of the non-appearance of tetanus when 
given by the stomach is the slowness of absorption of sufficient quantity to induce 
convulsions, as the nitroglycerine is not very soluble in water (1 in 760) ; and, further, 
the absorbed ether is rapidly partially decomposed into nitrite. The excretion of nitro- 
glycerine is by the urine, from which, after large medicinal doses, it can easily be 
extracted by means of ether. 
It is obvious, therefore, that in nitroglycerine we have a twofold action, that of 
nitroglycerine and that of the resulting nitrite. Nitroglycerine, sui generis, acts as a 
convulsive agent, the nitrite which results from its decomposition as a paralyzing. 
(Fuller details of this paper will appear in the Journal of Anatomy and Physiology 
for January, 1888.) 
DISCUSSION. 
Dr. William Murrell, of London.-During the last ten years I have devoted 
much attention to the investigation of the physiological action of the nitrites, and 
especially nitroglycerine. As a result of this work, nitroglycerine has been intro- 
duced as a remedy in angina pectoris. Its action is quite different from that of the 
nitrite of amyl in this affection. It has been employed with advantage not only in 
angina pectoris, but also in pseudo-angina, cardiac asthma, and similar morbid states. 
The tabellæof the British Pharmacopoeia are not a good form of administration, and 
a simple one per cent, alcoholic solution is to be preferred. Originally, I gave this 
by itself, or with a little water ; but now I always combine with it spirits of chloro- 
form, tincture of capsicum or peppermint, to promote rapid absorption. I have 
seen many cases of angina pectoris practically cured by this method of treatment, 
although it was absolutely necessary for the patient to continue the use of the drag 
for months or even years. When the anginal attacks are slight, nitrite of amyl 
answers admirably, but when they are more severe, it is necessary to resort to nitro- 
glycerine to control them. With regard to the nitrites, I had an unfortunate experi- 62 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ence. Dr. Law recommended nitrite of sodium in twenty-grain doses in epilepsy 
and angina pectoris. Upon adopting this recommendation, 1 had unfavorable results ; 
and it subsequently turned out that Dr. Law had been using an impure drug, while 
I had used the pure salt. I subsequently concluded that the field was so much 
better occupied by the nitrite of amyl and nitroglycerine that I did not need the 
nitrite of sodium. In one case I noted that it acted very decidedly as a diuretic. 
Dr. Upshur.-What is the dose of nitroglycerine? 
Dr. Murrell.-I cannot lay down any rule, but one-hundredth of a grain is 
the usual dose. Some persons can take very little without producing headache ; 
others can take fifteen minims of a one per cent, solution, and I have known a man 
who could take one minim without bad result. Patients can keep on taking the drug 
for a long time. It should be carried in the pocket ready for use if an attack 
threatens, or the patient might die before the remedy could be obtained to relieve 
him. 
Dr. Upshur.-Is it equally useful in other forms of neuralgic attacks, especially 
such as the reflex neuroses attending uterine disorders? At the climacteric period, 
women suffer from various forms of nervous disorders, especially sub-mammary 
pain, and headache located just to the left of the parietal suture, and when it becomes 
more violent, radiating over the entire head. This accompanies uterine disease. For 
this neurosis he had tried almost everything, but had not yet used nitroglycerine, on 
account of uncertainty as to dosage. 
In the cases of puerperal septicaemia, nitrite of amyl was given with marked 
success. The patient was in a state of collapse ; skin cool and bathed in perspiration ; 
the only evidence of life was a fluttering action of the heart. As the patient was 
dying of heart failure, it occurred to him to use the nitrite of amyl to sustain the 
circulation. Within three minutes from the time she began the inhalation of the amyl 
the skin became dry and the pulse returned to the wrist, and she opened her eyes. I 
watched her for two hours, and then left the agent in the hands of an intelligent 
nurse, directing that it was to be resorted to when there was evidence of the failure of 
the pulse. The patient took the remedy, at intervals, for forty-eight hours, when it 
was gradually withdrawn, and alcoholic stimulants substituted. My friend, Dr. 
Ashton, of Port Royal, has used the amyl in a similar case, with the happiest results. 
Dr. H. G. Beyer, U. S. Navy.-Is the dilatation of the blood vessels from nitro- 
glycerine a general or local effect? Is the diuresis which follows due to dilatation of 
the blood vessels or to a direct action upon the kidneys ? 
Dr. Murrell.-I have used nitroglycerine in the following kinds of cases : angina 
pectoris, pseudo-angina pectoris, cardiac asthma, some kinds of headache, and in 
some forms of neuralgia in cases of Bright's disease. It has also been recommended 
in sea-sickness, in asthma, both cardiac and spasmodic, and surgical shock. As to the 
dose, much depends upon the form in which it is administered. The best form is the 
centesimal alcoholic solution. With regard to the effect, I consider that it is a general 
and not a local one. 
Dr. Wade.-The pearls of nitroglycerine are convenient for use. I consider it the 
best heart stimulant known for sudden emergencies. A very convenient way to carry 
it is as a ten per cent, solution in alcohol, which can also be used for inhalation. 
Dr. Phillips.-In regard to the dose of nitroglycerine, in cases of angina pec- 
toris, I have found it very variable. In difficult cases I give one minim of the one 
per cent, solution every half hour, for four days. Some patients take twenty-five SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
63 
and even thirty minims, in the form of the tabellæ of the Pharmacopoeia, each of 
which contains one minim. In other patients I found it impossible for them to 
tolerate more than three or four minims. With regard to the nitrite of sodium, I 
found it very valuable in dyspnoea from bronchitis ; the effect is more prolonged than 
from the other nitrites, and it is better taken. 
Dr. Brackett.-I have listened with interest to the remarks with regard to the 
use of nitrites in epilepsy. In one case of my own, the action of the nitrite of amyl 
was very favorable. It is necessary, in order to use it, that there should be some 
warning of the attack. My patient, who was a printer, on the appearance of the 
symptoms indicating the approach of a convulsion, crushed a nitrite of amyl pearl, 
and by inhaling it, warded off the attack. The tendency to convulsion passed away, 
and he was able to go on with his work. The effect did not seem to be curative at 
all, except that it was abortive, and lessened the number of convulsions. If it only 
aborts the attacks it is a remedy of great value. The great point is to keep the 
patient supplied with the drug for prompt use. 
Dr. Woodbury.-I would like to know the hypodermic dose of the one per cent, 
solution. I have seen it stated that it was superior to brandy for heart failure, and 
could be administered in doses of from five to fifteen minims. 
Dr. Murrell.-The pearls are too expensive, and the same objection might be 
urged against the tabellæ. The best way is to keep the solution in a small bottle. 
The capsules are mere chemists' curiosities. I have not had much experience with 
the hypodermic use of nitroglycerine, which is slower than by the mouth, and I prefer 
to give it by the mouth. 
Dr. Wade.-I have used the nitrites, on theoretical grounds, in localized suppu- 
ration of the brain, in cerebral embolism and thrombosis, in order to prevent the ten- 
dency to defective nutrition of the brain. The effect was very decided in several cases, 
and was shown by great improvement in intelligence. 
Dr. Phillips.-A dose of twenty minims hypodermically is too large, as it would 
represent from forty-five to sixty by the mouth. I have given five minims of the one 
per cent, solution, and it brought on headache and dizziness, although it relieved the 
neuralgia for which it was taken. 
ÜBER DAS GIFTSEKRET DER NAJA TRIPUDIANS, GÜNTH. 
(COBRA DE CAPELLO). 
ON THE VENOMOUS SECRETION OE NAJA TRIPUDIANS, GÜNTH. 
(COBRA DE CAPELLO). 
SUR LA SÉCRÉTION EMPOISONNÉE DU NAJA TRIPUDIANS. 
VON J. GNEZDA, M. D. 
Der Umstand, dass die giftigen Sekrete der Schlangen in ihren fortdauernden Ein- 
griffen in die organische Lebewelt, ihrem exceptionellen physiologischen Herkommen 
uud in ihrer chemischen Natur, sowie als Venenum selbst wenig gekannt sind, befür- 
wortete die Untersuchung eines der verbreitetsten derselben. Die Gelegenheit zu einer 
solchen wurde durch Prof. E. DuBois-Reymond in Berlin geboten, welcher ein von 64 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dem Leiter der Deutschen Cholera-Commission, Prof. R. Koch, aus Indien gebrachtes 
Quantum von reinem Gifte der Naja tripudians dem Verfasser zur Verfügung stellte. 
Zur Schilderung des Giftes nach verschiedenen Seiten hin übergehend, sei bemerkt, 
dass mit derselben nur Thatsachen und Resultate von mit diesem Giftpräparate vor- 
genommenen Experimenten registrirt werden sollen. Aus diesem Grunde kann auf 
die, dieser vorangegangenen Arbeiten von Brainard, Vulpian, Fayrer, Sedier, Gautier, 
Aronsohn, u. s. w., hier nicht eingegangen werden. 
Das zu den Reaktionen mid Experimenten benützte Präparat zeichnete sich durch 
möglichste Reinheit aus, indem bei der von Prof. Koch mitgetheilten Gewinnungsweise 
des Giftes keinerlei chemische Umwandlung damit vorgegangen sein konnte. Man 
liess nämlich die gereizten Brillenschlangen in Muschel- oder Schneckenschalen, deren 
Mündungen mit Pergament verschlossen waren, beissen. Das flüssig eingedrungene 
Sekret erstarrte bald an der Luft und bildete nun eine Substanz, welche sich in un- 
regelmässigen amorphen, kleinen Splittern präsentirte, etwa wie grobkörnig gestossenes 
Glas. Es besitzt strohgelbe Farbe und bricht das Licht einfach. Wenn gelöst (3% ), 
ist es stark adhärent am Glase. Die wässerige Lösung sieht schleimig und bläulich 
opalescent aus, reagirt neutral und ergiebt, geprüft auf das chemische Verhalten: 
Das Cobragift ist leicht löslich in Wasser, unlöslich in Alcohol, Aether und 
Eisessig. 
Mit Salzsäure giebt das Gift einen weissen Niederschlag, welcher unter dem Micro- 
scop amorph erscheint, in Ueberschuss von Salzsäure sich nicht löst, wohl aber in 
Wasser. Trägt man in eine salzsaure Lösung des Giftes Steinsalz ein, so bildet sich 
um den Steinsalz-Crystall herum ein weisser Niederschlag. Mit Salpetersäure giebt die 
Giftlösung einen reichlichen weissen Niedershlag, welcher bei starkem Erhitzen und 
Ueberschuss von Salpetersäure gelb wird. In verdünnter Lösung verschwindet der 
Niederschlag beim Erhitzen. 
Sättigt man die neutrale Lösung mit Steinsalz, so entsteht ein weisser Niederschlag. 
Mit Natron- oder mit Kalilauge, sowie doppelkohlensaurem Natron entstehen keine 
Fällungen. 
Die Lösung trübt sich beim Sieden ; setzt man Essigsäure dazu, so bildet sich kein 
Niederschlag, auch nicht beim Kochen mit Kalisulphat, sondern eine blosse Trübung. 
Die Giftlösung verliert durch Kochen ihre giftige Wirkung. (Versuch an Kaninchen.) 
Mit neutralem Bleiacetat entsteht eine schwache Trübung, mit basischem ein 
schwacher Niederschlag. Mit Platinchlorid giebt das Cobragift einen starken Nieder- 
schlag, mit ammoniacal. Silbernitrat keinen. Quecksilberchlorid giebt einen weissen 
Niederschlag. Ferner tritt eine starke Fällung ein mit Quecksilbernitrat, mit Jod- 
kalium, Jodquecksilber. 
Essigsäure und Ferrocyan-Kalium, sowie Phosphorwolframsäure geben Nieder- 
schlag. 
Wird eine geringe Quantität des Giftes mit Millons Reagens erhitzt, so entsteht eine 
rothe Färbung. 
Mit Natronlauge und Kupfersulphat giebt das Gift in der Kälte die Biuretreaction. 
Die mit dem Cobragifte vorgenommenen Experimente* ergaben : 
Subcutan oder subperitoneal injicirt, tödtet es Amphibien, Reptilien, Fische, Vögel 
und Säugethiere. Letztere gehen bei gleicher Dosis und unter Berücksichtigung des 
Körpergewichtes am ehesten zu Grunde, während Tauben relativ immun sind. Das 
Verhältniss gestaltet sich derart, das bei dergleichen Giftmenge (0,003) ein Kilogramm 
Frosch binnen 5} Stunden stirbt, ein Kilogramm Hecht binnen 2 Stunden, ein Kilo- 
gramm Katze binnen 10| und dieselbe Menge Taube binnen 26 Stunden. Am schnell- 
sten gingen Kaninchen zu Grunde, nämlich binnen einer halben Stunde. 
* Verwendet wurde eine 3$ wässerige Lösung. SECTION VI THERAPEUTICS AND MATERIA MEDICA 
65 
Der Igel (Erinaceus europ. L.) wird vom Cobragifte ebenso gut getödtet, als andere 
Säugethiere. 
Wird das Cobragift durch den Oesophagus in den Magen von Fröschen gebracht, so 
tödtet es dieselben. Ebenso Sperlinge. Das Cobragift wird von der Schleimhaut der 
Conjunctiva und Vagina resorbirt. Eine Blasenbildung wurde nicht beobachtet. 
Was die Wirkung des Najagiftes auf einzelne Gewebssysteme und Organe betrifft, 
so konnte man beobachten an Nerven : 
Die Bewegungslosigkeit der vergifteten Thiere rührt nicht von einer directen 
Lähmung der motorischen Nerven her. Man konnte an todten Kaninchen und Fischen 
dieselben mit Erfolg reizen. Bei Parallelversuchen mit normalen Fröschen, sowie 
einseitig unterbundenen Nervmuskelpräparaten, zeigte sich eine verminderte Reizbar- 
keit des vergifteten Nerven im Vergleiche zum intakten. Das elektrotonische Ver- 
halten zeigte eine Abschwächung des myopolaren Kat- und Anelektrotonus. 
Eine erhöhte Reflexerregbarkeit wurde ausnahmslos bei allen vergifteten Thieren 
beobachtet. 
Bei Kaninchen, Meerschweinchen und Katzen zeigte sich : Gesteigerte Puls- und 
Athemfrequenz, Erweiterung der Pupillen, Aufrichten der Ohren, Salivationen, Bre- 
chen, Zwangsbewegungen, Zwangsstellungen und Coordinationsstörungen, Convul- 
sionen, bis zum Zusammenfall. Bei Tauben gesellt sich dazu das Unvermögen, zu 
fliegen, trotzdem zweckmässige Bewegungen dazu stattfinden. Auf optische und 
acustische Reize reagiren erwähnte Säugethiere gut. Enthirnt man Frösche, so zeigen 
sich keine abweichenden Vergiftungsphänomene in Bezug auf Dauer oder Bewegungs- 
erscheinungen ; vergiftet man jedoch das Rückenmark eines decapitirten Frosches, so 
stellt sich Strychnintetanus ein. Post mortem weist das Gehirn der Säuger stark 
injicirte Gefässe der Pia auf. 
Vorherige doppelte Vagusdurchschneidung bei Kaninchen, mit darauffolgender 
Giftinjection erschien indifferent in Bezug auf Athmung und Herzschlag. 
Die Muskeln der vergifteten Thiere als System zeigten keine Abnormitäten. Wurde 
Gift direct in einen Muskel (M. gastrocnemius) injicirt, so erhielt man beim Frosche 
etwas verminderte Reizbarkeit auf directe elektrische Reize. Muskeln unmittelbar 
verendeter Kaninchen reagiren physikalisch und chemisch gleich denen normaler. Der 
Rigor mortis tritt bald post mortem ein und ist sehr stark. 
Die verschiedenen Drüsen betreffend, so secerniren die Frösche (früher abge- 
trocknet) ihr Hautsekret nach der Vergiftung sehr reichlich. Vögel und Säugethiere 
bekommen Salivationen und Regurgitationen. 
Bei der Section erscheint die Leber schwammig, leer und leicht zerreissbar, die Milz 
zusammengeschrumpft, das Pancreas als in voller Thätigkeit gewesen. 
Weder das Herz der Kalt- noch der Warmblüter scheint direct beeinflusst zu 
werden. Parallelversuche an ausgeschnittenen Froschherzen in physiolog. Kochsalz- 
lösung ergaben häufige Contractionen des vergifteten unmittelbar nach der Injection 
von Cobragift. Diese vermehrte Frequenz weicht bald einer constanten Abnahme. 
Vagisection ändert bei Kaninchen an der Frequenz wenig. 
Die Respirationen nehmen gleich den Herzstössen an Zahl erst zu und dann constant 
ab. Künstliche Athmung bei Erzeugung von Apnöe bewirkte in drei Fällen bei 
Kaninchen verlängerte Vergiftungsdauer ; die Thiere gingen nicht wie sonst in einer 
halben, sondern in bis 2 Stunden zu Grunde. Die Lungensäcke der vergifteten 
Frösche erscheinen collabirt, hyperäsmisch and bläulich ; die Lungen der Säugethiere 
hellroth mit hämorrhagischen Herden. 
Eine Wirkung des Cobragiftes auf das Blut, resp. einer oder mehrerer seiner Bestand- 
theile, konnte mit dem Holm-Green'schen Apparate an den Capillaren der Froschlunge 
beobachtet werden. Die geradlinig verlaufende Capillare nimmt wellenförmige Con- 
touren an, nachdem vorher durch die V. hypogastrica das Cobragift injicirt wurde. 
Vol. Ill-5 66 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Die rothen Blutkörperchen werden deformirt, indem sie Stechapfelform annehmen. 
Der Blutdruck (gemessen an Kaninchen) wird durch das Cobragift, wenn auch in 
geringem Maasse, doch constant etwas erhöht. Blut von Fröschen und Kaninchen 
direct mit Cobragift versetzt, nimmt eine schmutzig-rothbraune Färbung an. Das 
Blutspectrum wird durch das Cobragift verändert. An der injicirten Stelle zeigt sich 
ein missfarbiger, dunkelrother Fleck, um den sich ein heller Hof bildet ; die Gefässe 
um dieselbe in einer weiten Ausdehnung sehr stark injicirt. 
Die Harnblase der vergifteten Säugethiere war stets stark gefüllt ; am Harn nichts 
Auffälliges zu bemerken. 
Die Körpertemperatur eines winterschlafenden Igels, dem 0,03 Cobragift injicirt 
wurden, stieg binnen f ünf Stunden um 3° C. bei constanter Zimmertemperatur. Eine 
leichte Erhöhung der Temperatur ist bei Säugethieren in der Agonie wahrnehmbar 
und hält bei Katzen noch post mortem eine halbe Stunde an. 
Die Frage nach einem Antidot des Cobragiftes betreffend, so wurde davon ausge- 
gangen, erst die Wirkungsweise des Giftes kennen zu lernen, um dann weitere Ver- 
suche zu unternehmen. Die Beantwortung der Frage, ob das Agens des Giftes ein 
Ferment, ein Alkaloid oder eine Cyanverbindung, würde es in Verbindung mit den 
Ergebnissen des Experimentes erst ermöglichen, einen Erfolg für die Therapie 
zu erwarten. Denn die durch eine Speculation herbeigeführten Versuche zeigten, 
dass den wirkungslosen Substanzen anderer Autoren noch zuzuzählen seien : Borax, 
Salicylsäure und Curare. 
Eine Beschreibung der Experimente und extense Darstellung des Gegenstandes soll 
an anderer Stelle erfolgen. 
DISCUSSION. 
Dr. Phillips.-The method of collecting the poison was ingenious, and the report 
of its physical and physiological qualities is very interesting. 
Dr. Lewin.-Ich möchte gern den Vortragenden fragen, ob er das Blut spectro- 
scopisch untersucht hat. Es würde dies vielleicht gerade in Rücksicht auf die berich- 
teten microscopischen Veränderungen der rothen Blutkörperchen zu einem Resultat 
geführt haben. Denn es scheint ein gewisser Zusammenhang zwischen diesen beiden 
Punkten zu herrschen, wie es sich zum Beispiel nach der Vergiftung mit chlorsaurem 
Kali und anderen Giften zeigt. In Bezug auf die Gegengifte des Cobragiftes sei 
hervorzuheben, dass alle uns bekannten chemischen Antidote nur wirken, wenn sie 
an der Bissstelle mit allen Theilen des Giftes in Berührung gekommen sind. Es ist 
sicher, dass solche Stoffe, wiedas von Lacerda empfohlene Kalium permanganicum, 
in grosser Menge vorhanden sind. Doch sei auf den in neuerer Zeit aus Indien 
berichteten Punkt hinzuweisen, dass Schlangenbeschwörer in manchen vollkommen 
verzweifelten Fällen von Cobrabiss durch Inoculation eines unbekannten Stoffes com- 
plete Heilung erzielt haben. Es ist nicht von der Hand zu weisen, dass ein solcher 
chemisch wirkender, wahrscheinlich aber nur symptomatisch wirkender Stoff vor- 
handen ist. 
Dr. J. Gnezda.-Die Gestaltveränderung der rothen Blutkörperchen in Stech- 
apfelform ist als gebräuchlicher Terminus hiermit definirt. Die spectroscopische 
Veränderung des Blutes kann nicht eher als von einem bestimmten Körper herrüh- 
rend bezeichnet werden, bevor dieser Körper dargestellt ist. 
Dr. Lewin.-Die von dem Herrn Vortragenden gesehenen Streifen sind inter- 
essant ; aber ähnliche nach der Linie D liegende drei (3) Streifen habe ich bisher 
nicht gesehen. Ich mache nochmals besonders auf die Wichtigkeit des Zusammen- 
hanges zwischen Veränderungen der rothen Blutkörperchen und chemischen Verän- SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
67 
derung des Blutes aufmerksam und verweise in dieser Beziehung auf die Unter- 
suchungen von mir und C. Posner über das Methämoglobin und Hämatin. 
Dr. F. Woodbury.-The results of the investigations of the lecturer were in the 
same line as those of Mitchell and Reichert upon the poison of the rattlesnake. It 
will be remembered that these observers reported the finding of two proteid toxic 
substances in the rattlesnake virus. The incident recorded in the life of Buckland 
gives a good idea of the effect of the cobra poison upon man, and shows that ammo- 
nia and brandy will save life provided that only a small amount of the poison has 
entered the circulation. 
Dr. Traill Green.-The question of the treatment of snake poison has interested 
me for many years. In one instance, in which a rat died instantly when struck by the 
snake, I found that the fang had penetrated the jugular vein. The toxic effect 
may be prevented if the virus does not enter the circulation. 
Dr. L. Lewin, of Berlin, read a paper- 
ÜBER DIE MAXIMALDOSEN DER MEDICAMENTE. 
ON THE MAXIMAL DOSES OF MEDICINES. 
SUR LES DOSES MAXIMUM DE MÉDECINES. 
VON DR. L. LEWIN. 
Von den vielen Schwierigkeiten, mit denen die Pharmakotherapie zu kämpfen hat, 
ist nicht die geringste die Dosirung der Medicamente. Es kann wohl der Satz ausge- 
sprochen werden, dass jede übliche Dosirung einer Arzneisubstanz unzuverlässig ist 
und immer nur einen Versuch darstellt. Die Gründe hierfür sind einleuchtend genug; 
von den wesentlichen führe ich nur an : 
I. Die Verschiedenheit 
«) der Menschen untereinander ; 
b) des einzelnen Individuums zu verschiedenen Zeiten ; 
c) in der Intensität der Erkrankung der Menschen an ein und demselben Leiden; 
d) der Krankheiten unter sich, gegen die das gleiche Arzneimittel gebraucht wird. 
II. Die Schwankungen in der Wirksamkeit eines grossen Theiles unserer Arznei- 
stoffe. 
Von dem wesentlichen Einflüsse dieser und anderer Factoren ist man von jeher 
überzeugt gewesen. Dieselben lassen sich jedoch im einzelnen Falle wenig oder gar 
nicht in Berücksichtigung ziehen, weil der grössere Theil derselben der menschlichen 
Erkenntniss wahrscheinlich für immer verschlossen bleiben wird. Man suchte deshalb 
bis in unsere Zeit hinein die Dosirung der nicht, oder nur erst in sehr grossen Mengen 
heroisch wirkenden Heilmittel so zu gestalten, dass man gewisse, meist durch Empirie 
gewonnene Durchschnittsdosen als normale ansieht, und bei dem Gebrauche derselben 
auch die Individualität, soweit es angeht, berücksichtigt. Nur in einigen Pharmako- 
poen, wie z. B. der britischen und spanischen, sind diese, gewissermaasseu traditionellen 
Arzneiangaben freilich nur zur Information der Aerzte und ohne bindende autoritative 
Kraft angegeben worden. 
Äusser diesen Durchschnittsdosen besitzen aber die Pharmakopoen der meisten 68 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Staaten gesetzmässige Feststellungen der einzelnen und der täglichen Gabe, oder wie 
die schwedische und norwegische Pharmakopoe nur für die Einzeldosis, von solchen 
Stollen, welche eine Wirkung schon in relativ kleiner Menge eintreten und beim Steigern 
der Dosen leicht Giftwirkungen erscheinen lassen. Die Nothwendigkeit solcher maxi- 
malen Dosirung, die selbstverständlich nicht das freie Ermessen einer Ueberschreituug 
ausschliesst, leuchtet ein, wenn man bedenkt, dass gerade die unzweckmässige Verab- 
folgung derartiger Substanzen leicht zu schwerer Schädigung der Gesundheit führen 
kann. Dem Arzte wird dadurch, nicht als absolute Vorschrift, sondern zur warnenden 
Belehrung, eine approximative Grenze für sein Verschreiben angegeben. Es wäre sehr 
zu wünschen, dass die Staaten, welche eine solche officielle Begrenzung von Arznei- 
dosen bis jetzt nicht besitzen, dieselben einführten. Es würden dann z. B. die An- 
klagen beim Eintreten einer perversen Arzneiwirkung, denen der Arzt am leichtesten 
da ausgesetzt ist, wo keine derartigen Bestimmungen vorhanden sind, nicht vorkommen 
können. 
Zwei Gruppen von Präparaten fallen in den Bereich dieser Maximaldosen. 
1) Pflanzen, rohe Pflanzenprodukte und pharmaceutische Darstellungen aus den- 
selben. 
2) Chemisch einheitliche, wohlcharakterisirte Substanzen, wie Metalloide, Metall- 
salze und Kohlenstoffverbindungen. 
Die erstgenannten Stoffe sind an sich ihrem Wirkungswerthe nach fast insgesammt 
inconstant, und soweit die galenischen Präparate hierbei in Frage kommen, weisen sie 
ausserdem noch bedeutende Verschiedenheiten in ihrer Wirkung auf, weil eine inter- 
nationale Uebereinstimmung in der Darstellung sich bisher nicht hat ermöglichen 
lassen. Die Arzneimittel der zweiten Gruppe sind dagegen überall gleichwerthig 
herstellbar und äussern demnach ceteris paribus die gleichen Wirkungen. Die 
Grenzdosen, welche von diesen Stoffen nicht ohne triftigen Grund überschritten werden 
sollen, wurden durch Versuche an Gesunden und Kranken, durch Vergiftungen von 
Menschen und das Thierexperiment gewonnen. Trotzdem also die Basis hierfür eine 
ausreichend breite ist, sind doch die entsprechenden Angaben in den verschiedenen 
Pharmakopoen bei vielen Stoffen sehr verschieden. Diese Differenz ist hinsichtlich 
der ersten Gruppe verständlich, aber unbegreiflich, soweit die zweite in Frage kommt. 
Dieser Punkt bildet den Anlass zu der vorliegenden Auseinandersetzung und den 
sich daran knüpfenden Vorschlägen. Wäre es möglich, alle starkwirkenden galeni- 
schen Präparate international in gleicher Weise darzustellen, so wäre damit auch die 
Möglichkeit einer allgemeinen gleichen maximalen Dosirung aller hierhergehörigen 
Stoffe gegeben. Ich halte dies aber bis auf weiter für unerreichbar. Dagegen lässt sich 
sehr wohl die zweite Gruppe und ein Theil der ersten der mit maximaler Dosis zu ver- 
sehenden Stoffe in dieser Beziehung äqualisiren. Die Wichtigkeit einer derartigen 
Ordnung liegt auf der Hand. Der jetzt so rege internationale Verkehr, die Thatsache, 
dass Recepte des einen Landes vielfach in einem anderen dargestellt werden und 
dadurch schwere Unzuträglichkeiten entstehen können, erfordert dringend, dass 
wenigstens das in dieser Beziehung Erreichbare erstrebt wird. 
Die bisher bestehende Ungleichheit in der Dosirung und der Auswahl der bezeich- 
neten Substanzen sind zum Theil ausserordentlich beträchtlich. So wird Codein in der 
Pharmakopöa Hungarica (1871) zu 0.03 grm. maximal begrenzt, in der Pharmakopöa 
Swedica (Ed. vn) zu 0.25 grm. Die Pharmakopöa Neerlandica versieht die verdünnten 
Mineralsäuren mit einer solchen Grenzzahl, während sie Guttæ davon frei lässt. 
Ausserdem aber vermag ich auf Grund meiner toxicologischen Studien mit Bestimmt- 
heit auszusprechen, dass manche dieser officiellen Angaben einer wissenschaftlichen 
Basis entbehren und schon aus diesem Grunde einer Revision bedürfen, andere für den 
Arzt bequemer eingerichtet werden können, ohne dass dadurch wesentlich an dem 
Erfolge der Dosen etwas geändert wird. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
69 
Ich habe deswegen mit Berücksichtigung meiner eigenen Forschungen und der 
meisten Pharmakopoen, welche maximale Dosen anf ühren, einen Entwurf der Stoffe 
verfasst, welche zu der von mir skizzirten, zweiten Gruppe gehören, und sie mit den 
Grenzzahlen versehen, die ich als empfehlenswerth ansehe. Jeder Pharmakopoe, auch 
denen, die nicht maximale Dosen enthalten, sollte eine solche Tabelle im allgemeinen 
Interesse beigef ügt werden, um den Arzt in den Staud zu setzen, auch stark wirkende 
einheitliche Präparate, die in seiner Heimath nicht officinell sind, in richtiger Menge 
verschreiben zu könuen. 
Es wäre zu wünschen, dass von dem internationalen Congresse aus der Anstoss 
gegeben wird, diese Materie in dem hier betonten Sinne international and bald zu 
regeln. 
ENTWURF ZU EINER INTERNATIONALEN MAXIMALEN DOSIRUNG 
GLEICHMÄSSIG DARSTELLBARER HEILMITTEL. 
Pro 
dosi. 
Pro 
die. 
Pro 
dosi. 
Pro 
die. 
Acidum arsenicosum 
0.005 
0.02 
Hyoscyaminum crist 
0.01 
0.04 
Acidum carbolicum 
0 2 
0.6 
lodoformium 
0.2 
0.6 
Acidum oxalicum 
0.4 
1.0 
Iodol 
0.2 
0.6 
Aconitinum crist Duquesnel 
0.001 
0.003 
lodum 
0.1 
0.4 
Apomorphinum hydrochloric 
0.01 
0.04 
Kalium bichromicum 
0.03 
0.1 
Argentum nitricum 
0.05 
0.2 
Kalium chloricum 
2.0 
10.0 
Arsenicum jodatum 
0.01 
0.04 
Kalium cyanatum 
0.03 
0.1 
Atropinum sulfuricum 
0.002 
0.005 
Kalium osmicum 
0.03 
0.1 
Auro-natrium chloratum 
0.05 
0.2 
Kalium sulfuratum 
0.5 
2.0 
Barium chloratum 
0.4 
1.0 
Kreosotum 
(1* Ac. 
0.2 
0.6 
Bromum 
0.05 
0.2 
Liquor kalii arsenicosi 
0.5 
2.0 
Brucinum 
0.1 
0.4 
arsenicosum) 
Caffeïnum 
0.4 
1.0 
Morphinum 
0.03 
0.1 
Chininum sulfuricum 
2.0 
4.0 
Morphinum sulfuric, u. 
hydro- 
Chloralum hydratum 
2.0 
4.0 
chi 
0.03 
0.1 
Coeainum hydrochloric 
0 2 
0.6 
Narcelnum 
0.1 
0.4 
Codeinum 
0.1 
0.4 
Narcotinum 
0.5 
2.0 
Colchicinum crist 
0.005 
0.02 
Natrium arsenicicum 
0.005 
0.02 
Coniinum 
0.002 
0.005 
Nicotinum 
0.002 
0.005 
Coniinum hydrobromatum 
0.05 
0.2 
Nitroglycerinum 
0.002 
0.005 
Cuprum sulfuricum 
1.0 pro 
emetico. 
Oleum croton is 
0.05 
0.2 
Delphininum 
0.01 
0.04 
Opium (10 $ Morphin) 
0.2 
0.6 
Digitalinum crist. Nativelle 
0.001 
0.003 
Papaverin um 
0.4 
1.0 
Digitalinum crist. Homolle 
0.002 
0.005 
Phosphorus 
0.005 
0.02 
Duboisinum sulfuric 
0.002 
0.005 
Physostigminum salycilic 
0.002 
0.005 
Ferrum arsenicicum 
0.01 
0.04 
Pikrotoxinum 
0.01 
0.04 
Homatropinum hydrobromic 
0.01 
0.04 
Pilocarpinum hydrochlor. 
0.03 
0.1 
Hydrargyrum bichloratum 
0.03 
0.1 
Plumbum aceticum 
0.2 
0.6 
Hydrargyrum bijodatum 
0.03 
0.1 
Santoninum 
0.2 
0.6 
Hydrargyrum chloratum 
1.0 
2.0 
Sparteïnum sulfuricum.... 
0.2 
0.6 
Hydrargyrum cyanatum 
0.03 
0.1 
Stibium sulfurât, aurant... 
0.2 
0.6 
Hydrargyrum jodatum 
. 0.1 
0.4 
Strychninum 
0.01 
0.04 
Hydrargyrum nitric, oxydul 
0.03 
0.1 
Strychninum nitricum.... 
0.01 
0.04 
Hydrargyrum oxydatum 
0.03 
0.1 
Tartarus stibiatus 
0.2 
0.6 
Hydrargyrum oxydul. nigr 
0.2 
0.6 
Veratrinum 
0.01 
0.04 
Hydrargyrum sulfuric, basic 
0.4 pro 
refr. 
emetico 
dosi. 
Zincum chloratum 
Zincum cyanatum 
0.03 
0.03 
0.1 
0.1 
Hyoscinum hydrojodic. u. hydro- 
0.002 
0.005 
Zincum sulfuricum 
1.0 pro 
emetico. 
brom 70 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ENTWURF ZU EINER INTERNATIONALEN MAXIMALEN DOSIRUNG 
GLEICHMÄSSIG DARSTELLBARER HEILMITTEL. 
Pro 
dose 
Pro 
die. 
Pro 
dosi. 
Pro 
die. 
Aconitinum crist. 
Argentum nitricum. 
0.001 
0.003 
Digitalinum nativelie. 
Auro-natrium chloratum. 
Atropinuin sulfuric. 
0.05 
0.2 
Bromuni. 
Coni in uni 
Coniinum hydrobromatum. 
Digitalinum Honiolle <t Quevenne. 
Oleum crotonis. 
Duboisinum sulfuricum. 
Brucinum. 
0.002 
0.005 
Hyoscinum hydrojodicum u. hydro- 
Cadeinum. 
bromic. 
0.1 
0.4 
Hydrargyrum jodatum. 
Nicotinum. 
lodum. 
Nitroglycerinum. 
Narcelnum. 
I'li ysost igm in um sal icy licum. 
Acidum carbolicum. 
Acidum ärsenicosum. 
Cocainum hydrochloricum. 
Colchicinum. 
Hydrargyrum oxvdulatum nigrum. 
0.005 
0.02 
Natrium arsenicicum. 
lodoformium. 
Phosphorus. 
lodolum. 
Apomorphinum hydrochloric. 
0 2 
0 fi 
Kreosotum. 
Arsenicum jodatum. 
Opium. 
üelphininum. 
Plumbum aceticum. 
Ferrum arsenicicum. 
Santoninum. 
0 01 
0 04 
Homatropinum hydrobrom. 
Sparteïnum sulfuricum. 
Hyoscyaminum crist. 
Stibium sulfurât, aurantiacum. 
Pikrotoxinum. 
Tartarus stibiatus. 
Strychninum. 
0.4 
I 
lydrargyrum sulfuric, basic. 
Strychninum nitricum. 
Acidum oxalicum. 
Veratrinum. 
Barium chloratum. 
Hydrargyrum bichloratum. 
1.0 
Caffeinum. 
Hydrargyrum bijodatum. 
Papaverinum. 
Hydrargyrum cyanatum. 
Liquor kalii arsenicosi. 
Hydrargyrum nitric, oxydulatum. 
0.5 
2.0 
Kalium sulfuratum. 
Hydrargyrum oxydatum. 
Narcotinum. 
Kalium bichromicum. 
Cuprum sulfuricum. 
v.vo 
0.1 
Kalium cyanatum. 
Zincum sulfuricum. 
Kalium osmicum. 
1.0 
2.0 
1 
lydrargyrum chloratum. 
Morphinum et ejus salia. 
2 o 
Chininum sulfuricum. 
Pilocarpinum hydrochloric. 
«•V 
Chloralum hydratum. 
Zincutn chloratum. 
2.0 
10.0 
falium chloricum. 
Zincum cyanatum. 
DISCUSSION. 
Dr. F. Woodbury.-It is known that the doses of medicines must vary according 
to circumstances. Patients recovering from mania a potû may take an ounce of chloral 
hydrate without any ill effect ; others are dangerously affected by ten grains. More- 
over, patients may take a certain quantity for a dose for a long time and regard it as 
a safe dose, and yet on some occasion this same dose will rapidly bring on fatal coma. 
I have observed that fatal cases occur after eating a meal. Is it possible that chlo- 
roform might be liberated, when chloral is given during digestion, so that it comes in 
contact with the bile, which is a highly alkaline fluid? In some patients even the 
smallest quantity of chloral is fatal. 
Dr. H. G. Bf.yer, U. S. Navy.-The remarks just made remind me of a paper 
by Dr. Mayer, which appeared in the Archiv für Pathologische Pharmacologie, and in 
which the author tried to prove experimentally that the action of chloral hydrate, as 
well as that of trichloracetic acid, and, in fact, all other halogen derivatives of organic 
compounds, produce their effects by the chlorine which they contain, which, indeed, is 
said to be set free whenever these compounds are brought into an acid medium. The 
cells of the cerebrum are supposed to react slightly acid during intellectual activity. 
When trichloracetate of sodium is injected into the blood the chemical is decomposed, 
chlorine set free, and sleep is produced, or intellectual torpor, in the same manner as 
that is done by chloral hydrate. 71 
SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
Dr. Stockman.-It is not probable that the small amount of chloroform liber- 
ated by decomposition of an ordinary dose of chloral would be more injurious than 
the chloral hydrate, which is itself a direct muscle poison. It is known to all as a 
depressing agent to the heart, and ether is, therefore, much safer as an anaesthetic. 
On the other hand, there is a good deal of dissatisfaction felt with chloral on account 
of this depressing action. 
The following paper was read :- 
THE EMMENAGOGUE ACTION OF THE MANGANESE 
PREPARATIONS. 
L'ACTION EMMENAGOGUE DES PRÉPARATIONS DU MANGANESE. 
DIE EMMENAGOGE WIRKUNG DER MANGANPRÄPARATE. 
BY JOHN N. UPSHUR, M.D. 
Richmond, Va. 
Empiricism in medicine, we desire to avoid, so far as may be, and in this modern 
age the ever increasing tendency to exactness makes it obligatory upon us as physi- 
cians to administer remedies intelligently and not by a system of guessing. When 
Murrell and Ringer suggested the Manganese Preparations as a remedy in the treat- 
ment of amenorrhoea, an important advance was made in the medication of this 
affection. But it remains forthem er others to systematize and arrange, and determine 
when properly to exhibit the remedy, and when it should be withheld. Careful obser- 
vations were necessary in order that useful deductions might be drawn and definite 
rules of administration formulated. 
This was the more needful because of the multiple causes which may give rise to 
menstrual disorders, and hence the importance of carefully scanning not only all forms 
of amenorrhoea, but of dysmenorrhœa also. 
Furthermore, it is important that we should investigate the remedy as to its physio- 
logical action, that we may fully comprehend the manner in which the beneficial 
results accrue, or the cause of failure when no benefit is derived. It is thus, and thus 
alone, that we can intelligently arrive at sound conclusions with regard to this or any 
other remedy. 
And first let us interrogate this agent as to its physiological action on the system, 
see to what beneficial results are to be ascribed, and why, if there should be, any choice 
in the particular preparation selected for exhibition. The virtue of the remedy, of course, 
is found in the manganese base. 
PHYSIOLOGICAL ACTION. 
The only definite knowledge we have of the action of the manganese preparations 
is in the local action of the Permanganate of Potash when used as a deodorizer and 
disinfectant, its value being based upon the readiness with which it parts with its 
oxygen. This, as well as other manganese preparations, is easily decomposed in the 
presence of any organic matter, giving up its oxygen freely. Bruce says of its action 
internally, that nothing definite is known (Materia Medica, p. 83). The readiness of its 
decomposition tends to prove that it enters the blood in some nascent form, and 
possibly may exert its influence on the uterus and appendages through the stimulant 
influence of the oxygen on the red blood globules, and by diminishing the lymph 72 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
constituent of the blood, thereby diminishing its plasticity, and thus promoting the 
increased fluidity of the vascular fluid, it antagonizes inflammatory action, so far as 
the endometrium is concerned. Or the stimulant influence of the blood nutrition, by 
virtue of an increased amount of oxygen contained, so influences the innervation of 
the ovaries and tubes as to effect a healthy, or at least, improved molimen. 
In considering these agents the fact that manganese is found in combination with 
iron in its mineral state, is likewise contained, though in small proportion, in the blood 
and a few other tissues, that it is sometimes exhibited in anæmic or cachectic blood 
states as a substitute for iron, gives us at least a hint as to the modus of its action in 
the treatment of menstrual disorders. 
Biddle tells us that "in small doses it improves the appetite, promotes digestion, 
and the body gains weight ' likewise, that ' ' in large doses cardiac action is depressed 
and the blood pressure lowered" (Materia Medica, 10th Ed., p. 139). Permanganate of 
potash, like others of the potash salts, is regarded as an alterative ; here we have a 
pointer, in another direction, of the mode of action in menstrual disorders. 
Bartholow says it enters the blood as an albuminate,that in large 
doses it produces effects analogous to the salts of zinc-progressive wasting and feeble- 
ness, staggering gait and paraplegia (Materia Medica, 5th Ed., pp. 136-7). Here we 
have suggestions of action, definite and pronounced, upon the spinal cord or its mem- 
branes, through the vascular supply. 
Brunton tells us that manganese salts have the power of interference with the 
transverse conduction power of the cord (Materia Medica, p. 640), but he does 
not even give us a suggestion of how this is effected. May it not be that reflex action, 
thus modified by smaller doses of these salts, the resultant action on the vasomotm 
nerves supplying the uterine blood vessels may permit dilatation of the uterine arteri- 
oles, and the consequence is an increased and easier flow of blood at the time of the 
period. There is no evidence, so far as I know, to show, or even suggest, that the agent 
under discussion possesses any ecbolic power, therefore its action must of necessity be 
in a different direction from stimulation to uterine contraction. 
Having thus considered the action of the drug, it follows naturally that the morbid 
conditions for the relief of which it is exhibited must be carefully scanned. Every 
physician is familiar with the fact of how varied may be the causes of amenorrhoea. 
The age of the patient is primarily a factor. Has she arrived at the age of puberty ? If 
so, has she ever menstruated at all; if not, why not? Does the cause lie in arrest of 
development or malformation of the organs of generation ? Or is it located in the 
general system somewhere ? If the girl has once had her menses established, what is 
the cause of the arrest? Is it physiological, as pregnancy, or pathological, from some 
diseased condition susceptible of removal ? If she menstruates, what then are the con- 
ditions of the flow, scanty, painful, or irregular? Why these factors present? An 
answer to these questions gives us the various classes of cases to which the manganese 
preparations are now being daily administered. 
CHOICE OF PREPARATION AND MODE OF ADMINISTRATION. 
The two preparations usually administered are the permanganate of potash and 
oxide of manganese, and both, I believe, are best given in pill form. When an agent 
is so readily decomposed in the presence of any organic matter, its pharmacy must, of 
necessity, be difficult. Permanganate of potash is most easily made into pill with 
fuller's earth and administered in capsule. It is given in the dose of half a grain 
to two grains three times a day, after meals, beginning a week before the expected 
return of the period. The objection to its use being that it is so badly tolerated by 
the stomach that sometimes and in some subjects it is rejected almost as soon as swal- 
lowed, bringing with it the entire contents of the stomach, and, if this be not the case, SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
73 
it causes such an uncomfortable burning sensation in the stomach as to aroiise great 
opposition on the part of the patient to its administration. So great, indeed, is this 
aversion to it, that some patients who suffer most acutely at the time of the monthly 
period declare that they prefer to endure the pain, rather than tolerate the disagree- 
able effects of the remedy. This is the chief objection. I have not noted that it 
produces other disagreeable effects, except, perhaps, slight diarrhoea in a few subjects. 
To get the full effect of the remedy, it must be given before three successive periods. 
The oxide of manganese should be given in the form of gelatine-covered pills. It 
has the advantage of being far less disagreeable to the stomach than the permanganate 
of potash. It should be administered in one or two-grain doses, after meals. My habit 
is to give it for a month, sometimes two months, with a slight interval, beginning 
immediately after a period and continuously on through the succeeding one. If benefit 
accrue from its exhibition it is demonstrated by a more comfortable flow, indicated by 
increase in quantity, improvement in color, and abolition or diminution largely of 
pain. These results, if the drug is to do good, may be expected the first month. 
Finally, in what cases should the agent be exhibited and when withheld? In 
amenorrhæa due to an impoverished and cachectic condition of the blood, oxide of 
manganese, given in combination with some preparation of iron, will undoubtedly be 
of benefit. In that condition in which the amenorrhæa is due to defective vascular 
or nervous supply to the generative organs, benefit may be hoped for. When we have 
pain due to functional cause, as when no obstruction exists, but there is or has been 
some previously diseased condition which has left the endometrium in a state of abnor- 
mal congestion. Cold may have been contracted during a previous period, or there 
may have been an inflamed condition of the uterine mucous lining, due to an obstruc- 
tion which has been removed, such as a cervix previously stenosed or flexed. In those 
cases in which we see vicarious menstruation. In amenorrhæa due to plethora and 
obesity. Here I would recommend larger doses, as it is claimed, as part of its physio- 
logical action, that it has the power of producing waste and lowering blood pressure. 
When existing in patients accustomed to self-indulgent and luxuriant habits. This 
class of patients are especially prone to menstrual disorders. In fine, when the menstrual 
derangement is due to functional and not mechanical or obstructive cause. Especially am 
I inclined to the opinion that the agent under consideration is of decided benefit in 
membranous dysmenorrhœa. Though I have seen a number of cases benefited, I have 
not seen a sufficient number to speak positively. Take a single case, by way of illus- 
tration. Mrs. T. C. W. suffered as a girl from anteflexion and consequent dysmenor- 
rhœa. After the cervix had been slit posteriorly by her physician, and the endome- 
tritis, from which she coincidently suffered, had been cured, she married, soon became 
pregnant, and I delivered her at full term, after a short and unusually easy labor. She 
developed puerperal septicaemia, and had a protracted and dangerous illness. In a few 
months after her recovery she began to suffer again at her periods, the suffering increas- 
ing, and she soon developed well-marked membranous dysmenorrhœa, which, despite 
all treatment, and marked improvement of the uterine disease, persisted, and each 
month a tough, fibrous membrane was cast off from the uterine cavity. The first 
month after taking the manganese oxide there was a change in the constitution of the 
membrane ; it was thinner and more delicate ; she had amelioration in all of the trying 
symptoms she had so long endured. The second period after only a thin pedicle was 
thrown off, and by the third it had entirely disappeared. After the remedy was 
stopped the membrane was again seen, but never in as aggravated a form as before. 
This same patient also complained of great lassitude and debility after a protracted use 
of the remedy. 
These preparations are contraindicated in those conditions of the system in 
which the amenorrhæa is a conservatism of nature, serious organic disease of some 74 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
vital organ being the cause. Also in another class of cases, in whom they produce the 
most intense headache. These patients are not only forced to discontinue it in a few 
days, but if they have the fortitude to persist, my experience has not gone to prove 
that the menstrual derangement was in any degree corrected by it. In other patients, 
it seems to cause suffering by the intense nervousness which seems to follow its admin- 
istration, and though they may derive some benefit, it is not to be confidently looked 
for. Analysis of the cause back of this will show the existence of ovarian irrita- 
tion, hypertrophy or inflammation, and that they have long been the subjects of serious 
uterine disease. 
Thus, I have endeavored, in some measure, to formulate the conclusions of a large 
use of this remedy; how imperfectly I have done so none can be better aware than 
myself. I trust, however, that what I have said may be, in some measure at least, a 
stimulus to others to closer and more accurate investigation. 
FORMULA FOR OFFICIAL DILUTE HYDROBROMIC ACID OF THE 
UNITED STATES PHARMACOPOEIA. 
FORMULE POUR L'ACIDE HYDROBROMIQUE DÉLAYÉ OFFICIELEMENT DE LA 
PHARMACOPÉE DES ETATS UNIS. 
FORMEL FÜR DIE OFFICIELLE VERDÜNNTE BROMWASSERSTOFFSÄURE DER 
PHARMAKOPOE DER VEREINIGTEN STAATEN. 
DE WITT CLINTON WADE, M. D., 
Holly, Michigan. 
In 1874 I produced hydrobromic acid by the decomposition of bromide of potassium 
with two equivalents of tartaric acid, and immediately commenced the study of its 
therapeutic properties. My first paper appeared in the Peninsular Medical Journal 
(Detroit), in February, 1875. Previous to these dates this acid had not been made by 
this process, and had never been used or written upon as a medicine. It is now in 
general use in all countries, and the therapeutic and pharmacological literature regard- 
ing it has been many times enriched in all languages. My original formula, which 
was designed to make each fluid drachm of the finished product represent ten grains 
of bromine, was published thousands of times, and I have reason to believe is in general 
use to-day. The last revision of the United States Pharmacopoeia made dilute hydro- 
bromic acid official, and its strength equaling ten per cent, of acid. Since this revision 
I have seen no formula published for the production of the official acid by the decom- 
position of bromide of potassium with tartaric acid. As the requirements of the Phar- 
macopoeia give an acid representing only about sixty per cent, of the amount of bromine 
contained in my formula, and as I am quite sure, from a personal examination of the 
subject, that there is a great lack of uniformity in the strength of the acid being dis- 
pensed in this country, it would appear none too early to present a formula for the 
production of the official acid that is at once the simplest to adopt, and as has been 
shown by years of application, is free from objectionable features. The formula is as 
follows:- SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
75 
Take of- 
Bromide of potassium four (4) avoirdupois ounces. 
Tartaric acid five (5) avoirdupois ounces. 
Water seven (7) fluid ounces. 
Dissolve the salt in the water, and add the acid. When thoroughly mixed set aside 
in the cold, for the precipitation of the resulting bitartrate of potassium. Decant the 
supernatant fluid and dilute it with sixteen fluid ounces of water. The result is a ten 
per cent, solution, by weight, of hydrobromic acid. 76 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIFTH DAY. 
The President in the Chair. 
The following paper was read by title :- 
COLLINSONIA CANADENSIS. 
BY JOHN V. SHOEMAKER, A.M., M.D., 
Of Philadelphia, Pa. 
Collinsonia Canadensis, commonly known as stone root or knob root, is one of the 
most valuable of indigenous American medicinal plants. It is w idely distributed, being 
found in richly wooded soils, from April to October, in all sections of the United 
States. 
It possesses a rank aromatic odor, and is hot and somewhat pungent to the taste. 
Its principal medicinal constituent appears to be a volatile oil, which is driven off by 
boiling or drying. 
All parts of the plant may be used in medicine, but the root is the most powerful, 
and the portion usually employed. As it yields its virtues to water and alcohol it may 
be administered in the form of a powder or as the tincture, the fluid extract or the infu- 
sion. The dose of the powdered root varies from ten to sixty grains, that of the tinc- 
ture from twenty drops to two drachms, the fluid extract from fifteen minims to a 
drachm, the infusion from one to four ounces. 
The physiological action of Collinsonia has not been accurately studied. Small 
doses do not appear to produce any effect upon healthy persons, except a sensation of 
warmth in the stomach and bowels ; large doses produce diaphoresis and nausea, fol- 
lowed in some cases by repeated but painless vomiting. 
Collinsonia is highly esteemed in many sections of the country as a domestic remedy 
for gravel and other urinary affections. Clinical observation indicates that its power is 
not limited, by any means, to this class of disorders. 
It appears to be especially valuable as a sedative and antispasmodic. It is also 
possessed of considerable astringent and tonic properties. The popular belief in its 
efficacy in promoting the expulsion of urinary calculi is well founded. It relaxes the 
spasm of the ureters, or of the urethra, and by increasing the flow of urine, and by 
lessening the sensitiveness of the genito-urinary membrane, facilitates the expulsion of 
small concretions. When they are of large size, collinsonia is powerless to either dis- 
solve or expel them, but it will alleviate the sufferings of the patient by diminishing 
the irritability of the bladder and urinary canal until complete relief is afforded by sur- 
gical methods. 
Acute cystitis can be more quickly relieved by collinsonia combined with aconite 
and morphia, than by the administration of any other remedial agents. In two cases 
of this painful affection treated by me during the last four months in this manner, the 
patients were free from pain and fever on the fourth day, and discharged, cured, one SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
77 
on the eighth and the other on the eleventh day. Cases previously treated without 
collinsonia invariably lingered from two to three weeks, and suffered for six or eight 
days from pain and vesical tenesmus. 
I have not had an opportunity to try this remedy in chronic cystitis, but reasoning 
from analogy, it should be similarly efficacious in that tedious and troublesome affection. 
Incontinence of urine in children due to spasmodic contraction of the bladder can be 
permanently relieved by the administration of one drachm of the tincture of collinsonia 
after supper and at bedtime, for several nights in succession. 
Nervous individuals who may or may not have suffered from gonorrhoea not unfre- 
quently complain that one or two minutes after having urinated and readjusted their cloth- 
ing several drops of urine will involuntarily ooze out, staining their clothing and produc- 
ing an unpleasant odor, which they imagine every one around them can perceive. This 
trivial but annoying affection is due to hyperæsthesia of the prostatic urethra or of the 
neck of the bladder, and can be effectually removed by the persistent use of the fluid 
extract of collinsonia, in twenty-drop doses, four times a day. In chronic gonorrhoea, 
when copaiba, cubebs and oil of sandalwood have failed to arrest the discharge, or have 
been rejected by the patient's stomach, drachm doses of the fluid extract of collinsonia, 
given every four hours, will not unfrequently effect a cure. Leucorrhœa and prostator- 
rhœa may be relieved or cured in the same manner. 
Constipation, hemorrhoids, rectal neuralgia, and vague pelvic or abdominal symp- 
toms are due, more frequently than is generally supposed, to spasm of the sphincter ani. 
Dr. J. M. Matthews, of Louisville, Kentucky, has shown that prompt relief can be 
obtained in such cases from division or forcible dilation of the refractory muscle. My 
experience, though limited to three cases, leads me to believe that the persevering 
employment, every night, of suppositories containing from forty to ninety grains of the 
powdered collinsonia root will, in many cases, render any operative procedure unneces- 
sary. 
The first patient was a woman, forty-five years old, who suffered for years from 
darting pains in the rectum, especially severe just before defecation. She had visited 
numerous celebrated springs, and consulted several regular and irregular physicians, 
without obtaining marked relief. When she placed herself under my care, I instituted 
a general tonic, anti-neuralgic treatment, combined with suitable laxatives. Her gen- 
eral health improved almost immediately, but the local disorder remained stubborn. 
Finally, suspecting the existence of an anal fissure or ulcer, I made an examination of 
the rectum, but discovered nothing abnormal but the vise-like grasp in which the 
finger or the speculum was held by the sphincter muscle. Suppositories composed of 
opium, opium and belladonna, opium and quinine, were then ordered, in succession, and 
successively failed to more than temporarily relieve. I then decided to either divulse 
or incise the sphincter, but being desirous to ascertain the relative merits of the opera- 
tions, I ordered her, as a placebo, four suppositories, each containing thirty grains of 
powdered collinsonia, with instructions to use one every night, as* usual. To my sur- 
prise and gratification the patient appeared at my office two days afterward, and 
informed me that "the last cartridges which I had ordered for her had given her so 
much ease, that she used two a day instead of one, and wanted more of the same kind, 
as she was convinced that I had found 'the right cure at last.'" I questioned her 
closely, and found that her relief was genuine and not assumed, and that it began within 
an hour after using the first suppository. I then ordered eight more, containing forty 
grains each, instead of thirty, and directed her to use one night and morning. She 
returned on the sixth day and told me that after having used five she felt so well that 
she did not think it necessary to finish the rest. The improvement was complete and 
permanent. During the year and a half that has elapsed since then, she has consulted 
me twice for other troubles, but the rectal pain has never reappeared. 78 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The second case was a woman, thirty-five years old, and was similar to the pre- 
ceding one, and was cured in a week by collinsonia suppositories. 
The third case was that of a young man nineteen years old, who suffered from 
violent headache every second day. Inquiry revealed the fact that the headache was 
almost invariably accompanied by a feeling of weight in the abdomen and a desire to 
defecate, which could only be accomplished by much straining and repeated efforts, 
extending sometimes over a period of twenty to forty minutes. At the expiration 
of that time a large evacuation of the bowels usually occurred, followed by the 
immediate disappearance of the sense of weight in the abdomen, and the gradual 
cessation of the headache. The patient had taken all the varieties of pills in the market 
without any appreciable benefit, except when they left his stools thin and watery. 
As defecation was not preceded or accompanied by pain, and usually relieved the 
other symptoms, I concluded that there was no ulceration or fissure present, and that 
the trouble was due solely to spasmodic stricture of the sphincter ani. I ordered him 
four suppositories, containing one drachm each of powdered collinsonia, one to be used 
each night at bedtime. He returned in four days as bad as ever, and inclined to doubt 
the value of " those things." I encouraged him to try again, and ordered six more, 
each containing seventy-five grains. I did not see him again for two weeks, when he 
came back and stated that when he had used four he felt so good that he threw the 
other two away, but that the trouble had returned and was now' worse than ever. I 
then ordered eight suppositories, with ninety grains of collinsonia in each, and directed 
him to use one every second night, regardless of how well he might be. He obeyed 
these instructions faithfully, and during the five months which have since passed by he 
has not had any symptom of his former troubles. 
It is more than probable that vaginismus or spasm of the sphincter vagina can be 
readily and safely relieved without resorting to the ludicrous or painful methods nar- 
rated in the text-books, by the continued employment of vaginal suppositories of collin- 
sonia ; opium, belladonna, chloral, conium, hyoscyamus, or stramonium may be added 
if advisable. 
The antispasmodic properties of collinsonia render it of value in flatulent colic, 
infantile colic and biliary colic. It is especially serviceable in the latter affection, if 
given in the form of warm infusions, so as to thoroughly relax the biliary passages and 
facilitate the onward movement of the irritative calculi. 
The most available preparation in colic is the tincture, the dose of which ranges 
from ten drops to half a drachm for children, and from one to two drachms, frequently 
repeated, for adults. Collinsonia alone will be found quickly curative in many cases of 
colic, when unaccompanied by rise of temperature. It will not relieve lead colic, or the 
pain of peritonitis or entero-colitis. 
Collinsonia has proved curative, in my hands, in two cases of gastralgia, in which 
morphia, cannabis indica, belladonna and various other remedies only gave temporary 
relief. I also obtained markedly beneficial results from its use in five cases of dysmen- 
orrhœa. Each patient was directed to take half a drachm of the fluid extract three 
times a day, for a week before the appearance of the menses, and two drachms of the 
tincture every four hours during their continuance. In the first and fifth cases the 
pain, though previously severe, was not noticeable; in the remaining cases it was so 
much lessened that the patients pursued their daily avocations as usual, one as a seam- 
stress, one as a saleswoman, and the other as a telegraph operator, instead of being com- 
pelled to stay in bed for two or more days. 
Ordinary colds and mild attacks of lumbago can be quickly broken up by taking a 
cupful of a hot infusion of collinsonia at bedtime. Spasmodic croup can be immediately 
relieved by the same means. 
Collinsonia is an effective remedy in relaxation of the uvula, chronic pharyngitis, and SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
79 
hoarseness dependent upon a lack of toncity of the vocal cords. The fluid extract 
may be given in these affections, in half drachm doses four times daily, and employed 
also as a gargle when diluted with four times its volume of water. It is also of value 
in gastro-intestinal catarrh and the catarrhal gastritis of beer and alcohol drinkers. It 
lessens the desire for liquor, restrains the secretion of mucus, and restores the normal 
tone of the alimentary canal, and reinvigorates the depressed nervous system. 
Collinsonia is equal, if not superior, to cimicifuga in the treatment of chorea, and 
may be substituted for arsenic, with advantage, in many cases of that disease occurring 
in infancy and early childhood. In three cases recently treated with collinsonia, all 
traces of the disease disappeared in from two to four weeks. It is but fair to state that 
the same remedy failed to make any impression on two previous cases. 
Collinsonia will be found palliative, if not curative, in whooping-cough, and may 
safely be given in that affection without the dread of disordering the stomach or pro- 
ducing any other unpleasant symptoms. It may also be given with confidence in 
nervous cough and the irritative cough of pharyngeal catarrh. 
Collinsonia is also of value, in moderate doses, as a mild but certain general tonic, 
increasing the appetite, promoting digestion, and gently stimulating all the organs 
of excretion. It may be given with decided benefit in anæmia, chlorosis, incipient 
phthisis, and convalescence from the various eruptive fevers. 
Externally it constitutes an excellent application to contused and incised wounds. 
Indolent ulcers may be stimulated to healthy action by an ointment consisting of one 
drachm of powdered collinsonia and one ounce of fresh lard. 
Ascarides may be effectually destroyed by rectal injection, composed of the fluid 
extract diluted with four parts of water. 
The following paper was read by title:- 
COLD WATER AND ICE AS REMEDIES IN INFLAMMATORY 
AFFECTIONS. 
EAU FROIDE ET GLACEE COMME REMEDES DANS LES AFFECTIONS INFLAM- 
MATOIRES. 
KALTES WASSER UND EIS ALS HEILMITTEL BEI ENTZÜNDLICHEN AFFEKTIONEN. 
BY HIRAM CORSON, M.D., 
Of Conshohocken, Pa. 
Sixty-three years ago an incident occurred-the death of a beloved niece, suffering 
with measles and tortured with hot teas, while begging for water, which filled my 
young heart with sorrow, and turned my attention to the value of cold water, not only 
as a drink, hut as a remedy in disease. From that day to this, as the years have rolled 
on, I have carefully and anxiously observed the effects of cold water and ice in all the 
diseases here noticed, as they have presented themselves. 
In entering on the practice of medicine, in 1828, in defiance, of the traditions handed 
down to us through ages, that cold water as drink in measles was injurious, and that 
hot teas and warm rooms were efficient to promote the eruption, I rejected these tradi- 
tions and the practice founded on them, from a belief that the instincts of the sufferer and 
the highly inflammatory nature of the malady demanded the use of cold water as a 
beverage, to cool the heated system, and that cold air, and, when needed, sponging the 80 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
surface of the heated body with cool or cold water, would be means of great value. 
So, though I knew not of a single physician who gave cold water as drink in measles, 
or allowed the patient to be in a cool room, I began its treatment by forbidding all 
warm teasand urging the use of cold water as drink. My directions were, "give the 
children as much cold water as they can drink; keep the room cool; if they become 
very hot, restless and uncomfortable, sponge the surface with cool or cold water, until 
they are relieved." How grateful this was to the little sufferers, no one can so well 
appreciate as those who, having been tortured with hot teas, have been relieved from 
their use and allowed plenty of cold water. But little medicine was given, and now, 
in fifty-nine years, not one of my hundreds of cases thus treated has been lost by 
death. For a history of these cases see a paper by me, in Philadelphia Medical and 
Surgical Reporter, May 16th, 1872. 
Even yet patients in many places fall victims to the hot treatment. Three years 
since a fine, strong boy of 12 years was brought, dead, from Philadelphia, thus treated; 
by positive direction of the physician forbidden cold water, and kept in a hot room. 
And this very year, August 27th, a lady from Philadelphia who had taken boarding for 
herself and child with a family near to me, where measles prevailed, told me she had 
asked her doctor what she should do if her child should get them; he replied, "keep it 
warm." So it seems not inappropriate to present the subject here. For many years this 
cooling treatment was strongly opposed by physicians in my region. Long ago I brought it 
before our County Medical Society, from time to time, until finally the members 
became divested of their fears and joined me in its use and its praise; and here let me 
quote what was said by our American Dr. John Bell, in his work on " Baths and the 
Watery Regimen," published in 1850, in Philadelphia. " In the continued use of cold 
water internally, by drinks and lavements, and externally by bathing or by topical 
applications, the physician has a means of diminishing and removing inflammations, 
both of the internal organs and of the external surface and the joints, as also fevers, 
hemorrhages and all diseases associated with much vascular action and nervous excite- 
ment." This declaration is so in accord with my own half a century's experience, that 
it gives me pleasure to say that it strengthened my determination to carry this 
principle of treatment to the relief of inflammations wherever found in the human 
system. 
SCARLET FEVER 
Is another disease in which the cold or cooling treatment is indispensable, if the com- 
fort and safety of the patient are worthy of consideration. In 1830 I first encountered 
the scarlet fever, and at once pursued the same treatment as I had in measles, by cold 
drinks and, in severe cases with much eruption and great heat, by cool sponging. In 
1833 I began to use ice in the mouth and ice water as drink, while physicians near to 
me continued the use of hot teas, gargles of cayenne pepper infusion, poultices to the 
outside of the neck, sometimes fat bacon, etc. The only difference in our treatment 
was that I used cold drink and cool sponging, they used irritant gargles, hot drinks, and 
kept the patients in heated rooms. The poultices to the outside of the neck were used 
by us all until 1844, when, disgusted with the use of poultices, so often followed by 
destructive suppuration of the glands under the jaw' and discharges from the ears, and 
believing that I could hold in check the inflammation of the submaxillary glands by 
cold applications, I began the use of ice externally to the swelled glands of the neck. 
In that year, 1844, I was called to a boy of eight months, sick two days. There were 
great enlargements of the glands on both sides of the neck, hot skin, frequent pulse, 
slight discharge from the nose, the tonsils inflamed, drink came back through the 
nose, and the child could take but a single draw of the breast without dropping the 
nipple, because of the obstruction in the nostrils impeding respiration w hen the mouth 
closed. I had never saved a child so young, thus affected, by the poultice treatment, SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
81 
and prevailed on the mother to let me use ice. So with small pieces of ice in gauze 
slipped into its mouth and lumps of ice lapped in bits of muslin and held continuously 
over the swelled glands, I anxiously watched the case. I had never known the ice to 
be thus used. In a few hours improvement was shown in greater ability to swallow ; 
the swelling of the glands, heat of skin and frequency of pulse steadily diminished, and 
in two days the child nursed well aud was out of danger. Do I hear you say that you can 
scarcely realize that the relief of this merely local affection could have so speedy and decided 
an effect on the general system ? No, you did not say it; my dull ears misled me. You 
doubtless believe, with me, that there is never a fever in the human system which is not 
based upon (caused by) a local inflammation. This is not a new idea.* In 1832 the 
distinguished Dr.-Jackson, of Northumberland, Pa., when the life of his daughter, in 
the fourth day of her illness in scarlet fever, seemed trembling in the balance of life 
and death, ventured to give her, instead of hot teas and stimulants, some cold water and 
small pieces of ice, wrote as follows: " My anxiety became intense, for I was possessed 
of the opinion that on the speedy improvement of the local disease depended the fate of 
my child. Cold water she desired above all things. ' ' He gave it. Hear him again : 
"She drank the coldest ice water and held ice in her mouth, and now for the first time 
I was satisfied with my prescription; the good effects were immediate, surprising, 
incredible, almost divine ! Within a few hours the pulse was reduced from 160 to 120, 
the circumscribed crimson disappeared from her cheeks, the extremities became warm 
as the fauces became cooled, the whole countenance was changed, the typhous distress 
left it and something of the vivacity of common fever supervened." Afterwards he 
wrote : "I have had ample opportunity to test this remedy. In more than forty cases 
I have found it highly useful, and without it I am certain more than one-half would have 
been lost." This from its internal use alone. 
My praise of its results in my little patient's case, where I used it both internally 
and externally, should not be considered excessive. For more than fifty years I have 
used the ice and ice water internally to allay inflammation of the tonsils and pharynx; 
and for more than forty years, ice externally over the affected glands, in every severe 
case which has come to me, and with a success pleasant to remember. In 1857 a severe 
epidemic of scarlet fever occurred in the upper part of this county and the lower part 
of Berks. In every direction many cases were lost by those who held to the warm 
treatment. Some reported losses from "congestion of the brain," others from "effu- 
sion;" one "lost six from congestion, and believes no treatment has any power to save 
such cases." I had that winter more than a hundred, in which there was great ten- 
dency to disease of the brain; and this brings me to speak of another mode of applying 
cold, namely, by affusion of cold water on the head. To this I resorted in all cases 
where congestion or delirium was feared or present, and in this way, with ice and ice 
water in the mouth and for drink, and ice externally over the glands, and by affusion 
of it on the head when needed, not one case was lost to me that winter. The cases 
were severe and the treatment carried on heroically. It was no child's play. Boasting 
is it? Looks greatly like it; buta number of sharp, intelligent physicians practiced 
near to me ; our Society met every two months ; every year, sometimes at every meet- 
ing, my ice treatment and its success were reported to men not of my faith ; had they 
known a single death in my practice they would have reported it, as they were desired 
by me to do. Have I lost cases since? Certainly; several; some of whom would have 
lived had the attendants been faithful to the directions. Parents knew that there were 
physicians opposed to my practice; they used the remedy timidly, sometimes, in my 
absence, not at all. 
* The idea that the fever is reduced in exact proportion to the reduction of the local disease 
on which it is based. 
Vol. Ill-6 82 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Many physicians are embarrassed to know how to apply the ice. Allow me to quote 
from a paper published in 1864: " A piece of muslin twice folded, just'long enough 
to reach from ear to ear, should be applied under the jaw, and pieces of ice slipped 
between the folds on the sides, over the glands, and the whole be secured there by 
aband of muslin tied on top of the head, not around the neck. It should be closely 
and continuously applied; removed but the thickness of a knife blade, it wouldbe 
almost useless. If too cold for a young child, two more thicknesses of muslin may 
be interposed. Somefear the melted water dripping on the breast " will give the child 
cold." Instead of that it is delightful to the heated child, and as the body is above 
the normal temperature, no chilliness is caused by it. 
How shall the affusion of cold water be used ? Allow me to cite two cases:- 
. Case i.-In July, 1845, I was called to a girl four years and nine months old, who 
had been ill a day or two. She began with vomiting; the eruption had been out since 
morning (then 6 P.M.); the redness of the surface was as intense as I had ever seen; 
the pulse as rapid as it could be to be counted. The mother had been alarmed during 
the last few hours in consequence of delirium and jerking, which she feared were the 
prelude to convulsions. There was much swelling of the submaxillary glands, tongue 
furred, with projecting points, breath hot and offensive, and when she found some one 
holding her wrist, she started from her dozing state into one of the most terrific con- 
vulsions that I had ever seen. It lasted, in spite of ice water constantly poured upon 
her head, almost half an hour. I stayed with her, had her stripped and laid on a nar- 
row cot, then placed two of my nieces by her side, had a large tub of water with cakes 
of ice floating in it, brought into the room, and during the whole night these two per- 
sons bathed her from head to feet with this water, applying it profusely by means of 
large sponges. It was to me a most painful case, and in order to be sure that it was 
one fit for the trial of the ice, I sent for my brother, then practicing in Norristown, only 
four miles away, where the disease prevailed and was quite fatal, to see whether it was 
the same kind or type of disease as that which, for some weeks, had been carrying off 
the children of Norristown and spreading terror among its citizens. He assured me it 
was a case of the most violent character, and that she would in all probability not live 
till morning. At that time, 11 P.M., she was free from convulsions but in a muttering 
delirium. As I had entire control of the case, he was assured that she should live if 
the fire that was burning up her vitals could be quenched by the use of ice and ice 
water. Not a moment did these nurses whom I had placed by her side intermit their 
labors. Before midnight reason had returned, and her mother, one of the nurses, said, 
"she is more herself than she has been during the whole day." I left, but returned at 
sunrise and found her cooled off perfectly. There was scarcely an appearance of erup- 
tion, the head was cool, intellect clear and the pulse moderate in frequency and force. 
She had been unable to drink for many hours, and the tongue, which had been cut 
during the convulsions, was swollen, so as to obstruct a view of the throat. Directed 
the mother to sponge her only once every two hours, until my return. My return was 
delayed until 4 P.M. The heat of skin, eruption and delirium had all returned, and 
she was moving her hands as if feeling for something, slowly protruding and with- 
drawing her tongue and muttering; took no notice of her mother's questions, and was 
unconscious of all that was going on about her. We threw on ice water in utmost pro- 
fusion, and lapped cloths dipped in the water around the neck, changing them every 
few minutes, and poured it on her head constantly, in a small stream, from the height 
of a foot or two. In an hour reason returned. We continued it until the eruption 
almost disappeared, until the child shrank from it and was ready to shiver with cold. 
We then gave medicine to move the bowels, directed the water to be used as needed to 
keep down the heat, and afterward had no further trouble with her. I forgot to say, 
that as soon as she could swallow, the ice and water were given as drink and to cool 
the inflammation of the tonsils and fauces. She took no more medicine. The other SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
83 
two younger children of the family were attacked, but the disease was held in check 
by the cooling treatment and recovered speedily. 
A case of affection of the brain (convulsions) in a child ill with scarlet fever and 
treated successfully, more than twenty-five years ago, may be found in Dr. Meig's 
" Diseases of Children," published in 1848, and with the following case will show my 
mode of using affusion :- 
Case ii.-Was called to a child, two years old; sick two days; found her, at 8 A.M., 
pale, skin cool, pulse barely perceptible; eyes wide open; pupils dilated; no evidence 
that she could either hear or see; suspected brain disease from scarlet fever infection- 
and here let me say that, when the brain becomes early affected, the eruption will not 
appear until the brain shall have been somewhat relieved. The body was WTapped in 
blankets, and cold water, from a height of two feet, poured from a pitcher, on her head, 
moving it continuously from place to place with brief intervals, until noon. Pulse 
then stronger, readily counted at 140, body warmer, pupils insensible to light. Affu- 
sion continued. Next morning, at sunrise, found her with sight and hearing restored, 
and a bright eruption covering her body. She convalesced without further trouble. 
Allow me one more case, a brain affection from scarlet fever in a puerperal woman. 
Mrs. F., delivered of her fourth child November 7th, 1881. Her physician saw her on 
the 8th and 10th, and left her not as well as is usual for that time. On the 14th, he 
being away, I was called. She had been nearly four days poorly and with scarlet 
eruption; had pain in the head; was extremely restless; pulse 130, as nearly as could 
be ascertained ; her restlessness and tossing of her arms precluding accuracy. A phy- 
sician acting for me was directed to give her the cold treatment, regardless of her 
recent accouchement. "Nevermind that she has just been confined; disregard the 
name of scarlet fever; aim to relieve the head by pouring cold water on it, after our 
manner of doing it; repeat till the delirium is relieved." Suffice it to say, that it was 
done heroically, and the patient saved. The case is given in detail in Philadelphia 
Med. and Surg. Reporter, of May 27th, 1882. 
I may have spent too much time in showing the value of cold as a remedy in scarlet 
fever, but rarely has any one made a more careful trial of any remedy than I have 
made of this, in a practice of fifty-nine years, under the daily watch of intelligent phy- 
sicians, anxious no doubt for my success, but doubtful of the propriety of my practice, 
and too timid to resort to measures, to them, so heroic. And now, in closing my career 
as a practitioner, and looking back on the countless fights had with death, in hovel and 
in palace, I can truthfully declare that no means ever used by me, or which have ever 
been known to me as used by others, in scarlet fever, have so successfully warded off 
his blows and shielded patients from harm and restored them to health as the use of 
cold water and ice. 
My papers on scarlet fever and cold may be found in Pennsylvania State " Transac- 
tions;'' Montgomery County Reports, of 1857, '62, '64, '67, '71, '72, '76; in Medical 
and Surgical Reporter of Philadelphia, January 18th, '73, October 21st, '71, March 
18th, '76, May 2d, '82 ; in Philadelphia Medical Times, January 4th and 11th, 1873. 
DIPHTHERIA. 
As I have treated scarlet fever, so have I treated this disease. For many years, in 
my practice, the temperature was guessed at, as we had no clinical thermometers. Now, 
we can determine it so accurately that we need not err as to the need of reducing it. 
My treatment of the two diseases has been the same. When I speak of the great value 
of the cold treatment the severe cases are in my mind. It is in these dangerous ones 
that the remedy is so valuable. The physician then holds in his hands a remedy 
adaptable to every condition of the case. Besides this remedy, medical treatment so 
called was, of course, used by me, as called for by symptoms. 84 
SMALLPOX. 
The treatment of this, like the treatment of scarlet fever, should be of the cooling 
kind. In the very beginning the system should be kept cool by exposure to cool air or 
by sponging with cool water, and by light diet, and by cold drink freely used. These 
measures will insure a mild case. In the year 1840 was called to a young man covered 
with vesicles. His sister had died two weeks before ; he was very delirious, face and 
head much swelled, and he was making attempts to get out of bed. I fairly enveloped 
his head and the back of his neck with bladders of ice and water, and continued these 
measures until his delirium was subdued ; he convalesced well. In the graveyard of 
Boehm's Church there are, side by side, graves of five children of one family, of ages 
from five to fifteen years, all dead from smallpox, treated in the hot way in 1750-6. I 
have had in all my time not more than from fifteen to twenty cases. All did well but 
two, and one of them would not allow the cold treatment to be used at all. He lived 
alone, laid himself down near to the hot stove and staid there till he died. The other 
I did not see early ; he was kept from home when first poorly, by snow storm. The 
others were managed without difficulty. In Philadelphia, at the Municipal Hospital- 
a smallpox hospital-in 1871, according to a report to the State Society, there were 
admitted 677 cases, of which 353 died. This was the treatment : " From six to eight 
grains of quinine, one drachm tiuct. ferri muriatis, one quart milk, made into egg- 
nog, containing six or eight eggs, and six or eight ozs. of whisky, often increased to ten 
or twelve ozs. and one quart of beef tea. Alb this to be taken every day, in the vesicular 
stage and onward. 
INFLAMMATION OF THE BRAIN. 
After what I have already said, it seems unnecessary to give cases to show the value 
of affusion of cold water here. Dozens of cases have presented themselves, and the 
copious affusion of cold water-generally afterward-has been a means of inestimable 
value. To be efficient it must be done without stint. Whatever is worth doing, is 
worth doing well. I have not referred at all to the experience with cold, of John Smith, 
of Pitcairne, Hancock and others, who were advocates of its employment long before 
any man in this audience was born; nor yet of Currie or Gregory, of later time; but in 
1847, Dr. Henry Hartshorne, of Philadelphia, published a valuable " Essay on Water 
and its True Eclations to Medicine," from which, on page 68, allow me to quote the 
following utterances of Dr. Southwood Smith, in a case of fever, with marked cerebral 
affection and great heat of surface, and in which general and local bleeding had been 
already used. " Recourse," he wrote, " was had to a measure, the effect of which is 
but little known and less appreciated ; a remedy, the power of which is second only 
(if under some circumstances it be not superior) to that of the lancet ; a remedy which 
can never supersede the lancet, but which when added to it, forms by the combination 
a treatment so powerful and efficacious, that it might render death from the aeutest 
cerebral inflammations as rare as recovery is at present. It consists of pouring a column 
of cold water, in a continued stream, from a height of from six to ten feet. " After the 
patient has been wiped dry and placed in bed, the symptoms may soon return in all 
their violence. The same process will again remove them, and as often as they recur, 
the process must be repeated. Three or four repetitions will commonly suffice to sub- 
due the most intense cerebral affection." My long and thorough experience with a 
daring use of this remedy justifies me in making this language my own. 
NARCOTICS. 
Affusion of cold water on the head is not a new remedy for opium poisoning. 
Christison says it was proposed by a German physician in 1767, and Septimus Wray, 
in the London Medical Repository, gives three cases of opium poisoning successfully 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
85 
treated by it. From a paper in the American Journal of Medical Sciences, April, 
1852, by that excellent practitioner, Dr. Jesse Young, of Pennsylvania, I quote the fol- 
lowing cases:- 
Case i.-"A child in its second summer; narcotized almost to death; countenance 
blanched and all power of muscular contraction entirely suspended ; could not be aroused 
by any means then tried. I poured the coldest spring water, in a continuous stream, 
perhaps a gallon, on the crown of its head, when it began to show some signs of mus- 
cular contraction ; I continued it a little longer, when it roused up, cried lustily, kicked 
and plunged about so that we desisted. It recovered without difficulty." 
Case ii.-Negro girl, aged 18; had taken two ounces of laudanum within two hours, 
and had had it fosseveral hours. "We had her held over the tub by an assistant, 
with the face down, the cold water poured on as before, and in less than five minutes 
she was completely restored." 
No case of opium poisoning ever came to me, but a friend to whom I had spoken of 
the remedy had a case, which he soon restored, then went away without ordering the 
affusion to be repeated should coma return ; it did return and he was allowed to die 
This should always be remembered; that in such cases, though the narcotism has been 
counteracted by the affusion, it will soon return if suspended, and will require to be 
renewed from time to time for a few hours, till the poison is eliminated from the 
body. 
In two children poisoned by eating green stramonium stalks, after an emetic, the 
distressing delirium peculiar to this plant was speedily relieved by pouring cold water 
upon the head. 
Allow me another case : A married woman of middle age, after a few days of suffer- 
ing from an erysipelas of face, became deeply comatose. I was called after she had 
been wholly unconscious for many hours. Her head was brought over the tub at the 
side of the bed, in which great lumps of ice were floating in water ; the water was 
poured from a pitcher, in a large stream, for a full quarter of an hour, before she 
was fully restored to recognize friends. It was then evening and I left for home, eight 
miles away, but not till I had impressed on the attending physician the importance of 
repeating the affusion occasionally, till the poison be eliminated. He had it done 
until he left for home-a brief time-then the family failed to do it, as they regarded 
her apparently only sleeping ; thus she was allowed to drop into deep coma, and she 
died next morning. But even here the power of the affusion to remove a profound 
coma was well shown. 
Two cases of the most profound coma, produced by whisky, in children, were res- 
tored by affusion in a few minutes, by me. 
I am not ignorant of the practice which now prevails, of giving medicine to antag- 
onize the effects of the narcotic, and which occasionally fails; but the affusion is so cer- 
tain in its effects that it should always be borne in mind, as it is always at hand, while 
the medicine may not be. In the American Journal of the Medical Sciences, May, 1829, 
is reported a case of the deepest narcotism, caused by prussic acid, which it is likely no 
one of you has ever heard of, so allow me to give it to you. Dr. Herbst says of this 
poisoning: "Affusion can be relied upon when used immediately after the acid or 
during the convulsive stage, even as long as the eyes are insensible to light, or immov- 
ably fixed, the extremities and the head thrown back. To this state there succeeds 
relaxation of the muscles, the respiration becomes gradually imperceptible, the pulse 
slow, weak and scarcely to be felt, and in an instant afterward death supervenes. Even 
at this period of paralysis the cold water recalls the vitality ready to vanish ; the 
muscles again contract and become hard, the limbs rigid, and everything resumes its 
natural state." Could any agency do more than this? 86 
APOPLEXY. 
Of the value of this remedy in threatened or even present apoplexy, I have no 
doubt, but yet have seldom ventured to use a remedy, which by no possibility could be 
as prompt as venesection. The latter, therefore, with me, precedes the affusion. The 
two, where there has not been too great an effusion of blood within the cranium, are 
measures which I have seen act as by magic. Henry Ward Beecher's case was one 
favorable for their use. It was a slow one, heralded by unmistakable symptoms, and 
yet day after day passed, hour by hour the dullness increased, and nothing stayed its 
deadly progress, not even daily "bulletins." 
COUP DE SOLEIL. 
This disease is said to differ from apoplexy. It is not one recently discovered, nor is 
the treatment by affusion of cold water a new remedy for it. In 1829 Dr. Samuel Dickson, 
of Charleston, S. C., published, in the February number of the American Journal of the 
Medical Sciences, a paper "On the Effects of Heat," in which he says : " Of coup de soleil 
there are two forms, the apoplectic and phrenitic," or cerebral and meningeal; and of 
the former he writes : "They fall, after exercise and exposure to great heat, senseless 
and motionless, the breathing stertorous, pupil of the eye insensible to light, the skin hot, 
but no hotter than the natural standard, pulse full and slow. Unless speedy assistance 
was brought, death ensued in an hour or two. The apoplectic was most fatal, and in 
both forms the lancet was first tried." Of the phrenitic or meningeal form he thus wrote: 
" All that could be hoped for from venesection at this period was as perfectly and surely 
effected by cold affusion. He who has not learned the efficiency of this simple remedy 
in cerebral affections may add another important agent to his list." " The patient 
raised to a sitting posture, cold water should be poured on his head, from a height 
of a few feet; the flushed face then will become pale, the hard, quick pulse will sink 
to a mere thread, and the coma and stupor will rapidly disappear." Again and again 
the symptoms returning will call for a repetition of the affusion. Italics mine. My object 
by this emphasis is to impress this fact, observed so long ago, and corroborated by every 
careful observer since. Thus fifty-eight years ago my attention was turned by Dr. Dick- 
son to this mode of treating not only coup de soleil, but also congestions and inflamma- 
tions of the brain, from whatever cause, and the results of the treatment have been most 
gratifying. Thirty years ago the engineer of the Spring Mill furnace worked in a small 
basement room, a hot place, in which he spent twelve consecutive hours every day during 
every other week ; the alternate week his nights were spent in the same heated place. 
One day he was found in a comatose condition and died in a few hours. Another, who 
took his place, was a victim to the heat in the same way. A third man was overcome, 
but was gotten to his home; then his nose began to bleed, which soon relieved him, he 
became conscious, but as the bleeding continued he became greatly weakened, and I 
was called. Found him much exhausted; efforts were made to arrest the bleeding, but 
without success, until a stream of w'ater was poured on the low'er part of the forehead 
and over the nose, which soon arrested it. After a short time the bleeding began again, 
but was promptly stopped by a renewal of the remedy. Thus for many hours we held 
it in check, until the overheated system became cooled, after which, without stimulants, 
he was soon restored to health. What were these cases? Coup de soleil ? Thermal 
Fever of Professor Horatio C. Wood ? Apoplexy ? It matters not what the name. 
The affusion would, no doubt, have been applicable to them all : and the epistaxis in 
the last shows that venesection, followed by affusion, would, in such cases, be even bet- 
ter than either remedy alone. How many people have been sacrificed to the stimulant 
practice ! A practice not yet entirely abandoned. The paper of Dr. Dickson is quite 
worthy of perusal by those who fancy that the stimulant treatment is so indispensable. In 
all cerebral affections tending to reflex and coma I have used affusion, with best results. 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION VI-THERAPEUTICS AND MATERIA MEDICA 
87 
PERITONITIS, PHLEBITIS, ETC. 
Peritonitis.-In this disease cold is of great value as a local application. It is easily 
applied, and because of its nearness to the diseased surface, quickly efficient. In 
February, 1845, was called to Mrs. Aaron, aged 30; no children; lying on her back, 
limbs drawn up, belly tender to the touch and greatly distended. It was winter time, 
and the ground covered with snow. Masses of it were put between single thicknesses 
of old muslin and laid over the whole abdomen, renewed whenever needed, for two days 
and nights, with great comfort to the patient and relief from the malady. From that 
time to the present I have used it in all inflammations of the peritoneum, as a local 
remedy, instead of turpentine stupes, poulticesand blisters, all of which are so unpleasant 
to the patient and inefficient, if not really hurtful. 
PELVIC ABSCESS. 
I was called, in 1850, by Dr. Martin, to see Mrs. Wertsner, and found her pale and 
weak from long suffering under the hot poultice treatment. Suppuration was evident; 
an opening made with the lancet gave exit to the pus and she slowly recovered. Since 
that time, in 1866, Mrs. Davis, some days after her confinement, had chills, followed by 
fever, with pain in the left inguinal region ; her left leg was drawn up, and there was 
swelling and tenderness over an area of several inches in that region. The location and 
symptoms reminded me of Mrs. Wertsner's case and her suffering under poultices; also 
of Mrs. Aaron's case, in which the snow did so well. Two thicknesses of old wet mus- 
lin were laid on the part, and on that a bladder of ice and water, and kept there night 
and day for several days. Relief from the heat and pain was soon experienced, and in 
a few days she was well, without suppuration. Many physicians fear to apply the least 
amount of cold to a puerperal woman. There is not a particle of danger while the part 
to which it is applied is above the normal temperature, or while the general temperature of the 
body is above its natural temperature, but a certainty of comfort and relief being produced 
by it. In crural phlebitis I have twice applied it, with good results, in recently confined 
women. In peritonitis, where the inflammation is so near to the applied ice, and the 
cooling influence of the latter felt almost as soon as applied, it is a certain and efficient 
remedy. 
TYPHLITIS. 
This disease, so insidious in its approaches, so often fatal, is one in which ice is very 
efficient, besides being from the first hour of its application pleasant to the patient, who 
feels that it is doing saving work. August 14th, 1848, I was called to a friend ill with 
this disease, and despite "appropriate remedies," under the persistent use of poultices, 
he died October 1st, though Dr. Isaac Parrish aided me in the treatment. It saddened 
me greatly when, on examination after death, the parts were found gangrenous ; the 
fæces had passed through the side of the bowel down among the glutei-muscles. When, 
seven years afterward, in 1855,1 was called to a boy of eleven years of age, on his back, 
with legs drawn up and a dull swelling occupying the region of the ileo-colic valve, the 
fate of my friend came before me, as did the case of Mrs. A. and the snow. Regarding 
the swelling, tenderness and pain as evidence of a serious inflammation in a dangerous 
locality, the ice was at once placed on the affected part, because elsewhere the boy was 
well. I well knew that if the cold would remove that inflammation, my patient would 
be well. Opium was given, to allay pain, the ice continually applied, and next day 
he was much better; not so sore; not so much pain; the skin where the ice bag lay cold, 
almost as the bladder of ice and water; the patient not restless but comfortable under 
his ice cushion. In a few days he was well. I have often wmndered what would have 
been the result had President Garfield been put on a cushion of ice and water and kept 
heavily under the use of opium (to allay pain) and nothing more. You say something 
more ? A proper solution of corrosive sublimate injected into the wound a single time, 88 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to kill the microbes, and a plaster over the wound to keep them out ? Well, perhaps 
so; but I think it would have been rather cold for them to operate there. The ball 
lodged so near the surface that the ice would probably have prevented the inflammation 
and averted suppuration. It is pleasant to have a hobby? Yes, and more useful than 
to have no thought, and blindly follow teachers. Since the success in the boy's case, I 
have resorted to it in every inflammation of the abdominal organs which has presented, 
and with good results. 
GASTRITIS. 
In 1835 Mrs. R. began to reject her food and drink, and after several days of vain 
eflbrts to prevent it, I was called to see her. She could not keep either food or drink 
but a few minutes. It was a plain case of gastritis, and she was at once given small 
lumps of ice to swallow; the effect was quite marked; no vomiting of it occurred for 
many hours, while occasionally using it. Then we tried some mild food, which was 
soon rejected. Thus we went on during several days, occasionally making trials of 
food, before she was able to retain any. Herself and friends thought she would die of 
starvation, but there seemed to be no good reason why we should change the treat- 
ment, inasmuch as she was comfortable under its use. The ice was broken into pieces 
small enough to be swallowed, and it was amazing to me to see her swallow one piece 
after another, until a teaplateful of them would be used at a single meal. Seven days 
from the time she began the ice she was able to take food in moderate quantities, and 
soon recovered perfectly. 
Ever since that time, in my cases of gastric irritation and persistent rejection 
of food, resort has been had to the ice. Ten years since, a physician, very ill with gas- 
tritis, had had a warm poultice over the epigastric region for a day or two; with 
his own consent, at my suggestion, it was removed and the ice applied. He has 
since told me that no one who has not experienced it can have a full appreciation of 
the relief which it brought to him. The poultices made him feel as if he could not 
get his breath properly ; he was hot, oppressed and uncomfortable. The change from 
the poultice to the ice was delightful. 
GLOSSITIS. 
In May, 1864, was called by Dr. Vanartzdalen to see Isaac Rozelle, who had been 
during several days ill, with inflammation of the tongue. Dr. Vanartzdalen was 
called two days before my visit and found him under a heated steam treatment. He 
was desirous to apply ice, as he knew was my practice, to the inflamed tonsils of scarlet 
fever, but they all feared the change from such a heated condition and the steaming 
was continued. It was my first case of that disease, save that which occurred occa- 
sionally in salivation. His tongue was enormously swollen, separating his teeth in 
front, his voice a mere whisper, his whole body enveloped in steam. The kettle of boil- 
ing water had been kept on the stove night and day, so that the vessel under the 
blanket which entirely covered him might be refilled when needed. He had a feeling 
of impending suffocation. The treatment by incision or by leeches was not regarded 
with favor, as the latter were not accessible, and the former too dangerous, from hemor- 
rhage. The hot water and blanket were taken away, and though he was in a profuse 
sweat from the feet to the top of the head, the ice was applied in large quantities, 
under and on the sides of the jaws, and small pieces were stuffed into the mouth, 
wherever room could be found for them. It was then evening; the next day our patient 
greeted us as though he were the happiest of men. He could talk; before he could 
but make the faintest whisper. From the first hour the ice gave positive relief, the 
swelling subsided rapidly and the cure was complete. A more grateful man never 
convalesced from a disease of danger. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
89 
MUMPS. 
I have used the ice-water cloths where the swellings were large and painful, with 
comfort to the children and without causing metastasis to other parts. 
ORCHITIS, AND HERNIA HUMORALIS, FROM GONORRHŒA, 
Have been treated by me most successfully; and this reminds me that in gonorrhoea 
the injection of cold water into the inflamed canal, and application of cloths wet with 
ice water around the penis, is considered good practice by some physicians. Hard on 
the germs though. 
INFLAMMATION OF THE MAMMARY GLAND-MASTITIS. 
In 1884 I gave up the poultices and began the use of ice in this disease. It was a 
grand success. It is impossible for the inflammation to cause suppuration if the ice be 
applied before that result has occurred. It is, too, a most agreeable remedy. My first 
paper on this treatment may be found in the Philadelphia Medical and Surgical Reporter 
of August 16th, 1878. 
CROUP 
Is an inflammation of the lining membrane of the upper part of the windpipe. In the 
early stage, before the strong fibrinous membrane has been produced by the unchecked 
inflammation, the application of ice to the front of the trachea will almost certainly 
prove quickly curative, because the ice is so close to the inflamed tissue that the inflam- 
mation cannot continue and extend, but will as certainly and speedily be arrested as 
it is in mastitis. Many practitioners have from time to time spoken of its great value, 
and I can bear testimony of the same character. It is amazing to know that turpentine 
and other external irritants are still persistently used. How do these things act ? Who 
ever has seen relief produced by them ? Scores of times I have seen children thus tor- 
tured without an iota of relief. Laryngitis is, too, subdued by the application of ice in 
the same way. In what is called hoarseness from bad cold, I have seen prompt and 
pleasant effects from the same treatment, and in quinsy have used it for the last thirty 
years with the best results. It is, too, with ice water in the mouth, agreeable to the 
patient. 
PNEUMONIA 
Is an inflammation of the lung. The fever and pain are caused by the local disease. 
J ust in proportion to its extent and severity will be the gravity of the general symp- 
toms and the danger. If the local affection can be arrested, the suffering and danger 
will disappear. Believing, as I do, that every febrile condition of the system is caused 
by a local irritation or inflammation, and knowing from much experience how efficient 
the cold is when applied over the diseased lung, to aid in the arrest of the extension 
of the inflammation, I apply it with the utmost confidence that it will be pleasant to 
the patient and aid in his recovery by reducing local and general heat of the system. 
A few winters ago, two boys, fourteen and sixteen years of age, were ill with this 
disease, and the ice cloths and bladders of ice and water were freely used. They both 
said the application was most pleasant; the great sense of heat giving way to a cool, 
agreeable condition. I havé used this remedy often ; always with comfort to the patient 
and satisfaction to myself. You think poultices are better ? You have never tried the 
cold. For nearly forty years I had experience with the blisters and poultices, and 
know how they caused the patients to suffer, and of what doubtful value they were. 
TYPHOID FEVER. 
More than twenty years ago I was called in haste to one of my patient's, who, on a 
previous visit, was doing well, and found her pale and prostrate, from an enormous 
hemorrhage from the bowels. A bladder filled with ice and water was at once placed 90 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
over the right ileo-cæcal region; the discharge soon ceased and she went on to recover. 
"She might have gotten well without it?" That is, perhaps, true. But it shows 
that the cold, so much dreaded, is not objectionable. Two years since was called to a 
similar case by a friend. A young married woman had an exhausting hemorrhage. 
Bladders of ice and water were applied. The pale, prostrate woman, worn down by 
her two weeks' illness and the hemorrhage, was not chilled, but comfortable under its 
use. I am not ignorant of the common belief that this crisis, as it is called, is a relief 
in some cases; but that there is no danger in the use of the cold over the inflamed area, 
is an important fact, and was well shown here, the patient being comfortable under its 
use and recovering speedily. For many years, whenever in this fever soreness was 
manifested in the right iliac region, I have had ice applied there, to allay irritation and 
avert hemorrhage; and, doubtless, with success in some cases, as none have since 
occurred, where the ice and ice water were freely applied over the tender abdomen. 
In 1879, four adults of one family had typhoid fever; three suffered from much 
bronchial affection, with a tenacious, slightly bloody expectoration, with a sense of heat 
and oppression. Cloths dipped in ice water were freely applied over the front of the 
chest. The cold was agreeable, relieved the unpleasant sense of heat, and all recov- 
ered. Whenever, in this disease, the fever is high, my practice has been to sponge the 
body and limbs with cool water, and to give plenty of cold water as drink. The poul- 
tice is simply digusting, oppressive and useless. 
RHEUMATISM. 
I have never seen a metastasis of this disease to some other part caused by cold 
applications to an inflamed rheumatic joint. My patients have used them many a time, 
with great comfort and entire safety. There lives near to me now a woman of fifty 
years, who, when under twenty, was suffering greatly with rheumatism of the ankles; 
they were so hot, swelled and painful that she was advised by me to put them into a 
bucket of cold spring water. It was most comfortable to her, and since that time, 
whenever attacked, she resorts to that means of cure. To joints where it can be readily 
applied, I invariably have it used. Here let me call attention to the tradition so firmly 
fixed in the mind of nearly all practitioners, that "cold applications to the inflamed 
joints in rheumatism will drive the rheumatism to the brain or heart." What is it that 
will be driven ? What is rheumatism ? The heat, the swelling, the pain of the joint ? 
And is the heat of the system, the fever, so-called, caused by the inflamed joint? 
Yes, that is my opinion. You think it a constitutional disease, do you? Well, what of 
it, if it be so ? Shall I abstain from allaying the inflammation in the joint; allow it to 
torture the patient and keep up the fever, from a mere fancy that the disease is in the 
blood, possibly a germ, and that the cold, by heading off this outbreak in the joint, 
may compel it to seek an outlet elsewhere? Relieve the joints and your patient will 
soon be well. Be your general treatment what it may, aid it by the local application 
of cold to the affected joints. 
In conclusion, the fevers, so called, claim attention. I group them, and say the 
general reduction of temperature by cooling drinks and cool sponging with water, and 
special local applications of ice or ice water to inflamed organs or tissues, to aid the 
judicious use of medicine, is good practice. But there is yet a question which you 
will be quick to ask me, namely, Where, in fevers, is the local inflammation which 
causes the fever, the increased temperature? And I shall answer as soon as the 
questioner proves that no local disease exists in these fevers. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
91 
The following paper was read by title :- 
THE APPLICATION OF ALCOHOLIC STIMULANTS TO MEDICINE, 
HAVING ESPECIAL RELATION TO THE THERAPEUTICS OF 
ALCOHOL IN DISEASE. 
APPLICATION DE STIMULANTS ALCOOLIQUES À LA MEDECINE, AYANT UN 
RAPPORT SPÉCIAL À LA THERAPEUTIQUE DE L'ALCOOL 
DANS LES MALADIES. 
DIE ANWENDUNG ALKOHOLISCHER REIZMITTEL AUF DIE MEDIZIN, MIT SPEZIELLER 
RÜCKSICHT AUF DEN THERAPEUTISCHEN NUTZEN DES ALKOHOLS IN KRANKHEITEN. 
BY EDWARD N. LIELL, M. D., 
Of New York. 
The subject of the application of alcoholic stimulants to medicine is of such vast 
importance, and the expression of opinion among medical men as to its application and 
utility in disease so varied, that a few words upon my part, I trust, will not be amiss 
in endeavoring to place the matter before you in, as I deem it, its true sphere of use- 
fulness. I shall have reference, and concern myself in this paper only, to the indica- 
tions presented for its use in disease; in fact, to deal with the therapeutics of alcohol in 
disease, leaving out of consideration all other questions pertaining to it. 
There are those who to this day will be found enjoining the practice of abstention, 
believing the administration of alcohol to be wholly unnecessary; others are more 
guarded in the matter, in that they believe it useful in certain forms of disease; still 
others, and at the present time by far the greater number, take a more pronounced 
view and advocate the administration of alcohol, or the principle of judicious stimula- 
tion, to be legitimate, and the only rational course to pursue, especially in acute febrile 
disease. 
But why should these varied opinions or disagreement of facts exist among the 
members of our profession ? they who, as regarded by the laity, are specially trained 
to observe, because of intimate contact among their fellow men. In the words of Sir 
Dyce Duckworth ("On the Medical Injunction of Stimulants in Disease and Health." 
British Medical Journal, Nov. 10th, 1886,) "there is no middle course to pursue; either 
stimulants are all right if they be rightly used, or they are all wrong if they be used at 
all, or in any degree." 
No routine practice can be made in the use of alcohol in disease, nor are we to 
understand such was intended ; the true clinical acumen is called for in determining 
the necessity for its use, as for any other drug. 
The injudicious or indiscriminate use of alcohol is certainly to be opposed; but to 
condemn it entirely because of its abuse, seems to me an argument that would con- 
demn for the same reason most, if not all, of our reliable and more or less so-called 
dangerous remedies. 
We are told by some that the practice of alcoholic stimulation frequently aggravates 
trains of morbid symptoms, establishing new centres of irritation, and thus proving 
somewhat disastrous in its effects upon disease; also leading to the undermining of the 
morals of the patient. Such, no doubt, is the fact where stimulants are administered 
indiscriminately, either in excessive doses or unnecessarily; when properly and judi- 
ciously administered, however, its action is highly favorable, increasing the power of 
resistance to disease. 
The remarkable statement has but lately been made that " the range of the use of 
alcohol in disease is very restricted, and its use in disease with the object of keeping 92 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
up the strength of the patient is certainly unscientific; it is but adding another com- 
plication to the disease already existing, and frequently antidotes other remedies." 
Let us see if there is any proof for the above statement, by asking, what is the prop- 
erty of alcohol in relation to animal heat, muscular power and nervous energy; is it 
utilized in the animal economy ? 
There are certain points of interest that bear directly upon its administration in 
disease, in that the true therapeutics of its employment has reference to its tolerance 
and the limitations as to quantity ; the individual case and stage of the disease, age, sex, 
etc. Most of us are familiar, no doubt, with the fact that, in the febrile state, the 
relations between health and disease, as regards the quantity of alcohol taken, are cer- 
tainly changed, in that, in disease, a much larger quantity can be administered without 
producing any morbid phenomena. The fact is evident, and there is little need, there- 
fore, to state, that because of the moral and physical evils attending the abuse of 
alcohol, especially as a beverage, prejudice against its use in disease has naturally been 
excited. 
In the employment of remedial measures, we should look beyond the immediate 
results of treatment, and have due regard to the remote effects of certain remedies, as 
not infrequently we are brought face to face with the fact of the injurious remote effects 
of measures which are immediately beneficial; frequently, therefore, in our anxiety to 
keep up the strength of the patient, we allow ourselves to forget certain precautions 
necessary in our treatment. To defend the administration of alcohol, especially in 
acute febrile disease, requires some conception of its action upon the human organism. 
Regarded as a stimulant, when given in moderate doses, its immediate action is upon 
the sympathetic, combined with a sedative influence upon the vaso-inhibitory nerves, 
thus increasing the frequency and force of the heart action, and causing dilatation of 
the capillaries, diffusing a temporary warmth throughout the body, at the same time 
increasing the supply of blood to the nerve centres. 
The existence of high temperature includes active destructive metamorphosis, with 
excessive oxidation of tissue, constituting, generally, one of the most dangerous symp- 
toms of disease. The researches of Anstie {Practitioner, Lond., 1874, xiii); Binz. 
{Practitioner, Lond., 1869, iii); Ringer {Proc. Roy. Med. and Chir. Soc., Lond., 1866, v) 
Riegel {Deut. Archiv f. Klin. Med., Leipzig, 1874, xii), and others, prove that alcohol, in 
moderate doses, causes a small, and in larger doses, a considerable reduction of tempera- 
ture, the diminution in temperature being proportionate to the amount of alcohol 
ingested; this reduction, however, is but temporary, lasting, in moderate doses, but a 
lew hours; the quick, tense pulse almost invariably becomes slower, and at the same 
time stronger. 
On therapeutical grounds, the large proportion of hydrogen contained in alcohol, 
when oxidized in the body, would seem to augment the temperature; practically, how- 
ever, as proved by Binz (the influence of alcohol on the temperature of the body, Prac- 
titioner, Lond., 1869, iii), " the fact has been overlooked, that the influence which checks 
other oxidation processes is more powerful than the effect of its own oxidation, 
accounting, therefore, for the reduction of temperature in the administration of alcohol; 
alcohol is, therefore, apyretic in its action, as also paratriptic, in protecting the tissues 
from oxidation by its own powers of oxidation." Another influence which alcohol 
possesses is its sedative and hypnotic effect, due to its action upon nerve tissue, calm- 
ing the restlessness and erratic movements of an excited brain ; in other words, lessen- 
ing excitement and calming delirium ; this can be brought about more quickly by 
moderate doses of alcohol, repeated more or less often, than by any other means; the 
parched and dry tongue and skin also become moist. 
From these practical observations, therefore, not easily controverted, is shown the 
fact that alcohol, when introduced into the system, creates and evolves heat, due to SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
93 
its rapid decomposition; in other words, alcohol feeds organic combustion, thus creating 
and evolving heat. 
Too free alcoholic stimulation leads to interference with endosmosis and exosmosis 
in the lung capillaries, and thus with its free oxidation in the system. 
In acute febrile and inflammatory disease the organs essential to the digestion and 
absorption of food are to a great extent affected ; under the circumstances, the matter 
of a supporting treatment is to be strongly considered, and it, is here that alcohol plays 
an important part, having a special and favorable influence as well upon digestion, in 
that it decidedly increases both the acidity and flow of the gastric juice; if given in such 
amount as not to be fully utilized and disposed of, its action is that of a veritable 
poison, in that the reverse of its favorable action is the case. 
Does alcohol undergo combustion when introduced into th e system, and thus act as 
a food, aside from its stimulant action ? In other words, can alcohol be considered a 
food as well as a medicine, in relation to disease, or is it eliminated in greater part 
unchanged, by the various emunctories ? The experiments of Lallemand, Duroy and 
Perrin (on the rôle of alcohol and anæsthetics in the organism, Paris, 1860), as also 
those of Richardson {Medical Times and Gazette, London, 1869, ii), showed that when 
taken into the system, alcohol is freely eliminated as alcohol, apparently unchanged, 
and could, therefore, in no sense be termed a food; these experiments were not conclu- 
sive however, in that actually they showed but a part of the alcohol was excreted and 
eliminated, the quantities administered at a time being excessive, oxidation of which 
was impossible within the time limited. 
The researches of Liebig and Baudot ( Union Médicale, Paris, 1863, xx, 1864, xxi), 
and later on those of Anstie {Practitioner, London, 1874, xiii); Duprè {Practitioner, 
London, 1872, viii); Brunton {Practitioner, London, 1876, xvi); Thudichum, H. C. 
Wood and other physiologists, however, tend to prove satisfactorily that, when admin- 
istered in moderate quantities, and at the same time judiciously, it is practically 
wholly consumed in the system, and not eliminated as alcohol, showing, therefore, its 
actual value as a food. In the excellent paper by Duprè, on the " Elimination of Alco- 
hol," is shown the fact, that there exists normally in the human urine a substance 
which, by distilling the urine with an acid, gives the reaction ordinarily employed for 
the detection of small quantities of alcohol ; this has, no doubt, as stated by Duprè, led 
some experimenters to the belief that the elimination of alcohol continued much longer 
than in reality it did. 
In the words of Brunton (Physiological Action of Alcohol, Practitioner, London, 1876, 
xvi), "We may conclude that, in moderate doses, alcohol undergoes combustion in the 
body, supplying energy, yielding warmth and tending to sustain life in the same way 
that sugar would do, and is therefore to be reckoned as a food, greatly increasing its 
utility in disease." 
The apparent unphysiological and hurried acceptance of the conclusions of Lalle- 
mand, Duroy and Perrin, as regards alcohol not being a food, seems to pervade still, 
after many years, the minds of many medical men; furthermore, if alcohol is to be 
reckoned as a "nerve stimulant," incapable of adding substantial aid and force to the 
body, how are we to explain its happy action in acute febrile disease ! Its action as a 
" nerve stimulant " is, as stated by Anstie, " merely to encourage its rise in states of 
chronic feebleness, marked by outward signs which are the reverse of those of the 
febrile state, and more especially for conditions of nervous exhaustion complicated with 
mental depression." 
In acute febrile disease, alcohol undergoes combustion itself, instead of the tissues ; 
in other words, though not adding to the growth of any tissue, it certainly protects it 
against oxidation by its own oxidation, thus retarding tissue change- incident to the 
vital processes. This combustion and apparent entire consumption of alcohol in the 94 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
system is at the expense of the oxygen to be applied for the natural heating of the 
body, being, as stated, a process of oxidation, this chemical change taking place only in 
proportion to the amount of oxygen existing in the blood; whereas, in the experiments 
of Lallemand, the amount of alcohol ingested being excessive, or the percentage of 
oxygen in the blood lessened, a more or less greater proportion of the alcohol may be 
recovered by the excreta. 
In numerous instances of disease, where the danger of failing heart power is to be 
averted for a few days or even longer, or where the patient either refuses or rejects any 
form of nutriment, the administration of alcohol will be found of great service, tiding 
the patient over the worst stages, being therefore the agent by which he is kept alive 
and recovery possible. We are all aware that in acute febrile disturbances the increase 
of temperature produces not only a lack of desire for ordinary food, but more or less 
arrest of the muscular acts necessary to the forwarding of the solution of the blood ; 
alcohol here seems to fulfill the wants of the system in this respect ; the quantity of 
alcohol appropriate, therefore, will depend almost entirely upon the nature of the dis- 
ease and the strength of the patient to resist it, having special reference to the rapidity 
of oxidation of the tissues of the body ; with greatly increased temperature and rapid 
oxidation of the tissues, its employment is especially beneficial, acting both as a medi- 
cine and food, the latter especially, because it replaces the tissues of the body, in that 
it affords material for the oxidation process to feed upon. It may, perhaps, be stated, 
in a concise way, that the meagreness of its nutritious properties is often made up in 
usefulness by the rapidity of its assimilation ; also, that it requires the least expendi- 
ture of digestive and assimilative force, at the same time being an element of heat and 
force to the system. Finally, in the words of Dujardin-Beaumetz (On the Beverages in 
Common Use, Therap. Gaz., Nov., 1886), "alcohol is a food, a waste-restraining food, 
which, instead of energizing the combustions, slows them, by robbing the haemoglobin 
of the blood-corpuscles of a certain quantity of oxygen ; the character of alcohol as an 
aliment, therefore, may not improperly be included, in a therapeutical sense." 
Caution is certainly required in its employment, especially when employed for a 
prolonged time. Many of us have been made aware, however, of the fact that appar- 
ently unlimited quantities of alcohol may be given in some forms and stages of disease, 
which otherwise appear hopeless, without any untoward effects ; in such cases, the 
carrying of it to intoxication is what is required. The physician should have due 
regard for, or he guided greatly by the feelings or desires of his patient, if any sense of 
discomfort is expressed from its previous administration ; in fact, when a peculiar 
idiosyncrasy to its effects exists. He should not fail to ascertain for himself that the 
dosage required during the illness of the patient is relinquished when the occasion for 
its employment has ceased ; also, that the amount administered in the acute stages of 
disease is gradually lessened toward convalescence ; a failure to perform this duty 
not infrequently leads to a craving for alcoholic stimulants. 
The question of alcohol being generated in the animal organism through the diges- 
tive processes, especially in the combustion of the carbohydrates, is one still undecided 
and open to further research ; the probability of such, however, is highly suggestive. 
Not infrequently the unfortunate impulse to alcoholic excesses is due to its indiscrimi- 
nate and careless prescribing in diseases "nervous" in character, especially in women. 
This is a melancholy fact, and to expose them to such temptation is certainly to be 
decried, when we are familiar with the fact that their power of mental resistance, under 
the circumstances, is generally weak. Cases are met with, however, not infrequently, 
and so constituted that they are utterly, and thus unfortunately, unable to bear any 
mental strain whatever, succumbing almost immediately to its effects. Relief is cer- 
tainly afforded by having recourse to temporary alcoholic stimulation. 
In reference to the assertion that the employment of alcoholic stimulants in acute SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
95 
febrile disease is apt to lead to subsequent excesses; on the contrary, a more or less 
rapid intolerance is observable very early in its administration, due to the quantity 
indicated and ingested in the short space of time. The reverse, however, is evidently 
the case in chronic and nervous diseases. 
In the application of alcoholic stimulants, to enumerate the various diseases in 
which its administration is deemed advisable, would consume too much time. I shall 
content myself by referring to the main indications and morbid conditions presenting 
themselves. To choose the proper moment for their employment is essential ; we are 
not to administer them too early in the disease, where no special indication presents 
itself, especially so in severe general inflammations, where a dilatation of the arteries 
and obstruction of the capillaries exists. First of all, we are to take into consideration 
the fact of the resistance of the patient to the disease, whatsoever the latter may be. 
It is argued by some that their administration is to be deferred until the appearance of 
adynamia, but it may be stated, as a general rule, we are not to wait until signs of dan- 
ger arise, but rather to anticipate them, resorting to stimulants with little hesitation 
when necessary. In acute febrile disease we are to take into consideration, aside from 
the fact of warding off threatened asthenia, the intensity of the pyrexia, the cerebral 
symptoms and state of the digestive and assimilative processes. The existence of 
pyrexia in itself, unaccompanied by any other signs, does not call for its employment. 
Once, however, the indications arise and are recognized, measures should be immedi- 
ately taken to counteract or avert any threatening danger. Under whatever circum- 
stances deemed necessary, its administration should never be left to the hands of the 
patient. Let me state here, also, that in the insufficient and thus imperfect adminis- 
tration of alcoholic stimulants in acute febrile disease, especially when accompanied by 
symptoms of adynamia, we permit the tendency to danger to increase. This would be 
obviated by a more strict attention to the indications presented for their employment 
in the course of the disease. Again, not infrequently, the injudicious and excessive 
administration of alcohol, especially in the form of brandy or whisky, undiluted, leads 
to a gastritis, more or less complicating the disease. Let the fact that alcohol requires 
no digestion be kept in view. It is rapidly diffused throughout the system. This dif- 
fusibility being more rapid when given undiluted. The indications for administering 
it in an undiluted form are, however, few. 
The stronger alcoholics when diluted from five to ten times their bulk with water, 
in febrile disease, act both as diuretics and diaphoretics, in that the activity of the kid- 
neys and sudorific glands are markedly increased. As the febrile condition advances 
the quantity of alcohol is to be proportionately increased, the reverse being the case 
upon the gradual decrease of the pyrexia and toward convalescence; when, however, 
with the decrease in the pyrexia, asthenia supervenes more or less rapidly, as in the 
latter stages of typhoid fever, pneumonia and diphtheria, stimulants are to be adminis- 
tered freely and often, without reserve; the appearance of adynamia, in these cases 
especially, frequently precludes efforts at nourishing the patient, through a decided les- 
sening or failure in the power of the gastric juice to form peptones; to support the fail- 
ing powers, therefore, our main dependence must be in the employment of stimulants. 
In persons ill with acute disease and previously anæmic and reduced in strength, 
the necessity for alcoholic stimulants is more urgent than in those previously healthy 
and plethoric. In phthisis and other wasting diseases, the indications for alcoholic 
stimulants are undoubted; aside from its property of retarding waste of tissue, I believe 
its happy action is due partly to its solvent action on fats, in rendering them more easy 
of digestion and assimilation. 
In sudden collapse or great prostration from recent hemorrhage or shock due to 
severe injuries, surgical operations, or from whatever cause, with feeble or labored heart 
action and preponderance of blood in the venous system, it is especially indicated, and 96 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
should be administered in the form of brandy or whisky, undiluted, its analeptic action 
being desired. 
In septic disease, where the powers of life are actually oppressed, as also in puer- 
peral sepsis, the resisting powers of the organism combined with a sedative and hypnotic 
action, are best maintained by the administration of alcohol in large doses, frequently 
repeated; in puerperal sepsis, tepid baths should also be given in this connection, as 
but recently recommended by Runge, of Dorpat. 
In the grave forms of dysentery, with accompanying adynamia, we have an 
immediate indication for resorting to its use. In diphtheria, with its tendency to rapid 
heart failure, little danger exists in what may seem free stimulation; it is indeed sur- 
prising to what extent stimulation by alcohol may be carried in severe cases, without 
producing any ill effects or even signs of intoxication ; it is especially in these cases 
marked by toxaemia, that, aside from its stimulating property, stamps alcohol as a food 
of great value. In this connection, quite recently, the question has been propounded as to 
whether the sudden death after diphtheria may not be due to thrombosis or embolism of 
the pulmonary artery, through the power of the alcohol to coagulate the albumen of the 
blood, induced by free stimulation? The question is, no doubt, an appropriate one, 
but I have failed to find any record of such, and in my own mind doubt very much its 
occurrence, in so far as induced by alcohol, as numerous cases have been reported of 
sudden death from diphtheria where no alcohol was administered in the course of the 
disease. 
In the later periods of life, the necessity for stimulants is always greater, and in 
whatever febrile disease, where the patient is addicted to the free use of alcohol, the 
latter should never be withheld. 
In nervous diseases great care and discrimination should be exercised, there being 
but little indication for the application of alcoholic stimulants. Where there exists an 
aversion to liquors, the dry or what are termed stronger wines, because of their richness 
in alcohol, are also indicated in febrile disease and states of prostration. 
In chronic diseases with more or less anorexia, the giving of the red or light wines, 
because of their tonic character, will be found beneficial in increasing the appetite and 
aiding the digestion of food; again, in individuals possessing but feeble powers of resist- 
ance, especially in the aged, the administration of lighter or even the stronger wines, in 
moderate doses, will prove especially beneficial. 
In this connection, I would refer to the effervescent or sparkling wines, especially 
champagne; containing but a small percentage of alcohol, and because of the presence of 
the carbonic acid, it is especially serviceable, not only as a quick stimulant and restorative 
in cases of exhaustion, but in allaying gastric irritability and obstinate vomiting, it 
being retained where other measures of treatment are rejected and prove futile; in 
numerous instances I have found it the best and only diffusible stimulant to be 
employed, its rapidity of action and exhilarating power being, in all probability, due to 
a vinous ether diffused by the liberated carbonic acid. 
In all cases in which it is necessary to support life by nutritious enemata, the addi- 
tion of alcoholic stimulants will be found of service, as also in accelerating their absorp- 
tion. Its use, hypodermically, in sudden collapse or shock after surgical operations, is 
so well known that I refrain from any further mention in this regard. In this connec- 
tion, it would be well to state, that in affections of the bladder and urinary organs, 
especially the various forms of Bright's disease; in the various hepatic affections and 
in cases of gout and rheumatism uncomplicated by severe endo- or pericarditis, alcohol 
is contraindicated. Finally, that the adulteration of liquors and wines has a distinct 
bearing upon a discussion of the therapeutics of alcohol seems to me evident, inasmuch 
as in its employment we apply the various liquors and wines, greatly because of their 
bouquet and flavor, in place of alcohol in its pure state; in desiring its true physio- SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
97 
logical effects, therefore, we are to be careful always to ascertain and select a pure 
article. 
' A résumé of the preceding may be tersely given as follows: (1) In alcohol, we have 
one of the most powerful and substantial agents in the treatment of disease, combining, 
aside from stimulant, anti-thermic, paratriptic, alimentary and tonic properties. (2) 
The mechanism of its favorable action upon the animal organism and its utility in 
disease, more especially acute febrile, may be explained in several ways : (a) its 
dynamic action, particularly in greatly lowered arterial tension, in increasing and 
sustaining the vital powers, through its action upon the vascular system and nerve 
centres; (6) its antithermic or apyretic property, in causing a reduction of temperature 
apparently proportionate to the amount of alcohol ingested; (c) its alimentary and 
paratriptic property, due to its own combustion and oxidation, thus retarding disinte- 
gration and oxidation of the tissues. ( 3) No routine practice can be made in the use 
of alcohol in disease ; each case should be treated upon its merits and the indications 
presented ; because of the advantages accruing in most, its unqualified recommenda- 
tion in all disease is not to be thought of ; in this way, it should be prescribed, similar to 
any other drug or therapeutical measure. 
(4) Finally, measures adopted with the view of modifying or protecting any changes 
that take place in the tissues in disease, are certainly legitimate and rational in pro- 
cedure. 
The following paper was read by title :- 
THE PROTEIDS OF THE SEEDS OF ABRUS PRECATORIUS 
(JEQUIRITY) AND A SHORT ACCOUNT OF THEIR 
PHYSIOLOGICAL ACTION. 
LES PROTEIDES DES GRAINES DE LA LIANE À REGLISSE (ABRE) ET UN 
BREF RAPPORT DE LEUR ACTION PHYSIOLOGIQUE. 
DIE PROTEÏN-STOFFE DES ABRUS PRECATORIUS-(JEQUIRITY)-SAMENS, NEBST KURZEM 
BERICHT ÜBER IHRE PHYSIOLOGISCHE WIRKUNG. 
BY SIDNEY MARTIN M. D., B. SC. (BOND.), 
In a communication made to the Royal Society* this year I showed that the proteids 
existing in jequirity seeds were similar in chemical properties to those occurring in other 
seeds, and consisted of a globulin and an albumose. • 
The globulin and albumose are best extracted by treating the ground seeds (which 
have been freed from the red cuticle) with an excess of 15 per cent, sodium chloride, 
filtering, and saturating the filtrate with neutral ammonium sulphate, which causes a 
precipitation of both the proteids. Collecting this precipitate, mixing it with distilled 
water and dialysing it for several days, throws down the globulin in great part, leaving the 
remainder of the globulin and the whole of the albumose in solution. The globulin 
was collected in a filter and washed with distilled water for two days, until the wash- 
ings gave no evidence of a soluble proteid ; the proteid in the filter was then only 
globulin. It was dried over sulphuric acid. The albumose was purified by filtering the 
dialysed liquid into rectified spirit and allowing the precipitate formed in the liquid to 
stand for three to six months, when the whole of the globulin was coagulated and the albu- 
Vol. Ill-7 
* Proc. Royal Soc., Vol. xlii (1887.) 98 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
min could be obtained in solution by treating the dried precipitate with distilled water. 
The solution was re-precipitated by filtering into absolute alcohol ; filtered again and 
dried over sulphuric acid. * 
Clinical properties of the proteids of Abrus seeds. 
Globulin.-The globulin belongs to what I have elsewhere called the class of vegetable 
paraglobulins,* from their resemblance to animal paraglobulin. 1. Abrus-paraglobulin 
is readily soluble in 10 to 15 per cent, sodium chloride or magnesium sulphate solution; 
to a less extent soluble in a five per cent. NaCl solution, and scarcely at all in 0.75 per 
cent. 2. It is completely precipitated from solution by saturation with sodium chloride 
after acidifying, and with neutral ammonium sulphate. 3. It is coagulated by heat in 
ten per cent, magnesium sulphate solution between 75° and 80° C. 4. It is precipitated 
from solution by dialysis, but the precipitate is still soluble in saline solutions ; it is not 
precipitated by exposure to a temperature of 35° to 40° C. for even 48 hours. In these 
two facts it differs markedly from the other class of vegetable globulins I have differen- 
tiated ;f viz., the myosins existing in cereals, which are not only precipitated by 
dialysis, but are changed into an albuminate ; i. e., a body insoluble in saline solutions 
but soluble in dilute acids and alkalies ; and which are precipitated or changed into an 
albuminate by exposure to a temperature of 35° to 40° C. for a few hours. 
Abrus-paraglobulin is precisely similar in chemical properties to the globulin occurring 
in the fruit-juice of Carica Papaya, from which the ferment papain is 
Albumose.-Abrus-albumose belongs to the large class of what I have culled ph y t albu- 
moses, vegetable proteids which may be considered intermediate in properties between 
globulins and peptones. Though resembling the animal albumoses described by Kühne 
and Chittenden, they differ in so many particulars as to deserve a separate name. 
Abrus-phytalbuinose has the following chemical properties : 1. It is soluble in cold or 
boiling distilled water, its chemical and physical properties not being apparently altered 
by boiling its solution. 2. It is not precipitated by saturation with sodium chloride, unless 
a large excess of acetic acid be added. It is readily thrown down by saturation with 
neutral ammonium sulphate. 3. Nitric acid does not precipitate it unless solid sodium 
chloride be added nearly to saturation. 4. Its solution gives a pink color with sulphate 
of copper and excess of potash (' ' Biuret " or peptone reaction). 
Abrus-phytalbumose is identical in chemical properties with the phytalbumose occurring in 
the fruit juice of carica papaya, which is the proteid I have shown to be closely associated 
with the ferment 11 papain." 
I have dealt thus fully with the preparations and the chemical properties of the 
abrus proteids because of the important bearing on their physiological action. Warden 
and Waddell have shown | that the toxic principle of abrus seed is a proteid closely 
allied to Liebig's "plant albumin." They obtained it from a watery extract of the 
seeds. They did not further invéstigate the chemical properties present. 
In testing the physiological toxic action of a proteid, three points are of prime 
importance:- 
1. We must be sure that there is only one proteid present in the solution used. 
2. The presence of an alkaloid must be eliminated. 
3. The contamination or the presence of bacteria (schizomycetes) or their spores 
must be eliminated. 
As is well known, the action of jequirity was at first thought to be due to a bacillus, 
the so-called "jequirity bacillus," but this has been shown to be incorrect by the 
s Journ. of Physiology, Vol. VI, page 353. Physiolog. Soc. Proc., Feb. 12, 1887. 
f Op. cit., Proc. Phys. Society. | Op. cit., Jour Phys. 
$ "The Non-bacillar Nature of Abrus Poison." Calcutta, 1884. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
99 
experiments of Klein and. of Warden and Waddell. Klein, from his short investiga- 
tion, came to the conclusion that the poison was of a "ferment" nature ;* Warden 
ahd Waddell also came to this conclusion, with the addendum, however, that the 
" ferment " was closely associated with a plant albumin, which they called abrin. The 
chief reason for considering the toxic principle a " ferment," was that its activity was 
destroyed by boiling. 
PHYSIOLOGICAL PROPERTIES OF THE ABRUS PROTEIDS. 
This part of the investigation was done with Dr. Norris Wolfenden, who shares an 
equal responsibility with me; and the remarks now made must be considered only as 
a preliminary communication. 
In our experiments, we have made use of a solution of pure abrus-paraglobulin in 
sterilized fifteen per cent, sodium chloride solution, and of a solution of abrus-phytal- 
bumose in sterilized distilled water. The syringe used in inoculating was also care- 
fully sterilized. 
We have tested the physiological action in two ways: (1) by instilling the liquid 
into the eye; (2) by hypodermic injection. The chief points in the results we have 
obtained may be summarized as follows:- 
1. Abrus-albumose is much less active than the abrus-globulin. In the eye, it does 
not always produce conjunctivitis; subcutaneously, it does not always produce death. 
2. Abrus-globulin is very toxic. Instilled into the eye it produces '1 abrus-ophthal- 
mia, ' ' which, in most cases, ends in recovery, though in some cases, the animal (rabbit) 
dies in a few days (a fact previously noted by Klein).f 
If abrus globulin be placed in a solid form under the eyelid, it produces intense 
conj unctivitis, with local ecchymoses. 
Hypodermically, it always kills the animal, even when given in small dose ; and its 
toxic power is proportional to the dose. It produces great local congestion or oedema, 
with, in the majority of cases, ecchymoses, sometimes punctiform, sometimes diffuse. 
The post-mortem signs agree with those described by Warden and Waddell. 
3. The activity of abrus-globulin is at once and permanently destroyed by heating 
its solution in saline up to 75° C. (The heating was performed gradually; the test tube 
containing the solution of globulin being placed in a flask full of cold water, which 
was heated ; directly the temperature rose to 75° C., or any other temperature that 
was desired, the test tube was removed and rapidly cooled under the tap). Heating, 
in the manner described, up to 70° C. did not destroy the activity of the globulin, nor 
was this affected by any lower temperature. In ten per cent, sodium chloride solu- 
tion, the globulin is coagulated between 66° and 73° C.J We find that the toxic power 
of the globulin is destroyed at this temperature, and we cannot but point out that the 
activity* of the poison seems to be intimately connected with the uncoagulated condi- 
tion of the proteid. Full details of the experiments, with further remarks on the albu- 
mose and the action of these proteids on protoplasm, will shortly be published by Dr. 
Norris Wolfenden and myself. 
* " Microorganisms and Disease." 1884, p. 165. 
f Op. cit. J Proc. Roy. Soc., Vol. XLII, p. 333. 100 
NINTII INTERNATIONAL MEDICAL CONGRESS. 
Dr. Justus Andeer, of Munich, read a paper- 
DAS RESORCIN UND SEINE PRÄPARATE. 
RESORCIN AND ITS PREPARATIONS. 
LA RÉSORCINE ET SES PRÉPARATIONS. 
VON DR. JUSTUS ANDEER, 
München. 
Die vorliegende Mittheilung ist die Frucht meiner Beobachtungen während eines 
Zeitraumes vou zehn Jahren. Ungeachtet der vielen Angriffe, welche dieses Mittel 
von Seiten oberflächlicher Controlforscher zu erfahren hatte, bricht sich dasselbe immer- 
mehr Bahn in der medicinischen Welt auf Grund gediegener Erfahrungen ernster 
Forscher, wie Bouchut, Bongouche, Callios, Cattani, Ihle, Moncorvo, Unna, und so 
vieler Anderer. Ein Hindemiss für die Einführung des Resorcins in die praktische 
Medicin, die absolute Reinheit des Mittels, ist nunmehr gehoben, indem wir die Firmen 
von Meister, Lucius in Höchst, und von Monnet & Co. à la Plaine bei Genf, tadellose 
Präparate herstellen sehen. Besonders die Résorcine médicinale crystallisée des 
Letzteren genügt allen bislang gemachten Anforderungen, sei es in Bezug auf Güte wie 
Billigkeit des Mittels. Neben der chemischen Vervollkommnung, ist auch die pharma- 
ceutische Herstellungsweise des neuen Mittels erstrebt worden, so dass man dasselbe in 
passender Form äusserlich und innerlich anwenden kann. Für die äussere Anwen- 
dungsweise habe ich dadurch schöne Resorcinpräparate zu erhalten gesucht, dass ich 
aus Mischungen von Resorcin mit Cacaobutter Stangen und feine Platten herstellen 
liess, um selbe auf die kranke Haut oder auf Wunden zu legen. Als "herrliches 
Antisepticum ", wie Nussbaum das Mittel nennt, macht es Haut und Wunde schnell 
rein und führt dadurch eine schnelle Heilung herbei. Ganz brillant ist die Wirkung 
dieser Resorcinpräparate in Verbindung mit den Resorcinseifen bei Erkrankungen 
durch Parasiten : Sycosis, Lichen, Alopecia, Eczemen, Condylomen. Herpetische 
Prozesse, lupusähnliche Geschwüre, die allem Anderen trotzten, heilten mit diesen 
Präparaten, und nicht minder wurden hartnäckige Eczeme und torpide Geschwüre vom 
Resorcin ganz besiegt. Einzig in seiner Art ist die Wirkung des Resorcins auf Keloide, 
die bekanntlich bisher nahezu unheilbar genannt werden mussten. Die Resorcin- 
präparate, welche zu dermathologischen Zwecken verwendet werden sollen, brennen 
nicht, wenn sie nicht höhere Concentrationen erreichen, sie erodiren die Haut nicht wie 
Pyrogallol und reizen die Augen nicht -wie Chrysarobin. Am besten wird Resorcin als 
Salbenmull gebraucht und mit Collodium bestrichen. Will man für den Nothver- 
baud in Ermangelung der technischen Präparate eine Resorcinsalbe ad hoc sich ver- 
schaffen, so passt die Butter, welche überall mit grösster Leichtigkeit zu haben ist, am 
vorzüglichsten und in anfänglicher Concentration von 1 % Resorcin. 
Ich erachte die Einführung der obengenannten Resorcinseifen in die praktische 
Medicin für einen grossen Fortschritt aus mehrfachen Gründen. Während beispiels- 
weise die Carbolseife binnen weniger Tage einen grossen Theil ihres Phenols durch 
Verflüchtigung verliert und desinfectorisch unwirksam wird, ist dies bei den Resorcin- 
seifen nie der Fall, selbst nach jahrelangem Aufbewahren nicht ; ihre medicamentöse 
Kraft bleibt unverändert. Sie ist ferner geruchlos und reizt weder die gesunde noch 
die kranke Haut oder Schleimhaut und verleiht beiden einen weichen, zarten, elasti- 
schen Zustand im Gegensatz zur Carbolseife, welche die genannten Gebilde hart, unem- 
pfindlich, unelastisch macht und im Resorptionsfalle giftig wirkt, welche gefährliche 
Eigenschaft den Resorcinseifen völlig abgeht. Die Resorcinseifen empfehlen sich daher 
besonders für den Spitalgebrauch, für den Reise- und Kurgebrauch, wie nicht minder 101 
SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
als Ersatz für die gewöhnlichen Seifen in Haushaltungen, die auf Reinlichkeit und 
moderne Hygieine halten. Auch ist ihr Preis nicht höher wie der gewöhnlicher Seifen, 
die mit 50 cts. bis zu 1 frs. per Stück bezahlt werden. 
Seit Einf ührung der keratinirten Pillen durch meinen Freund Unna in Hamburg 
ist die innerliche Localtherapie durch Resorcin ebenfalls bedeutend vervollkommnet 
worden. Diese Pillen, welche bekanntlich erst im Dünndarm gelöst werden, ohne vom 
Magensaft vorher angegriffen und verändert worden zu sein, liess ich mit Resorcin und 
Ricinusöl füllen (Rec. Resorcin puriss 1.0 solve in 01. Ric. feroid 50.-100.0), und 
verabreichte ich sie dann mit bestem Erfolge bei verschiedenartigen Diarrhöen, Dysen- 
terien, Cholera infantum, Typhus, kurz bei allen oberflächlichen und tief excorirenden 
Prozessen des Darmes. 
Für den Genitalapparat und Tractus sind die Resorcin-Cocaostäbchen und Kap- 
seln, wie sie Apotheker Sauter in Genf auch für andere medicamentöse Zwecke 
herstellt, sehr schön. In praktischer Beziehung möchte ich, nach meinen bisherigen 
Erfahrungen wenigstens, besonders für eine vollständige Reinigung der Vagina, mehr 
den wässerigen Einspritzungen wie dem compakten Präparat des Resorcins den Vorzug 
geben, weil die Flüssigkeit besser in die Falten und Krypten der Scheidenschleimhaut 
eindringt, um selbe wirksam zu ätzen und zu desinficiren. Wie das Resorcin, wie 
kein anderes Mittel der Pharmakopoe, in jeder Flüssigkeit leicht löslich sich erweist, 
ebenso leicht ist es mit jedem Fette zu verbinden, um dasselbe an schwer zugänglichen 
Theilen des Organismus, wie Speiseröhre, Kehlkopf, Uterus, Mastdarm, an wenden zu 
können. Wie und bei welchen Hautaffektionen das Resorcin richtig anzuwenden ist, 
habe ich weitläufig in Unna's Monatsheften für Dermatologie, Jahrgang 1883-87, ange- 
geben, über seine innerliche Anwendungsweise behalte ich mir baldige Mittheilungen 
vor. Bei D., wo ich immer glänzende Heilergebnisse hatte, haben viele Aerzte das 
Mittel zu oft oder zu schwach angewTendet und dadurch nicht bessere Kuren als mit 
anderen Mitteln erzielt. Hier wie überall liegt das Richtige in der Mitte, wie ? 
DISCUSSION. 
Dr. L. Lewin.-Mit ausserordentlicher Ausdauer hat der Herr Vortragende seit 
Jahren das Resorcin in seinen mannigfaltigen Wirkungen erforscht. Die Ausdeh- 
nung, welche in neuerer Zeit Herr Unna dieser Substanz als reducirendem Stoffe 
gegeben hat, habe ich in der Berliner Klinischen Wochenschrift vor einiger Zeit zu 
bekämpfen versucht. 
Ich glaube, wir müssen solche Fragen von einem etwas allgemeinen Gesichts- 
punkte aus betrachten und uns vor allen Dingen hüten, eine Substanz wie das 
Resorcin auf Kosten aller anderen zu erheben. Hat das Resorcin wirklich fünfzig 
überlegene Wirkungen über andere Stoffe? So flüchtig wie der Herr Vortragende 
meint, ist die Carbolsäure in Carbolseifen nicht, dass die Wirkung dadurch beein- 
trächtigt werden könnte. Aber auch andere Stoffe, wie das isomere Hydrochinon, 
wirken ganz analog antiseptisch, so dass das Resorcin hierin keine so ausserordentliche 
Bevorzugung verdient. 
Der Herr Vortragende meint, dass eine innere Antiseptik damit erzeugt werden 
konnte, wenn es in keratinirten Pillen oder mit Ricinöl gegeben wurde. Aber ob 
nun auch die keratinirten Pillen im Magen unangegriffen bleiben oder nicht - ich 
habe sie bei Thieren im Magen zerfallen sehen - so kann man sicherlich mit anderen 
Mitteln in solchen Formen ähnliche Wirkungen herbeiführen. 
Also auch in dieser Beziehung sehe ich keine überlegenen Eigenschaften des 
Resorcins. Zuletzt muss ich die Giftigkeit des Resorcins hervorheben, die derjenigen 
anderer Stoffe der Benzolreihe nicht nachsteht. Ich schliesse, indem ich nochmals 102 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
die Wichtigkeit solcher speciellen Untersuchungen betone, aber doch davor warnen 
möchte, eines auf Kosten des anderen zu erheben. 
Dr. II. G. Beyer, u. s. n.-So far as concerns the assertion of Dr. Unna, of 
Hamburg, that resorcin is a reducing agent, I am inclined to agree with the last 
speaker, that it may also at times, and under certain conditions, act as an oxidizing 
agent. If resorcin be a reducing agent at all it can only be called so in its relations 
to certain definite chemical compounds. So far as its action on living mammalian 
blood is concerned, it would seem to be an oxidizing rather than a reducing agent ; 
for blood, when mixed with resorcin in certain proportions, may be kept without 
undergoing decomposition and remain of a bright arterial hue for many days, thus 
showing that it has antiseptic powers, and that it does clearly not have the power of 
reducing hæmoglobin. 
Dr. Andeer.-Resorcin wurde von mir nie als Reduktionsmittel, wie der Herr 
Opponent es meint, sondern ist zuerst von Unna gebraucht worden. In allen meinen 
Arbeiten habe ich immer nur vom Resorcin als Hydratationsmittel gesprochen. In 
gleicher Weise kann ich behaupten, dass ich ebenfalls nie vom Resorcin als einem 
Fiebermittel gesprochen, sondern nur von einem antiseptischen, kaustischen und 
hämostatischen. 
Die Vorzüge des Resorcins gegen andere Mittel sind zu evident, als dass man 
hier opponiren sollte. Von der Haut aus resorbirt, tritt nie Vergiftung ein, wie 
nach Phenolgebrauch ; es reizt und brennt nicht die Haut, wie Phenol, Thymol 
und andere; es macht nicht die Haut ungeschmeidig und hart wie die anderen, und 
desinficirt zugleich in 1 % Verbindung mit Vehikeln irgend welcher Art ebenso 
stark. 
Die vorgeworfene Giftigkeit des Resorcins ist bei richtiger Anwendung desselben 
völlig unzutreffend. Die besten Resorcinforscher, welche meine Angaben controllirt 
haben, stimmen darin überein, dass man 50-60 pro die ohne irgend welche Vergif- 
tungssymptome verabreichen kann. Die von Rossbach, Brieger und ihren Anhän- 
gern vorgeworfene Giftigkeit ist demnach unrichtig oder richtig nur bei tadelhaften, 
resp. unreinen Resorcin präparaten. 
In allen meinen Arbeiten und mündlichen Mittheilungen habe ich nie ermangelt, 
darauf hinzuweisen, dass das Resorcin keine Panacee sei, sowohl bei äusseren, wie 
bei inneren Krankheiten. Bei Affectionen von saurer Diathese beispielsweise ist es 
nicht blos indifferent, sondern sogar schädlich, mithin keine Panacee. Ein direct 
specifisch antifebriles Mittel ist es ebenfalls nicht, mithin keine Panacee. Und so 
könnte ich noch durch viele Argumente beweisen, dass der Vorwurf, ich wolle das 
Resorcin als Panacee anempfehlen, wirklich allen Grundes entbehrt. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
103 
ÜBER DIE NOTH WENDIGKEIT EINER INTERNATIONALEN 
PHARMAKOPOE. 
ON THE NECESSITY FOR AN INTERNATIONAL PHARMACOPŒIA. 
SUR LA NÉCESSITÉ D'UNE PHARMACOPÉE INTERNATIONALE. 
VON DR. F. DRONKE, 
Berlin. 
Eine vergleichende Zusammenstellung über die Zubereitung der verschiedenen, in 
den Pharmakopoen der einzelnen Culturstaaten gebräuchlichen galeuischen, nament- 
lich der starkwirkenden Mittel, sowie der Stärke und des Wirkungsgrades der chemi- 
schen Präparate der Pharmakopoen zeigt meist eine nicht unbedeutende Verschieden- 
heit. Wenn nun auch selbstredend jedes einzelne Land innerhalb seiner Grenzen die 
Berechtigung zu eigenen Vorschriften hat und hiervon Gebrauch macht, so wirft sich 
in Folge des täglich sich steigernden internationalen Verkehres der gesammten Cultur- 
staaten doch unwillkürlich die Frage auf, 
(1) ob es nicht wünschenswert!!, um nicht zu sagen nothwendig, erscheint, die 
Aufstellung einer Internationalen Pharmakopoe anzustreben, 
(2) ob es möglich sèin wird, dieses Ziel zu erreichen, und 
(3) welche Wege eventuell zur Erreichung dieses Zieles eingeschlagen werden 
können. 
Der erste Punkt, der Wunsch nach einer Internationalen Pharmakopoe, findet schon 
seit langen Jahren seinen beredten Ausdruck auf den verschiedenen in längeren oder 
kürzeren Zwischenräumen zusammentretenden Internationalen pharmaceutischen Con- 
gressen. Bereits auf dem ersten pharmaceutischen Congresse in Braunschweig, 1865, war 
die Gleichstellung aller starkwirkenden Arzneistoffe und Präparate in Bezug auf ihren 
Gehalt an wirksamen Bestandtheilen in allen Pharmakopoen angeregt und wurde dieser 
Punkt auch auf dem zweiten Internationalen pharmaceutischen Congresse, 1867, in 
Paris auf die Tagesordnung gesetzt. Der Vorschlag fand in der gesammten pharma- 
ceutischen Welt den grössten Beifall und die lebhafteste Zustimmung und auch von 
maassgebenden medicinischen Kreisen wurde der Vorschlag als zeitgemäss und die 
Durchführung als nothwendig und wünschenswerth anerkannt ; wie wir aber zu 
unserem Bedauern gestehen müssen, bislang leider ohne Erfolg. 
Im Jahre 1869 legten zwar die Herren Robinet und Mialhe dem dritten Internatio- 
nalen pharmaceutischen Congresse in Wien die Scizze zu einer derartigen, die Gleich- 
stellung bezweckenden Arbeit vor ; es wurden auch die genannten Herren ersucht, auf 
Grund der vorgelegten Scizze ein ausführliches Elaborat dem nächsten Congresse vor- 
zulegen, aber das auf Grund dieses Ersuchens auf dem vierten Internationalen pharma- 
ceutischen Congresse in Petersburg vorgelegte Elaborat entsprach nicht den gestellten 
Ansprüchen und musste trotz aller Anerkennung der ausgezeichneten Bearbeitung 
zurückgewiesen werden. Es wurden die Vertreter der St. Petersburger Pharmaceu- 
tichen Gesellschaft ersucht, die von Dr. Méhu, als Vertreter der Société de Pharmacie 
de Paris, angefertigte Arbeit- in geeigneter Weise umzuarbeiten. Leider unter- 
blieb die Arbeit und es wurde 1881 in London auf dem fünften Internationalen 
pharmaceutischen Congresse neuerdings beschlossen, die Gleichstellung aller in den 
Pharmakopoen der verschiedenen Länder enthaltenen, stark wirkenden Arzneistoffe 
und Präparate hinsichtlich ihres Gehaltes von stark wirksamen Stoffen in Angriff zu 
nehmen. Es wurde zu diesem Zwecke auf dem Londoner Congresse ein aus pharma- 
ceutischen Vertretern aller am Congresse betheiligten Staaten bestehendes Comité 
gewählt mit dem Auftrage, sich durch Vertreter der am Congresse nicht betheiligten 104 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Staaten zu verstärken und sodann baldmöglichst eine dem Beschlüsse des Congresses 
entsprechende sogenannte " Internationale Pharmakopoe" auszuarbeiten. Das Comité 
bestand in Folge dieses Beschlusses aus 35 Delegirten, welche 18 Staaten angehörten, 
und trat sofort in Thätigkeit, so dass dem sechsten Internationalen pharmaceutischen 
Congresse in Brüssel, 1885, ein ausführliches Elaborat vorgelegt werden konnte. Der 
Wunsch nach einer Internationalen Pharmakopoe ist also gewiss schon oft genug 
ausgesprochen worden ; die Nothwendigkeit tritt tagtäglich immer mehr hervor und 
mag durch einige Betrachtungen und einzelne Beispiele hier erläutert werden. 
Ein deutscher Arzt liest in einem wissenschaftlichen Journale eine warme Empfeh- 
lung von Syrupus Ferri jodati gegen diese oder jene Krankheit in näher angegebener 
Dosis und nimmt in nächster Zeit Gelegenheit, Syrupus Ferri jodati in der angegebenen 
Dosis zu ordiniren ; aber er ist nicht wenig unangenehm berührt von der Jod-Intoxi- 
cation, welche nach der verordneten Dosis von Syrupus Ferri jodati eingetreten ist ; 
er glaubt, dass irgend ein Missverständniss vorliege ; doch dem ist nicht so ; die Dosis 
im Journale stimmt, der Apotheker hat sich nicht verwogen, die Arznei ist richtig 
angefertigt, genau dem Patienten eingegeben, und doch Jodintoxication ! Die Sache 
klärt sich einfach auf : der Autor im Journale hatte den Syrupus Ferri jodati des 
Codex medicamentarius Gallicus (Pharmacopée française) vor Augen, welcher in 100 
Theilen 0.5 Theile Ferrum jodatum enthält, und der in Deutschland ordinirende Arzt 
erhielt den zehnmal stärkeren Syrupus Ferri jodati der Pharmakopöa Germanica II 
dispensirt ! 
Ein französischer Arzt liest in einem Journale die Anwendung von Syrupus Ferri 
jodati, er verordnet denselben auf Grund dieser ihm zuverlässig erscheinenden Angaben 
und ist nicht wenig erstaunt, dass von allen den gepriesenen Wirkungen nichts eintritt. 
Nun, die Lösung fand sich auch : der empfehlende Autor war ein holländischer Arzt ; 
der Syrupus Ferri jodati Pharmacopôæ Neerlandicæ enthält in 100 Theilen 20 Theile 
Ferrum jodatum, d. h. ist 400 Mal stärker als der Syrupus Ferri jodati Pharmakopôæ 
Gallicæ ! Einen Ueberblick von einzelnen Differenzen gewähren die hier folgenden 
Tabellen. 
In 100 Theilen des Präparates. 
Ph. 
Americana. 
Ph. 
Austriaca. 
Ph. 
Britica. 
Ph. 
Gallica. 
Ph. 
Germanica. 
Ph. 
Helvetica. 
• q 
Ä 
Acidum hydrochloric, enthält wasser- 
freie H. CI 
31.90 
59.50 
1.0Ö 
10.00 
8.00 
24.24 
48.00 
12'00 
5.80 
32.00 
60.00 
1.00 
5.70 
3.00 
+ 3.00 
Ka. J. 
34.40 
54.50 
0.1123 
0.50 
7.70 
25.28 
25.50 
5'00 
9.10 
12.40 
18.57 
1'00 
10.00 
30.50 
46.20 
20'00 
7.70 
Acidum nitricum enthält wasserfreie 
Säure N3O5 
Liquor Natrf arsen icosi enthält Natrum 
arsenicosum siccum 
Syrupus Ferri jodati enthält Jodeisen 
Tinct. Jodinæ enthält reines Jod 
TABELLE I. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
105 
Zur Herstellung von 100 Theilen der betreffenden Tinctur werden angewendet. 
TABELLE II. 
Ph. 
Americana. 
Ph. 
Austriaca. 
Ph. 
Britica. 
Ph. 
Gallica. 
Ph. 
Germanica. 
Ph. 
Helvetica. 
Ph. 
Neerlandica. 
Tinctura Aconiti 
40.0 
20.0 
12.5 
20.0 
10.0 
20.0 
Folia 
sicca. 
Tinctura Belladonnæ 
Tinctura Digitalis 
Tubera siccata. 
+ 0.4 
Acidum 
tartaric. 
Pharmakopöa 
Italica eodem 
modo. 
15 0 
Folia 
sicca. 
20.0 
Radix 
sicca. 
5.0 
Folia 
sicca. 
20.0 
Folia 
sicca. 
10.0 
Folia sicca, resp. 
50.0 Folia récen- 
tes Pharmakopöa 
Italica eodem 
modo. 
20.0 
Folia 
sicca. 
15.0 
20.0 
12.5 
20:0 
10.0 
20.0 
25.0 
Folia sicca. 
resp. bei Pharma- 
kopöa Germanica 
50.0 Folia récen- 
tes. 
Tinctura Opii simplex 
Das zur Herstellung der Tinc- 
tura Opii verwendete Opium 
soll Morphium enthalten in 
Procenten 
10.0 
12-16 
10.0 
10 
8.2 
9.5-10.5 
14.0 
10-12 
10.0 
10 
10.0 
10-12 
20.0 
ohne 
Vorschrift 
Noch schwieriger und unangenehmer sind die Verhältnisse bei der Darstellung der 
narkotischen Extracte, z. B. bei Extractum Aconiti. 
Das Extractum Aconiti wird bereitet in der 
Pharmakopöa Britica aus frischem Kraut und Blüthentrauben mit Zusatz des aus- 
geschiedenen Chlorophyll. Consistenz zwei. 
Pharmakopöa Neerlandica aus frischem Kraut (aquosum) ; aus frischem Kraut mit 
Spiritus (spirituosum). Consistenz zwei. 
Pharmakopöa Gallica aus trockenem Kraut mit kochendem Wasser. Consistenz zwei. 
Pharmakopöa Helvetica aus trockenem Kraut mit Spiritus von 50 Procent. Con- 
sistenz ein. 
Pharmakopöa Americana aus den trockenen Tuberis mit Spiritus 90 Procent und 
Säure ein Procent. Consistenz zwei. 
Pharmakopöa Germanica, Pharmakopöa Austriaca, Pharmakopöa Italica aus trocke- 
nen Tuberis mit Spiritus von bez. 60 Procent, 70 Procent, 90 Procent. 
Alle pharmakodynamischen Untersuchungen stimmen darin überein, dass dieTubera 
siccata bedeutend reicher an Aconitin sind als die Folia, und dass das beim Erhitzen von 
frischem Blattsafte sich ausscheidende Chlorophyll ganz unwirksam und frei von Aco- 
nitin ist. 
Trotz diesen ganz bekannten Thatsachen lässt die Pharmakopöa Britica ihr Extrac- 
tum Aconiti durch Auspressen der frischen Blätter und Blüthen mit Stengeln, Erhitzen 
des ausgepressten Saftes und Zufügen des ausgeschiedenen und abkolirten Chlorophylls 
zu dem eingedampften Safte bereiten, so dass jedenfalls das Extractum Aconiti Pharma- 
kopôæ Briticæ das an Wirkung schwächste ist und das in demselben enthaltene Chloro- 
phyll Zersetzungen und Verderbniss des Extractes noch möglichst beschleunigen wird. 106 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Ein in Deutschland verschriebenes und in England angefertigtes Recept wird sicher 
nicht die gewünschte Wirkung haben ! Umgekehrt kann ein in England verschriebenes 
und in Deutchland angefertigtes Recept sehr leicht zu unangenehmen nicht erwünschten 
Complicationen f ühren. 
Stärker, und zwar mindestens um das Doppelte, ist das nach der Pharmakopöa Neer- 
landica e succo foliorum recentium bereitete Extractum aquosum, da das beim Erhitzen 
ausgeschiedene Chlorophyll u. s. w. dem eingedampften Safte nicht wieder zugesetzt 
werden darf. Erfahrungsmässig beträgt das ausgeschiedene Chlorophyll circa 60 Pro- 
cent gegen 40 Procent des eingedampften Saftes. 
Noch stärker ist das nach der Pharmakopöa Neerlandica analog dem Extractum 
Belladonnæ Pharmakopôæ Germanica? aus dem frischen ausgepressten Safte der Blätter, 
nach dem Abkoliren des beim Erhitzen abgeschiedenen Chlorophylls durch Spiritus 
erhaltene Extractum Aconiti spirituosum, da hierbei sowohl das unwirksame Chloro- 
phyll, als auch noch ein grosser Theil der sonstigen unwirksamen Schleim- und Extrac- 
tivstoffe ausgeschieden werden, und somit eine weitere nicht unerhebliche Steigerung 
des Aconitingehaltes und der Wirksamkeit des fertigen Präparates bedingen. (1 :2:3 
nach Schroff.) Die aus den getrockneten Blättern durch Infusion mit kochendem 
Wasser (Pharmakopöa Gallica) oder mit verdünntem 50-procentigen Spiritus (Pharma- 
kopöa Helvetica) bereiteten Extracte entziehen sich betreffs der Wirksamkeit jeder 
weiteren Beurtheilung, da bei dem Trocknen und der Aufbewahrung der narkotischen 
Blätter sich Einflüsse der mannigfachsten Art geltend machen und die wirksamen 
Bestandtheile in grösserem oder geringerem Maasse verändern. 
Wirksamer als die aus den Blättern dargestellten Extracte sind jedenfalls die aus 
den getrockneten Tubera erhaltenen :•!. sind die Tubera a priori reicher an Aconitin, 2. 
enthalten dieselben weniger sonstige, leicht zersetzbare und weitere Zersetzung her- 
vorrufende und bedingende Stoffe, 3. werden dieselben nur durch Extraction mit Spiri- 
tus hergestellt. Aber auch selbst die vier Pharmakopoen, welche die Anwendung der 
Tubera vorschreiben, also die Pharmakopöa Germanica, Pharmakopöa Austriaca, Phar- 
makopöa Italica und Pharmakopöa Americana, weichen in der Bereitungsweise unter- 
einander ab. Die drei zuerst aufgeführten Pharmakopöen schreiben resp. 60 Procent, 
70 Procent und 90 Procent Spiritus bei gleicher Extractions-Consistenz (2) vor, 
während die zuletzt genannte Pharmakopöa Americana den 90-procentigen Spiritus mit 
1 Procent Weinsäure versetzt anwenden lässt und das wirksamste Extract erhält. 
Wir dürfen uns daher nicht wundern, wenn nach den betreffenden Publicationen das 
spirituöse Extractum Aconiti e tuberis 6-7 Mal stärker wirkt als das Extractum e succo 
foliorum recentium ! 
Das sind in der That traurige Verhältnisse, die eine Verständigung auf dem Wege 
internationalen Zusammengehens gewiss dringend nothwendig machen ! 
Eine Internationale Pharmakopoe würde derartigen Uebelständen und Verschieden- 
heiten gründlich abhelfen; dieselbe würde dem Arzte und dem Pharmaceuten in gleicher 
Weise nützlich sein und würde jedenfalls von allen Seiten als eine wichtige Errungen- 
schaft mit grosser Freude begrüsst werden. 
Au der Möglichkeit, das vorgesteckte Ziel zu erreichen, wird wohl Niemand in den 
betheiligten Kreisen zweifeln. 
So wie sich das metrische System nach und nach Bahn gebrochen und in wissen- 
schaftlichen Werken eingebürgert hat, so wird sich auch bei ernstem Willen und eifri- 
gem Streben eine Internationale Pharmakopoe herstellen lassen und einbürgem, wenn 
von allen betheiligten Kreisen ein solches Verlangen einmüthig ausgesprochen und von 
allen Seiten gefördert und betrieben wird. 
Und es dürften sich wohl auch trotz den mannigfachen, gewiss nicht zu unter- 
schätzenden Schwierigkeiten die geeigneten Wege finden lassen, um dieses Ziel zu 
erreichen. SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
107 
Es sei gestattet, hier einige passend erscheinende Vorschläge zu machen. Zur Motivi- 
rung derselben gehen wir auf die bisherigen Bemühungen der verschiedenen Interna- 
tionalen pharmaceutischen Congresse zurück. 
Bei der Ausarbeitung einer Pharmakopoe, namentlich aber einer Internationalen 
Pharmakopoe, welche für eine grosse Anzahl von Kulturstaaten maassgebend sein soll, 
muss die Therapie und Pharmakologie als gleichberechtigte Wissenschaft neben der 
Pharmacie stehen und in einer Internationalen pharmaceutischen Commission muss der 
Mediciner zuerst gehört werden, bevor der Pharmaceut mitspricht. 
Der Mediciner muss sich darüber aussprechen, welche Medicamente er für nöthig 
oder wünschenswerth erachtet, er muss darüber Auskunft geben, ob ihm stark concen- 
trirte oder verdünntere Arzneimittel angenehmer zur Dosirung sind, und an Hand 
und nach Kenntniss dieser medicinischen Wünsche muss der Pharmaceut bemüht sein, 
die nöthigen Drogen zu beschaffen, die chemischen Präparate und galenischen Mittel 
herzustellen und dem Arzt zur Prüfung übergeben. 
Finden sich dann Schwierigkeiten, lassen sich die Anforderungen des Arztes nicht 
erfüllen, entsprechen die erhaltenen Präparate nicht den ärztlichen Anforderungen, 
dann muss durch Versuche, Verhandlung und Besprechung ein Compromiss herbeige- 
führt werden, und eine Verständigung dürfte sich wohl immer herbeiführen lassen. 
Mein Vorschlag würde dahin gehen, eine Commission zu erwählen, welcher Thera- 
peuten, Pharmakologen und Pharmaceuten der verschiedenen Länder angehören. 
Dieselbe würde einen Vorsitzenden, zwei bis drei Stellvertreter desselben und einen 
ständigen Sekretär haben, und in der oben angedeuteten Weise nach näher festzu- 
stellendem Plane an die Bearbeitung des Entwurfes einer Internationalen Pharmakopoe 
herantreten. 
Diese Commission würde die einzelnen Arbeiten unter sich vertheilen, geeignet 
erscheinende Persönlichkeiten um Auskunft ersuchen, durch ihre eigenen Mitglieder 
oder durch andere zuverlässige Personen die nöthigen Untersuchungen und Arbeiten 
vornehmen lassen und auf Grund der erhaltenen Resultate die nöthigen Ausarbeitungen 
vornehmen. 
Die Haupt-, um nicht zu sagen die einzige, Schwierigkeit würde die finanzielle 
Seite bilden. 
Wenn auch die Mitglieder der Internationalen Pharmaceutischen Commission ihre 
eigene persönliche Arbeitskraft vielleicht unentgeltlich der ganzen Sache widmen und 
die Arbeiten als eine wissenschaftliche Ehrensache behandeln, so dürften doch durch 
Portos, Correspondenz, Reisen, u. s. w., u. s. w., immerhin Kosten enstehen, deren 
Deckung durch einen Einzelnen nicht verlangt und erwartet werden kann. 
Vielleicht dürfte es gelingen, durch Beiträge Seitens der einzelnen ärztlichen und 
pharmaceutischen Vereine das nöthige Geld zu beschaffen, vielleicht übernehmen die 
einzelnen Staats-Regierungen die Unkosten, vielleicht auch finden sich reiche Private 
oder Fabrikanten, welche im Interesse der Sache die nothwendigen Mittel flüssig 
machen und zur Verfügung stellen, so dass es auf diese Weise ermöglicht werden kann, 
eine Internationale, die gesammten Kulturstaaten umfassende Pharmakopoe auszuar- 
beiten und einzuführen. 108 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Wm. Ward, of Washington, read a paper (which was not concluded before 
adjournment) on- 
SUPPLEMENTAL RESPIRATION SUPERINDUCED IN CHOLERA AND 
POST-PARTUM HEMORRHAGES, BY ADMINISTRATION OF 
SUITABLE OXYGEN-YIELDING COMPOUNDS, IN 
SOLUTION, THROUGH THE STOMACH, AS A 
RATIONAL MEANS OF TREATMENT. 
RESPIRATION SUPPLEMENTAIRE APPORTEE DANS LE CHOLÉRA ET LES HÉM- 
ORRAGIES POST-PARTUM, PAR L'ADMINISTRATION DE COMPOSES 
D'OXYGENE, EN SOLUTION DANS L'ESTOMAC, COMME 
UN MOYEN RATIONNEL DE TRAITEMENT. 
DIE HERVORBRINGUNG SUPPLEMENTÄRER ATHMUNG BEI CHOLERA UND PUERPE- 
RALEN BLUTUNGEN, DURCH EINFÜHRUNG VON GEEIGNETEN, SAUERSTOFF 
ABGEBENDEN LÖSUNGEN IN DEN MAGEN, ALS RATIONELLE 
BEHANDLUNGSMETHODE. 
Has the alimentary tract in man the power of supplementing the action of the lungs 
by absorption of oxygen-yielding substances and admission of them into the circulation, 
for the purpose of effecting those tissue changes incident to the respiratory acts ? 
In certain diseases, the alimentary canal has the power of thus supplementing the 
action of the lungs, of passing oxygen into the tissues for nutrimental purposes, and of 
expelling carbon monoxide as excremental matter. 
As far as oxygen is concerned, it is intestinal respiration and not intestinal digestion ; 
and as far as both oxygen and water are concerned, it is respiratory absorption and not 
digestive absorption, which I advocate. This phenomenon is observed also in the hypo- 
dermic tissues, under the same conditions, when oxygen, or oxygen-yielding substances 
in solution are injected therein; oxygen being absorbed without the action of digestive 
ferments, and oxygen in oxygen-yielding substances, liberated by electro-chemism of 
the animal membrane, being absorbed in like manner. Letourneau, however, in his 
work on Biology, says : "So far, at least, it has not been shown that the chemical 
reactions of (animal) nutrition set at liberty oxygen gas. ' ' His views, which are of 
great scientific value, are from a physiological standpoint; mine from clinical observation. 
Physiologists universally hold the opinion that oxygen is admitted into the system 
through the lungs only, and guided by them, physicians generally entertain the same 
views. In health, respiration and nutrition are so perfect, that it is very probable that 
all the oxygen necessary is carried into the system through the lungs; but in certain 
diseases-cholera, cholera-infantum, post-partum and secondary post-partum hemor- 
rhages-in which the lungs and blood fail in function, in consequence of an enormous 
loss of blood or serum by the vital organs, the system doubtless has the power, through 
the chemical, physical and electrical processes of absorption and nutrition, of liberating 
oxygen gas, and utilizing it in tissue changes, if that gas in suitable chemical and 
absorbable combination be given through the stomach. 
Heretofore, pulmonary respiration has seemed to fulfill so completely the purposes of 
ventilation of the human organism, that this question of supplementary respiration in 
disease has never before been advanced. However, it is neither a vain theory nor a 
philosophical conjecture; it is a clinical fact. 
Letourneau distinguishes ' ' between the fundamental biological fact of the absorption 
of oxygen which is one of the first conditions of nutrition, and the physiological func- 
tion, properly so called, which is simply the physiological process employed to render 
this absorption possible and easy. ' ' 
There are two chief modes of breathing in the vertebrates, one by the pulmonary, SECTION VI THERAPEUTICS AND MATERIA MEDICA. 
109 
the other by the branchial apparatus; and in these there is no fundamental difference. 
The gills can act in the air, provided they be kept sufficiently moist, while the pulmo- 
nary mucous membrane is ever in a state of humidity. Now the fundamental 
phenomenon of respiration is extremely simple ; it is merely the abstraction of oxygen 
from the air, formation of carbonic acid and its expulsion from the tissues-an electro- 
chemical and a physical process-falling under the laws of chemism, diffusion and osmosis. 
In the pulmonary tissues, in addition to the forces of diffusion and osmosis, the electro- 
chemical couplets impel the oxygen across the membrane into the blood, where it unites 
with the haemoglobin, and dissociate and expel carbonic acid; in the stomach and 
bowels, in diseases mentioned, when dilute sulphuric acid and waterare given, a variety 
of aquatic respiration is produced. Diffusion and osmosis carry the acid and water into 
the walls of the alimentary canal, and these same electro-chemical couplets decompose 
the acid and liberate oxygen; the red corpuscles carrying the oxygen into the circula- 
tion, while the tissues, yielding to the harmony of chemical law, associate that oxygen 
with the carbon and hydrogen of regressive organic matter, forming carbonic acid, and 
water, which are carried to the lungs with the reduced haemoglobin, whither the blood 
is sent to expel carbonic acid, and whence it issues again oxidized, and again sent forth 
on its mission. 
Electromotricity of the tissues is produced by an action similar to that of electrolysis. 
We are indebted to Becquerel for our knowledge on this subject. In a series of papers, 
extending from 1867 to 1870, he communicated the results of his investigations to the 
Academy of Sciences, Paris. 
According to the felicitous idea of Claude Bernard, all organisms, in fact, live an 
aquatic life; the histological elements are aquatic; the blood of animals and the sap of 
plants alike bathe them in a fluid medium. The oxygen we breathe is condensed and 
liquefied in the blood, is fixed in the blood corpuscles ; our food is liquefied during 
digestion and is carried to the tissues in a fluid state. Life is therefore maintained, as 
it were, in a sea of histological and aqueous elements; and be it the air we breathe, or 
food we eat, all is reduced to a fluid state before absorption into the human system. 
The essential act of respiration is oxidation of the effete anatomical elements, and 
the lungs are but '1 ports of entry ' ' for the oxygen of the air carried thither. The red 
corpuscles therefore, acting as carriers of oxygen, functionate as indispensable in the 
respiratory acts. The corpuscles of the blood being present in every part of the circula- 
tion, when the lungs fail in function, by "spasm of the pulmonary arterioles," or 
anaemia of the pulmonary tissues, supplemental respiration may be superinduced by 
vicarious action of other tissues, through the blood, in other parts of the circulation, 
notably the intestinal and hypodermic tissues. 
In case of an excessive drain on the vascular system, as in cholera and post-partum 
hemorrhages, when life is threatened by anæmia of the lungs and brain-asphyxia-if 
the suitable oxygen-yielding substance be given in solution, it will be absorbed by the 
vascular network of the stomach and bowels, the chemical compound broken down-de- 
oxidized-and oxygen carried hither and thither by the blood corpuscles and the liquor 
sanguinis- according to the selective affinity of this or that organ-to meet the respira- 
tory and nutritive demand of the tissues. Oxygen thus evolved and condensed by the 
haemoglobin of the blood, like that liberated by electrolysis on the surfaces of plates of 
metal, is said to be nascent. The employment of bodies in the nascent state has proved 
of the utmost service in organic chemistry ; and it is said that the great advances in 
this branch of science are largely due to the utilization of this property. Per contra, 
Dr. H. C. Wood, as elsewhere quoted, says: "It is seemingly self-evident that the 
physiological action of a remedy can never be made out by a study of its use in dis- 
ease. ' ' Besides, Beaunis states that ' ' Intestinal respiration, which presents a certain 
importance in some animals, as the cobitis fossilis, has hardly any in man. ' ' 110 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The principal function of the stomach is the secretion of gastric juice-this charac- 
teristic being that of a secreting organ, and unfavorable to absorption generally, which 
takes place mostly in the small and partly in the large intestines. Kuss cites the case 
of a man suffering from obstruction of the pylorus, whose stomach appeared perfectly 
healthy, but who experienced constant thirst, in spite of having swallowed large quanti- 
ties of water. Thirst was relieved only by injection of water into the rectum. 
Aliments pass out of the stomach in a semi-fluid mass, and attain additional fluidity 
when they reach the small intestines and acquire bile, pancreatic and enteric juices. 
Here this mass rapidly loses its fluidity by absorption, and is driven into the large 
intestines, whence it is issued, after further absorption, in a semi-solid form. The state 
of the blood has also a great effect on the intensity of absorption; it is slow in hydræmia, 
normal in health and active after bleeding and purgation. Absorption, however, takes 
place only when the membranes of the stomach permit, and those of the intestines favor 
this action. The decayed and wasting epithelium of the intestines, which is removed 
in the normal state partly by the bile, which is poured into the intestines seven or eight 
hours after the ingestion of food, may be removed also in the abnormal state of cholera, 
etc., partly by the influence of dilute sulphuric acid, if that acid, properly diluted, be 
given through the stomach in that disease. Absorption resulting from the former action 
is digestive, that from the latter is respiratory. In cholera, the shrunken tissues and 
the thickened condition of the blood point to the systemic want of water, but the tissues 
will not allow it passage; and it is only when we remember that the physiological exi- 
gencies require not water alone, but oxygen also, that we can obtain that result, lu 
cholera and post-partum hemorrhages, wThen normal absorption is arrested, or reduced to 
a minimum, water may be absorbed through the agency of the oxygen in sulphuric acid ; 
the restoration of diffusion, osmosis and electro-chemical action being effected thereby; 
the blood globules appropriating all of the oxygen, and the sulphur, seeking its next 
affinity in a union with hydrogen, forms hydrogen sulphide. The tissues, however, are 
the active, and the acid and water the passive agents, in these histological changes; for 
assuredly, if the tissues did not control absorption, the acid would destroy them. 
" Every living element" says Letourneau, "is athirst for oxygen, and to such a 
degree, that sometimes certain organisms steal it even from stable chemical compounds. ' ' 
* ' Vibriones, studied by Pasteur, decompose the tartrate of lime and transform 
lactic acid into butyric acid, to procure for themselves oxygen. It is, besides, by an 
analogous process that, in most of the vertebrates, the anatomical elements deoxidize 
the blood corpuscles." 
These facts and observations indicate that every living being, under the stress of cir- 
cumstances, has the power of exerting deoxidation for the preservation and maintenance 
of life. What those circumstances and conditions are, I shall now endeavor to show. 
To elucidate this point, I deem it important to explain the similarity between the 
symptomatology of barometric and corpuscular deoxygenation of the blood in man; 
because it is of paramount importance that a sufficiency of red corpuscles should always 
be moving in the ceaseless circuit of respiration from the lungs to the tissues and from 
the tissues to the lungs. I therefore call attention to the effects of mountain climbing 
and balloon ascension on the human system, before speaking of veritable diseases. Of 
course, I speak within a certain limitation. In ascending lofty mountains and in 
balloon ascensions, according to physiological observations, as soon as a certain height is 
reached, varied by the individuality of him who goes thither, the pressure of the air is 
felt to be greatly lessened ; the blood vessels of the surface, and the right side of the 
heart become filled, and those of the internal organs correspondingly empty; a quasi 
disease is produced, which is characterized by hyperæmiaof the superficial, and anæmia 
of the deep tissues. The mountain climber and the aeronaut alike suffer from afflux of 
blood-in fact, hemorrhage-into their cutaneous vessels; the more blood there is in the SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
111 
superficial, the less in the deep tissues; and, in losing blood, lose plasma and corpuscles, 
lose oxygen stored up in the corpuscles and the plasma in which they are carried. 
There is consequently anaemia of the abdominal viscera, with attendant respiratory and 
circulatory disturbances. Many of these identical symptoms occur in cholera and post- 
partum hemorrhage; the afflux of blood, however, goes to the bowels in cholera, to the 
uterus in post-partum hemorrhage, in both of which the system suffers actual loss of 
blood and serum, and anæmia of the lungs and brain follows : The ascent of great 
altitudes produces congestion of the capillaries of the skin, and free surfaces of the mucous 
membranes, with diarrhoea and nausea, and sometimes hemorrhages and sweating; while 
in cholera there is congestion of the bowels and closed mucous membranes, with diarrhoea 
and nausea, and sometimes sweating and hemorrhages; in great altitudes, the blood 
pressure on the skin increases the cardiac beats, and respiration becomes impeded ; while 
in cholera the vascular pressure in the bowels increases the cardiac beats, and respira- 
tion becomes impeded ; in great altitudes there is insufficient supply of oxygen and 
imperfect elimination of carbonic acid, owing to anæmia of the abdominal viscera, with 
extraordinary muscular weakness; while in cholera there is insufficient supply of oxygen 
and imperfect elimination of carbonic acid, owing to anæmia of the lungs with extra- 
ordinary muscular weakness; in great altitudes, the vagal centres are stimulated by 
insufficiency of oxygen and vomiting generally occurs; while in cholera, the vagal centres 
are stimulated by insufficiency of oxygen, and vomiting nearly always occurs ; in great 
altitudes, the blood being drawn from the internal organs to the surface, the brain is 
imperfectly supplied with oxygen, and faintness results, as well as diminished secretion 
of urine; while in cholera, the blood being drawn to the bowels, the brain is imperfectly 
supplied with oxygen, also the lungs, and faintness results, as well as diminished 
secretion of urine ; in great altitudes the traveler and the aeronaut alike complain of 
intense cold, owing to extraordinary loss of heat by radiation through the skin, and the 
failure of the system to reproduce heat sufficient to supply the extra demand in conse- 
quence of anæmia of the internal tissues; while in cholera there is a typical cold stage 
-the collapse-owing to the extraordinary loss of heat by discharges from the bowels 
and the failure of the tissues to reproduce normal heat in consequence of anæmia of the 
lungs and brain ; in great altitudes there is a peculiar form of venous congestion, par- 
ticularly marked in the superficial tissues and right side of the heart; while in cholera 
there is another form of venous congestion particularly marked in the deep tissues- 
abdominal viscera and right side of the heart; in great altitudes there is barometric 
deoxygenation of the blood ; while in cholera there is corpuscular deoxygenation of the 
blood. 
All the world knows that the remedy for ' ' mountain sickness, ' ' anoxyhæmatism, is 
to descend to a lower altitude. No better remedy can be given. This parallel is drawn 
to show that the immediate cause of death from cholera, like that from mountain- 
climbing and balloon ascension, is from oxygen-starvation-asphyxia; the same is true 
of post-partum hemorrhage and cholera-infantum. 
Fothergill, on the authority of Parkes and George Johnson, says : ' ' The now 
generally acknowledged starting point of the pathological processes in cholera is spasm 
of the pulmonary arterioles. Elaborate experiments as to how to relax such spasms, end- 
ing in clinical application of various agents, as belladonna, etc., have not yet, however, 
attained any practical results of moment." My observations, based on other premises, 
lead me to another conclusion. In cholera there are out-pourings of the fluids of the 
body so enormous, abstraction and inspissation of the corpuscles of the blood so great, 
and anæmia of the lungs so marked, that the interstitial tissues, the greatest sufferers, 
and those corpuscles which have escaped destruction, as well as the young corpuscles 
which act as carriers of oxygen but are unable to make their way to the lungs, find 
themselves in both an oxygen and a water famine. This condition clinically denomi- 112 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nated the collapse, or approaching collapse, is produced by asphyxia. This is why 
cholera is sometimes called cholera asphyxia. 
This pathological condition of Asiatic cholera, though merely outlined, suggests the 
physiological exigencies of the victims of that disease. In cholera there are impeded 
circulation and insufficient development of animal heat ; consequently the nitrogenous 
elements of the food and tissues fail to be oxidized and converted into urea. There is 
also ample material for combustion in the human economy, but no oxygen to effect it, 
and no water to transport that oxygen. Sulphuric acid and water respond to the 
systemic wants of cholera in furnishing both oxygen and water, which relieve the 
thirst and vomiting, gradually check the diarrhoea, favor the formation and excretion 
of urea, and restore the circulation and respiration. At the same time the decaying 
and wasting epithelium of the alimentary canal, upon which the microorganisms of 
cholera live and thrive, are oxidized and removed. Moreover, clinical observation 
leads me to infer that sulphuric acid and water sterilize the membranes of the alimen- 
tary tract and all other tissues of the body. 
This acid has long been used empirically in cholera and other diseases also, and has 
its enthusiastic advocates on the ground of experience. 
If sulphuric acid, largely diluted with water, be given through the stomach during 
an epidemic of cholera, cholera will be prevented by furnishing oxygen in a fluid 
medium, thus maintaining and restoring the dynamical forces of the circulation and 
sterilizing the membranes ; given early in the disease, the collapse will be averted ; 
given in the collapse as an oxidant-oxygen-yielding substance-it is the most rational 
treatment. Of course, other medicines will be required if there be complications ; in 
all cases a suitable diet will be requisite, and absolute rest must be enjoined. This 
experience is based on observation made while I was a student. 
The observations of Dr. R. G. Curtin, in the Philadelphia Medical Times, are as 
follows: "A very severe epidemic of cholera ceased in the Insane Department of the 
Philadelphia Almshouse within twelve hours after the lunatics were all put upon the 
free use of sulphuric acid lemonade ; the only new case after this being a man who 
refused to use the prophylactic. Two days after the use of sulphuric acid was stopped 
two new cases occurred, and the epidemic was again arrested by the use of the acid. 
In the surgical wards of the Hospital Department, the acid was used from the begin- 
ning of the epidemic ; and these wards, although in no way isolated, were the only 
parts of the institution unvisited by the disease." 
In post-partum hemorrhages, we have practically the same pathological con- 
ditions and the same physiological exigencies. The following cases are given 
to illustrate these views : In a case of secondary post-partum hemorrhage, No. 1, 
occurring July, 1880, ten days after delivery, the hemorrhage was stopped by 
manual expulsion of clots, the administration of teaspoonful doses of fluid extract 
of ergot every two or four hours, introduction of a silk handkerchief saturated 
with vinegar into the uterine cavity, and lastly, by repeated irrigation of the rectum 
with hot water, to remove all scybalæ, and to propagate heat to the uterus and 
its blood vessels, with a view to the transmutation of that heat into motion, and motion 
into contraction ; besides, by abstracting carbonic acid w ith the hot water, favor the 
same action. These means were successful, but as the patient had lost so much blood 
before I arrived, she was very weak and prostrated. Milk and beef tea were given 
every two hours, and drachm doses of ergot every two or four hours. The next day the 
prostration continued, and the temperature remained subnormal. Milk, beef tea and 
ergot were continued. The third day after the hemorrhage her condition was most 
deplorable. She had cold hands and feet, subnormal temperature, weak and feeble 
pulse, and repugnance to all foot! ; yet she was thirsty. Gave granulated ice and 
added lime water to the milk. I returned in an hour and finding her no better, gave a 113 
SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
hypodermic of ergotine and brandy. I saw her again in an hour and a half ; she was 
greatly changed ; changed for the worse. In my absence a draught of whisky and mint 
water was given her, but her stomach rejected it at once. Her hands and feet were 
then stone cold, there was no pulse at the wrist, she vomited everything given her, even 
grated ice, soon after it melted. Her breath felt cold to the palm of the hand, respira- 
tions were slow, and heart sounds scarcely audible. Her features were pinched and 
shrunken in appearance, her mind was apathetic, and, as I learned the next day, there 
was a sense of impending death. The collapse was complete and intense. At this 
moment I gave her thirty drops of aromatic sulphuric acid in twelve ounces of water, 
all of which she drank eagerly while the nurse held up her head. She went to sleep 
immediately, and slept like a child. The hour was four o'clock, P. M. In an hour and 
ten minutes there was a most remarkable change. Her hands and feet became warm, 
the pulse returned to the wrist, and her features and complexion were natural in appear- 
ance. My examination of the patient awakened her, and she asked for a drink of 
water. I gave her twelve ounces of cold water with ten drops of aromatic sulphuric 
acid, and she at once slept again, sleeping until eleven o'clock, P. M., when she awoke 
and asked for a drink of water. The nurse gave her twenty drops of aromatic sulphuric 
acid in twelve ounces of cold water, and she slept soundly until five o'clock, A. M. She 
was then given her last dose of medicine-twenty drops more of the acid, and twelve 
ounces of water. At this time she remarked to the nurse, ' ' I thought I died yesterday 
evening at six o'clock." Her condition at eight o'clock in the morning was marvelously 
improved. Her pulse was quite strong, temperature natural and her appetite craving ; 
she asking for something more than beef tea and milk. The uterus was firmly con- 
tracted and much reduced in size ; while the lochia, the true lochia, that yellowish or 
yellowish-green matter, the ash and cinder of oxidation after parturition, was established 
and found on the expectant napkin. The patient was declared to be convalescent. 
She made a speedy recovery. 
Now what caused this collapse ? A breach in the continuity of the tissues of the 
capillary walls caused a great drain on the system in the hemorrhage which ensued ; 
a loss of the dynamic force of the circulation, known as "the vis a tergo ; " an accumu- 
lation of venous blood in the venous column up to the heart ; slow movement of the 
blood in the capillaries of the lungs, and from the right to the left side of the heart, 
producing arterial anaemia. There was impeded respiration, in consequence of the 
resulting anaemia of the lungs, arrest of osmotic and electro-chemical action in the 
tissues, and insufficiency of blood in the respiratory circuit, from the lungs, to the 
tissues, from the tissues to the lungs, to keep up animal heat. 
Another case of secondary post-partum hemorrhage ; No. 2 ; appearing suddenly eleven 
days after labor, at one o'clock, A.M., February, 1881, was most profuse and alarming. 
The patient was twenty-four years of age, ruddy, plump and robust ; and up to this 
time had remarkably good health. This was her third child ; I had attended her in 
all her confinements, and never found it necessary to give her any medicine, save two 
or three drops of ergot, which were given as a preventive, after each parturition. After 
this confinement she was not doing so well ; on the third day her temperature arose to 
101° F., on the fourth, to 102° F. Her face was flushed and swollen, and she seemed 
plethoric. I prescribed for her, but the medicine was not taken, as she said she felt 
quite well. On the ninth day I found her sitting up in a chair ; when surprise was 
expressed, she declared she felt well, and could not stay in bed. At this time the dis- 
charge was scant, yet sanguinolent ; and, as involution had not been effected, the dan- 
gers of hemorrhage were suggested. She sat up only one hour on this day ; on the next 
day, however, the tenth, she remained up nearly all day. At three o'clock, A. M., two 
hours after the hemorrhage appeared, I gave her thirty drops of aromatic sulphuric acid 
in a tumbler of cold water ; and ten drops of the acid in half a tumbler of cold water 
Vol. in-8 114 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
every two hours thereafter. Beef tea, rice water and chicken tea were given as diet, 
every two or three hours. This patient, from the first dose given, did so well, that I 
resorted to nothing else to restore her. The next day this treatment was continued 
until twelve o'clock, m., when the true lochia appeared, the product of oxidation and 
hydration liquefied. The uterus, felt through the abdominal walls, was found to be 
firmly contracted and small in size. There was much more blood lost in this case than 
in the first (No. 1), yet the patient did not get cold or even cool, although it was winter ; 
there were no signs whatever of collapse. The second night after hemorrhage, how- 
ever, I was compelled to give eighty drops of tincture of opium to produce sleep, 
giving twenty drops every hour. No other medicine was given, and she made a com- 
plete recovery in seven days. There was no loss of animal heat. 
No. 3 was a case of post-partum hemorrhage, following immediately after parturi- 
tion, without a moment's notice. It commenced before expression of the placenta, the 
uterus and abdomen being found greatly distended with blood, after ligation of the 
funis umbilicalis. Expressing the placenta, the uterus was well squeezed and con- 
tracted ; as soon as the hands were removed, however, a most profuse hemorrhage set 
in; great pallor, anxiety, jactitation, and sighing respiration were manifested. Two 
doses of ergot were given, a drachm in each, one in cold, the other in iced water, and 
both were immediately vomited, not partly, but entirely. She turned and tossed on 
the bed, and rolled herself on the other side, seemed sleepy, the hemorrhage continuing. 
Thirty drops of aromatic sulphuric acid were given in a tumbler of cold water, and it 
acted with marvelous rapidity. The hemorrhage was arrested at once, color returned 
to the face, the pulse which was 130 fell to ninety, respiration became normal, and the 
patient in less than twenty minutes gave expression of admiration for the medicine, 
which she said went tingling all over her, like electricity. This was March, 1883, eight 
o'clock p. M. I gave her another dose of twenty drops in a tumbler of water at eleven 
o'clock, and as the uterus was firmly contracted, gave her no more. However, I watched 
her all night, resting in the same room. The nurse also kept vigil. No other medicine 
was given. She made a complete and rapid recovery, and arose from her bed on the 
twelfth day after delivery. There was no loss of animal heat. 
In another case, No. 4, of post-partum hemorrhage, apparently resulting from 
uterine inertia, occurring February, 1885, in which the uterus remained patulous after 
delivery, a piece of ice being placed over the hypogastrium produced immediate con- 
traction and stopped the hemorrhage. Fluid extract of ergot was then given in tea- 
spoonful doses every two hours until one ounce was thus used. The patient was in a 
comfortably warm room and well blanketed, yet her hands, arms and feet were very 
sensibly cold to the touch until midnight. Nor was animal heat entirely restored until 
twenty-four hours after the flooding was arrested, although the patient was fed on milk 
and beef tea every four hours. A sanguinolent discharge kept up for twenty-four days; 
after that period it became yellowish in appearance. 
Case No. 5 was one of secondary post-partum hemorrhage, occurring four days after 
delivery. Dyspnoea was very marked in this case-the patient imploring the nurse to 
fan her. As soon as thirty drops of aromatic sulphuric acid in twelve ounces of cold 
water was given her, I silently withdrew the fan from the servant and placed it on a 
table. The hemorrhage was immediately arrested, nor did the patient again ask to 
be fanned, as the dyspnoea was at once relieved. Another like dose was given her in 
two hours. She required no more medicine, and made a complete recovery in a few 
days. There was apparently no loss of animal heat. 
Now it may be asked: How are this and other acids absorbed? How are they 
utilized in the human system ? According to the theory of tissue respiration it is the 
increase in the intra-molecular actions, in the cells themselves, that occasions the 
demand for oxygen, and a more active condition of the circulation and respiration; and SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
115 
although the quantity of haemoglobin in the blood is the measure of the oxidizing 
power within the body, it is the tissues themselves that determine the amount of 
oxidation. Many experiments show that oxygen enters the circulation through the 
lungs by diffusion of gases, by osmosis and by chemism. To these already acknowl- 
edged forces, Becquerel adds that of electro-motory actions. 
This important and progressive view of the physiology of the capillaries, which is 
well supported by numerous experiments, brings us to the consideration of a new 
phenomenon of the circulation, and adds another phase to the connection between 
respiration and the circulation. If, through the agency of the Voltaic pile, we decom- 
pose water placed in a vessel divided by membrane, we shall see the level of the surface 
rise in the negative division; the water is, therefore, carried from the positive to the 
negative pole. According to Becquerel, analogous action takes place in the capillaries. 
Owing to the innervation of the tissues, the chemical and physical phenomena going on 
in them, electro-capillary currents are produced, phenomena peculiar to biological 
osmosis, and never effected in the endosmometer. In the capillary vessel, arterial 
blood is positive to all the other tissues thereabouts, hence the electro-capillary currents 
drive the oxygen into the surrounding histological elements wherein oxidation of the 
tissues occurs, producing carbonic acid, which is driven into a corresponding or an 
adjacent venous capillary, and turned into the great venous current on its way back to 
the lungs. In the pulmonary capillaries, electro-chemical actions are reversed. In 
the lungs, in consequence of the oxygen tension being less than the tidal air, the 
oxygen is impelled into the circulation hy electro-capillary couplets. The greater posi- 
tive of the stratum of tidal air prevails over the less in the pulmonary tissues, and 
oxygen is thus carried into the circulation, whence carbonic acid is eliminated. Accord- 
ing to Becquerel ' ' Electro-chemical capillary actions rest on a principle fertile in 
application, in nature organic as well as inorganic; since they are always manifested 
when two liquid conductors of electricity-having affinity for each other-are separated 
by a partition, of whatever nature, with capillary interstices in which these liquids are 
introduced by capillary affinity, then reacting one on the other disengage electricity, 
whence results an electric current by the intermediary of the excessively small liquid 
layer-or stratum-which adheres to the surface and acts like a solid body conductor; 
it is always indispensable that the current should he constant, because these latter 
surfaces are constantly depolarized ; this is necessary so that the elements deposed by 
electro-chemical actions may he raised by the surrounding liquids. Such is the couple, 
which we have called electro-capillary, by the aid of which one can reduce to the 
metallic state the majority of the metals and deoxidize others of them. To produce 
this effect, place the metallic solution in a cracked tube sealed at one end, and immerse 
it in a solution of monosulphide of sodium, or still better, two broad laminæ of glass 
connected with each other by lines, and plunge them likewise in the solution." 
' ' Electro-capillary action is produced in all bodies with capillary pores of some yj-g 
of a millimetre in extent which divide two liquids, according to the condition just indi- 
cated." Becquerel then proceeds to elucidate every point in the electro-chemical 
capillary couplet, and explains how this action takes place in organic as well as 
inorganic tissues, noting the difference that organic tissues have nervous connection, 
which have great effect and increase the action, while inorganic tissues have none. 
It is well known that sulphuric acid, largely diluted with water, has a degree of 
diffusibility specially great; it is moreover, the most powerful acid known. When 
thus diluted and introduced into the stomach, in cholera and post-partum hemorrhages, 
chemical reactions and transformations of great clinical consequence follow. In these 
diseases, the tissues are famishing, perishing for want of oxygen and water ; oxygen to 
sustain the failing circulation and eliminate effete organic matter ; water as a medium 
in which to float both the nutritive and waste materials of life in requisite molecular 116 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
division. This waste matter retained in the system tends to keep up a state of high 
tension and fullness iu the venous capillaries, to annul all physiological laws, and 
establish those of transudation. Oxygen, as the motive power of the circulation, owing 
to its great affinity for decaying organic cells, removes waste and liberates heat, while 
it produces motion in the circulation, by its electro-chemical effect. 
Nor must the influence of oxygen on the nervous system be omitted. The splanch- 
nics act as inhibitory nerves on the movements of the intestines so long as a normal 
current of oxidized blood traverses the vessels ; but when the blood becomes venous, 
inhibition is held in abeyance. This is a marked pathological condition in cholera, 
and consequently an immense accumulation of blood occurs in the abdominal vessels. 
The splanchnics are also the chief vasomotor nerves of the arteries of the abdominal 
viscera. This point should be considered iu post-partum hemorrhage also. 
Now, it is only through the intermedium of the red corpuscles and the plasma float- 
ing them, that the tissues hold commerce with the air ; and, when the paucity of these 
corpuscles in the respiratory circuit is great, the whole system suffers. As to the 
stomach, when the vagal centres are stimulated by insufficiency of oxygen, vomiting 
generally occurs. This is owing to the fact that the vomiting centre in the medulla, 
which has a close relation with the respiratory centre, is excited in a reflex manner by 
efferent impulses descending the vagi. 
The tissues laden with carbonic acid are athirst for oxygen, and the young corpus- 
cles ever springing up in the vascular area and waiting to functionate as vehicles of 
oxygen, and the red corpuscles despoiled of oxygen present themselves in the venous 
capillaries of the intestines, project themselves into the organic walls, or by amoeboid 
movement wander into the intra-molecular spaces. 
The organic membranes of the stomach and bowels which separate the blood from 
the tissues, are as living as the blood circulating therein. In these diseases of which 1 
have spoken, powerful osmotic and diffusive currents arise, when diluted sulphuric 
acid is given medicinally. The epithelial tissues of the bowels thus absorbing the acid, 
chemical transformations in the walls themselves, and in the strata of liquids on either 
side, one of which deporting itself as an acid and the other as an alkali, give rise to 
electro-chemical actions ; sulphuric acid is deoxidized, the oxygen is impelled into the 
interstitial tissue, unites with the hydrocarbons and the carbohydrates of the regressive 
tissues and forms carbonic acid and water, which are driven into the venous capillaries, 
and hurried into the general venous current ; at the same time, urea and the urates, 
formed by oxidation of the disintegrated nitrogenous elements of the tissues, are 
eliminated by the kidney. Doubtless in health the sulphates and phosphates are 
formed by decomposition of the alkaline and earthy salts of the blood ; not so in the 
diseases mentioned, in which the affinity of oxygen for the red corpuscles is greater 
than that for the alkaline and earthy salts, and greater for the tissue than the corpus- 
cles ; for the anatomical elements have their own special affinities which are entirely 
in harmony with chemical laws. This action of the electro-chemical couplets, in the 
capillary walls of the stomach and bowels, relieves the irritation caused by want of 
oxygen-as manifested by emesis or irritability of that organ-while the alimentary 
tract is thus supplementing the action of the lungs ; but the full organic expression of 
the tissues, arising from this action, is evinced by the changes effected in the vascular 
network and hypértrophied walls of the uterus. The effete and spongy cells in the 
capillary wall, which cause the breach in that vessel and keep it patulous, are oxidized 
and disassimilated by the oxygen of the red corpuscles carried thither by the blood. 
New cells glide into the places of the old cells, and, exerting their contractile power, 
heal the breach ; while the old cells, liberating energy in their death by the action of 
oxgyen, give rise to the so-called " vis a tergo," which removes the venous congestion, 
causes the blood to traverse the lungs more rapidly, passing from the right to the left SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
117 
side of the heart, and filling up the arteries. Oxygen and water thus restoring the 
pristine vigor of physiological respiration, and the circulation also. In post-partum 
hemorrhages, the physiological hypertrophy of the uterine walls has to be cut down by 
this same electro-motory action, by oxidation and elimination, otherwise, uræmic 
symptoms supervene ; in cholera, the effete and porous cells of the glands and mem- 
branes of the intestinal tract, which favor the enormous discharges of that disease, are 
oxidized and cast out, while new cells take their places and, exerting their contractile 
function, restore the healthy continuity of the tissues. I venture to say that in the 
future electro-motility of the tissues will find recognition in clinical medicine. 
This exposition, well founded or not, does not seem necessary to explain the action 
of dilute sulphuric acid in the cases under consideration. It is sufficient to remember 
that these diseases tend to produce death by asphyxia; and, in the words of Austin 
Flint, ' ' The distention of the heart in asphyxia is due to the fact that unaerated blood 
cannot circulate in the capillaries. ' ' It has lost its chemical affinity for the vessels and 
tissues, and cannot traverse the lungs as in the physiological state. In post-partum 
hemorrhage there is a breach in the continuity of the vascular wall ; in cholera, the 
blood falls under the influence of the laws of transudation. We have, therefore, in 
these diseases, as a consequence, anæmia of the lungs, a tendency to death by collapse, 
or loss of animal heat. Aromatic sulphuric acid and water, in case No. 1, restored 
animal heat, averted death by collapse, relieved vomiting, returned the pulse at the 
wrist, revived the failing respiration, and established the lochial discharge-the product 
of oxidation and hydration. This is just what oxygen, and nothing but oxygen, could 
have effected. It is the source of animal heat; it gives rise to the formation of carbonic 
acid and water, products of complete oxidation in the animal economy; and it causes 
the formation and elimination of urea and uric acid. Oxygen is the cause and agent of 
all combustion, of all oxidation which takes place in the body. Sulphuric acid and 
water given in this case (No. 1), in which the patient was rapidly sinking for the want 
of oxygen, that acid was decomposed-deoxidized-and its oxygen appropriated, ex 
necessitate rei, such was the vehement eagerness of the tissues for oxygen ; and since 
contemporaneous chemistry fails to explain the process by which the tissues obtain 
oxygen in this case, we may say with Letourneau that they " steal " it. Indeed, chem- 
istry teaches, in one of its first lessons, that the oxygen of this acid is some of the same 
oxygen that we breathe, taken from the air to make that acid ; and according to the 
doctrine of the correlation and conservation of forces, if that oxygen be liberated from 
its sulphur compound, and properly diluted with nitrogen gas, it can be again utilized 
as respirable air. 
Impressed with the views that the tissues in this case (No. 1) were famishing for 
want of oxygen, that they called even from the depths of the stomach for it; that sul- 
phuric acid abounding in oxygen possessed great affinity for water, and when that 
affinity was gratified it would yield its oxygen, preferably to waste organic tissue; that 
sulphur, in dilute sulphuric acid, was excreted primarily by the glands of the intestinal 
tract; that oxygen thus disengaged in the walls of the stomach, bowels, and uterus, in 
these maladies, was immediately precipitated toward the carbon and hydrogen com- 
pounds as in the combustion of tissue respiration ; that affinity of the red corpuscles 
for oxygen was very great, and that oxygen reached the anatomical elements through 
the intermedium of those corpuscles only ; that it was oxygen that produced motion in 
the blood, removed waste and made repair possible; that water was used in the system 
as a medium of irrigation, histological transportation and molecular division; I gave 
water and sulphuric acid, for the purpose of producing what may be called aquatic, or 
more properly supplemental and intestinal, respiration, as the only means of relief. 
This acid, which had long been used in empirical practice, as an astringent, and was 
known to be absorbable, as well as most diffusible, was given to produce this hitherto 118 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
unknown effect in theoretical and practical medicine. How it succeeded, I have already 
stated. 
To those who have not accepted the beautiful theory of the capillary circulation, as 
given by Becquerel, and who give no heed to clinical evidence, I present another inter- 
pretation of the action of this acid, in the diseases of which I have spoken. 
Many physiologists, for many cogent reasons, have assumed the existence and storage 
in the body of the intra-molecular oxygen. The electro-chemical couplets present in 
all of the tissues, as illustrated by Becquerel, and incessantly at work in hæmatosis, 
may fail to functionate in these diseases, and dilute sulphuric acid by chemical trans- 
formation, or by catalysis if you please, may evoke this intra-molecular oxygen thus 
stored up, which, acting as an oxidant, enables the system to utilize the energy arising 
therefrom in driving the heavy column of venous blood that inhibits nutritive action, 
until the physiological function of respiration shall have been restored. 
To the doubting Thomases, the tenth legion of the medical profession-and I speak 
in no disparagement of them-those who go to the kennel and laboratory to prove all 
things, I will say that I, too, have gone thither. The experiments which I there made, 
however, are too incomplete to form a part of this paper. It is necessary in experimen- 
tation to start with certain pathological conditions, associated with cholera and post- 
partum hemorrhages, always keeping in view the attendant respiratory and circulatory 
disturbances. This action under consideration cannot be effected in the physiological 
state; and an artificial condition, simulating in all characteristics one of disease, is not 
easily, if at all, attainable, at least in the canine race. 
Arguments from comparative anatomy, as I have before stated, sustain the theory of 
supplemental and intestinal respiration. The water loach (cobitis fossilis), a singular fish, 
swallows air by the mouth, and, after having absorbed a part of the oxygen, gives off 
carbonic acid by the intestines. Clinical experimentation also supports this theory. A 
plethoric man, thirty-nine years of age, who complained of fullness in his head, and 
feared apoplexy, was given an enema to unload his rectum, which was followed by a 
hydragogue cathartic and a foot bath. His temperature was 103.2° F., and his pulse 
was 132. He had been afflicted with hæmorrhoidal tumors for five or six years ; indi- 
cating that there was more or less general venous congestion, commencing in the portal 
circulation. After the action of the cathartic ceased, at his own request he was bled 
from the arm, bled until he was quite faint, taking eighteen ounces of blood. He was 
then given thirty drops of aromatic sulphuric acid in twelve ounces of water, sucked 
through a glass tube, suitable preparations having been made previously to collect the 
gaseous emanations from his intestines, and have them condensed in a flask of lime 
water. A white pulverulent deposit was seen afterward in the flask, which was fetched 
home, and the supernatant water decanted. The white deposit was treated with acetic 
acid, which was followed by effervescence, indicating the presence of carbonate of lime ; 
there was also the characteristic odor of hydrogen sulphide. This result proves that the 
gas that emanated from the intestines was carbonic acid ; this substantiating the theory 
of supplemental and intestinal respiration, in certain diseases and conditions in man. 
Under additional treatment and a sustaining regimen, the patient made a rapid 
recovery, and is now in good health. 
The failure of the lungs and blood to functionate, and the successful resort to the 
administration of sulphuric acid and water, as shown in this paper, to irrigate the tissues 
and keep up respiration through deoxidation of this acid by the haemoglobin of the 
blood, and cession of the oxygen to the anatomical elements until the physiological 
function proper was reestablished in its original vigor, as a necessary and indispensable 
antecedent, is identical with a cause, being that without which the effects would not 
take place. Moreover, logicians call a phenomena explained, when by illustration it 
has been discovered to what general classification of natural laws it can be assigned. SECTION VI-THERAPEUTICS AND MATERIA MEDICA. 
119 
If the length of this paper permitted, it might be stated how nitric and phosphoric 
acids in certain other diseases, act also in accordance with this hypothesis ; one in 
cirrhosis of the liver attended with dropsy from alcoholism, the other in nervous exalta- 
tion from sunstroke with inability to appear in the sunlight. In practice, these acids 
also have acted with great promptness, manifestly by yielding oxygen, in the first place, 
through the haemoglobin of the blood to the tissues of the liver ; in the second place, 
by the same means to the nervous tissues. 
Physiological chemistry has yet to speak on this subject ; let her hearken to the 
clinical necessities. 
At a meeting of the Council, Dr. Phillips of London in the chair, the following 
resolution was unanimously adopted :- 
' 'Jtesolved, That the officers and members of the Section in Therapeutics and Materia 
Medica tender their cordial acknowledgment and thanks to the President, Prof. Traill 
Green, m. d., of Easton, Pa., for the dignity and urbanity he has manifested in pre- 
siding over the deliberations of this Section; and for the faithful manner in which he 
has performed his arduous duties, both before and since the assembling of this Congress, 
and by which he has contributed materially to its signal and unprecedented success." 
Frank Woodbury, m. d., 
Secretary. 
A. 8. Gubb, 
French Secretary. SECTION VII-ANATOMY. 
OFFICERS. 
President: WM. II. PANCOAST, M. D., Philadelphia, Pa. 
VICE-PRESIDENTS. 
Prof. C. M. P. Albrecht, Hamburg, Germany. 
Dr. R. E. F. Altmann, Leipzig, Germany. 
Prof. L. Auerbach, Breslau, Germany. 
Dr. Wm. Mitchell Banks, f. r.c.s., Liverpool, 
England. 
Prof. Carl Bardeleben, Jena, Germany. 
Dr. Barfurth, Bonn, Germany. 
Dr. L. Becker, Würzburg, Germany. 
Prof. R. Bonnet, Munich, Germany. 
Prof. G. Born, Breslau, Germany. 
Prof. C. W. Braune, Leipzig, Germany. 
Prof. A. Von Brunn, Rostock, Germany. 
Prof. L. T. Budge, Greifswald, Germany. 
Dr. J. Cunningham, Dublin, Ireland. 
Prof. J. Eberth, Halle, Germany. 
Prof. F. Merkel, Göttingen, Germany. 
Prof. Eckhard, Giessen, Germany. 
Prof. Flemming, Kiel, Germany. 
Prof. Flesch, Berne, Switzerland. 
Prof. Froriep, Tübingen, Germany. 
Prof. Fritsche, Berlin, Germany. ' 
Prof. Frey, Zürich, Switzerland. 
Prof. Frommann, Jena, Germany. 
Prof. Gegenbaur, Heidelberg, Germany. 
Prof. Von La Valette St. George, Bonn, 
Germany. 
Prof. Von Gerlach, Erlangen, Germany. 
Prof. L. Gerlach, Erlangen, Germany. 
Prof. Jno. Gleeland. 
Prof. Kollmann, Basel, Switzerland. 
Dr. Reginald Harrison, f.r.c.s., Li verpool,Eng. 
Dr. C. E. A. Hartmann, Berlin, Germany. 
Prof. Hasse, Breslau, Germany. 
Prof. Henke, Tübingen, Germany. 
Prof. Hertwig, Jena, Germany. 
Prof. His, Leipzig, Germany. 
Prof. Holl, Innsbruck, Austria. 
Prof. Joessel, Strassburg, Germany. 
Clinton W. Kelly, m. d., Louisville, Ky. 
Prof. Kerker, Freiberg, Switzerland. 
Prof. Kölliker, Würzburg, Germany. 
Prof. Kollmann, Basel, Switzerland. 
Prof. Kupffer, Munich, Germany. 
Prof. Von Langer, Vienna, Austria. 
Samuel Logan, m. d., New Orleans, La. 
Prof. Alex. McAllister, London, Eng. 
I Prof. John Gray McKendrick, Glasgow, Scot. 
Prof. S. Mayer, Prague, Austria. 
Prof. Von Meyer, Zürich, Switzerland. 
Prof. M. Nussbaum, Bonn, Germany. 
Prof. Oellacher, Innsbruck, Austria. 
David Chas. Lloyd Owen, Birmingham, Eng. 
Prof. Pansch, Kiel, Germany. 
Prof. Jas. Bell Pettigrew, Edinburgh. 
Prof Pfitzner, Strassburg, Germany. 
Prof. Rabl, Prague, Austria. 
Prof. Räuber, Dorpat, Russia. 
Thomas Rich, m. d , Leeds, England. 
Dalla Rosa, m.d , Vienna, Austria. 
Prof. E. Rosenberg, Dorpat, Russia. 
Dr. Rückert, Munich, Germany. 
Prof. H. Rabl-Rückhard, Berlin, Germany. 
Prof. Rüdinger, Munich, Germany. 
Prof. Ruge, Heidelberg, Germany. 
Prof. Phile Sappey, m. d., Paris, France. 
Prof. Schaaffhausen, Bonn, Germany. 
Prof. Schwalbe, Strassburg, Germany. 
Prof. Schifferdecker, Göttingen, Germany. 
Prof. O. Schultze, Würzburg, Germany. 
Noble Smith, m. d., London, England. 
Prof. Solger, Greifswald, Germany. 
Prof. Sommer, Greifswald, Germany. 
Dr. Graf Von Spee, Kiel, Germany. 
Prof. E. C. Spitzka, m.d., New York. 
Prof. Stieda, Königsberg, Germany. 
Prof. Ph. Stöhr, Würzbuig, Germany. 
Dr. Strahl, Marburg, Germany. 
Prof. Strasser, Freiburg, Germany. 
Prof. M. Struthers, m. d., Aberdeen, Scot. 
Thos. P. Teale, Leeds, Eng. 
Prof. Teichmann, Krakau, Russia. 
Benjamin H. Throop, m. d., Scranton, Pa. 
Prof. Trubiger, Amsterdam, Holland. 
Sir Wm. Turner, m. d., London, Eng. 
Prof. Wagener, Marburg, Germany. 
Prof. Waldeyer, Berlin, Germany. 
Prof. Wiedersheim, Freiburg, Germany. 
Prof. Welcker, Halle, Germany. 
Walter Whitehead, m.d., London, England. 
Gladius Galen Wheelhouse, Leeds, England. 
Dr. Zander, Königsberg, Germany. 
Prof. Zuckerkandl, Vienna, Austria. 
SECRETARIES. 
Dr. Jno. J. Berry, Portsmouth, N. H. 
Dr. Gallet, Brussels, Belgium. 
Dr. C. Remy, Paris, France. 
Dr. Wm. C. Wile, Philadelphia, Pa. 
Dr. F. C. Ainsworth, U. S. Army. 
Dr. C. S. Briggs, Nashville, Tenn. 
Dr. Herman M. Briggs, New York. 
Dr. N. E. Brill, New York City. 
Joseph N. Dickson, m.d., Pittsburgh, Pa. 
Fred'k B. Downs, m.d., Bridgeport, Conn. 
Dr. L. H. Dunning, South Bend, Ind. 
C. L. Ford, m.D., Stamping Ground, Mich. 
Dr. Alfred Gubb, London, England. 
Dr. George Halley, Kansas City, Mo. 
Dr. William H. Helm, Sing Sing, N. Y. 
Dr. Addinell Hewson, Philadelphia, Pa. 
Pi of, C. L. Lord, Michigan. 
COUNCIL. 
Dr. James McCann, Pittsburgh, Pa. 
Dr. Orville H. Menees, Nashville, Tenn. 
Dr. John E. Owens, Chicago, Ill. 
James B. Murdoch, m. d., Pittsburgh, Pa. 
Dr. Thornton Parker, Newport, R. I. 
Prof. Charles T. Parks, m. d., Chicago, Ill. 
Dr. D. C. Patterson, Washington, D. C. 
Dr. Joseph Ransohoff, Cincinnati, Ohio. 
Dr. R. L. Rea, Chicago, Ill. 
F. C. Schaefer, m. d., Chicago, Ill. 
Dr. Francis J. Shepherd, Montreal, Canada. 
Dr. M. Stamm, Fremont, Ohio. 
Oeo Thin m n. London England. 
Dr. Hal. C. Wyman, Detroit, Mich. 
121 122 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met in the Georgetown Medical College, and was called to order 
by the President, who read the following- 
ADDRESS BY THE PRESIDENT, WM. H. PANCOAST, A. M., M. D., 
Professor of General, Descriptive and Surgical Anatomy, and Professor of Clinical Surgery, 
in the Medico-Chirurgical College of Philadelphia, etc. 
Gentlemen of the Section of Anatomy:-As your President, I take great 
pleasure in welcoming you. It is very pleasant to see, in this the first actual Inter- 
national Medical Congress ever held in this country, the first time that the Congress 
has officially adjourned to this new continent, so many gentlemen of our profession, 
not only from abroad, but so many of my fellow-countrymen. 
We are a Congress, composed of delegates from the countries of the old world 
and this new one ; it is very pleasant to see so many fellow-workers in our profession, 
who have thus assembled from so many climes, in the interest of humanity, to advance 
the various departments of our noble science, for the benefit of all peoples. 
I cordially unite with our President, and my fellow-presidents of the different 
Sections, in warmly welcoming you all, each and every one. I trust that our American 
hospitality will prove acceptable to you, and that you will make as long a stay with 
us as you possibly can. 
I know that I am speaking the sentiment, not only of the American profession, 
but of all my countrymen, when I say to our foreign brethren that they are doubly 
welcome, and that we will do all in our power to make their visit pleasant and 
instructive. 
In this, our Section of Anatomy, we have many interesting papers promised, and 
many of them will have a practical value, which will make them of general interest. 
Anatomy is recognized as being the foundation of our medical science, and is in 
direct connection with all its subdivisions. 
How can one mend, or manipulate properly, the living human mechanism, who 
does not understand that machinery? It is a living, daily useful knowledge. 
I have often, in my lectures, as Professor of Anatomy, both in the Medico- 
Chirurgical College and in the Jefferson Medical College, in Philadelphia, stated 
that I taught a "live anatomy from the dead body," and believe that I have intro- 
duced the phrase. 
I have always impressed the student that anatomy was of essential knowledge in 
the practice of medicine. That he should study anatomy on the dead body, so as to 
vitalize the knowledge so acquired upon the living ; to practically apply it to his own 
living structures. That anatomy is not a dead science, nor a mere closet study, but 
one of living, essential value. 
Not to be learned as a mere task, but so that it may be remembered, and applied SECTION VII-ANATOMY. 
123 
in daily use. Hence my phrase that I "teach a live anatomy from the dead body." 
Anatomy, so mastered, remains a basis of active, real knowledge. Physicians who 
have so studied it, are not in after years as prone to say that their anatomy has 
grown rusty. 
The great surgeon, Sir Benjamin Brodie, once said to me, "If you wish to be a 
surgeon, teach anatomy and practice surgery." 
It would be well if this advice was more generally followed. 
Anatomy for practical use is almost a complete science, but great work is being 
now done in minute anatomy. 
Any advance in anatomical discovery should be regarded as an event by our whole 
profession. Anatomy has been well called "the key and guide of medicine. " 
Prof. Leyden,* in his opening address to the Congress at Wiesbaden, in April of 
this year, well said : ' ' What raises medicine above all the natural sciences, is the 
fact that its object is man himself. " 
The most interesting and practical advance in anatomical knowledge in the last 
few years, I think we will all agree, has been in the study of the brain. The 
researches of Flourens ("Recherches Experimentales sur les Propriétés et les Fonc- 
tions du Systeme Nevreux," 2d edition, 1842; Longuet, "Traite de Physiologie," 
2d edition, 1866) gives us our chief knowledge of the results of the cutting away of 
the cerebral hemispheres, aided by other workers chiefly among the French, as, 
notably Vulpian, in his "Leçons sur la Physiologie du Systeme Nevreux," 1866. 
By these experiments upon animals, cutting off or destroying different portions 
of the brain, much clinical knowledge has been obtained ; but such investigations 
must always be more or less complicated with the question of shock to the whole 
brain structure. 
Anatomical and physiological researches must always go hand in hand ; are 
complementary to each other. The anatomical investigations of Lockhart Clarke, 
Meynert, and others, with those of physiologists, such as Brown-Séquard and Schiff, 
have advanced materially our knowledge of the nervous system and its centres. 
Fritsch and Flitzig have made a further advance in brain study by their discovery 
of the so-called electric excitability of the brain. These investigations have been 
brought to a practical focus by the clinical and pathological work of Dr. Hughlings 
Jackson, the physiological work of Ferrier and the surgical application made by 
Mr. Victor Horsley, at the Hospital for Epileptics, Queen Ann's Square, London. 
Mr. Horsley does some admirable surgical work. I saw him operate, with antiseptic 
precautions, for the removal of a cicatrix of the membranes of the brain, resulting 
from a fracture of the skull, in the upper parietal region, removing the cicatrix and 
the portion of the brain substance to which it was attached. I also saw two epileptics 
on whom he had operated. Diagnosing the tumor and its position, in each case, 
from the peripheral symptoms. In both he removed the tumor and a large piece 
of the substance of the brain ; if I remember correctly, nearly two inches square, and 
one inch of thickness of brain tissue. 
These cases were afterwards shown, at the meeting of the British Medical Asso- 
ciation at Brighton, by Mr. Horsley, where I again saw them. They excited great 
interest in the crowded Section. 
In a recent murder case in Mount Holly, New Jersey, I diagnosed the location of 
the pistol ball in the brain from the injury to the lip, tongue, and speech centres, 
in front of the fissure of Sylvius ; the opposite side of the body being affected with 
* Report of Fiftieth Congress of German Physicians at Wiesbaden. 124 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
paralysis. I trephined alongside the wound of entrance, about an inch in front of 
and above the left ear, letting out pus and remarkably relieving my patient, Miss 
Anderson. The paralysis almost entirely disappeared ; my patient regaining con- 
sciousness and speech. She sank again, and by the use of the induction balance of 
Dr. Girdner, used by him, thanks to his generous courtesy, and with the aid of the 
gentlemen engaged in the consultation, I was induced, as a last chance, to trephine 
on the opposite side obliquely backward, behind the parietal boss, opening an abscess 
resulting from the injury of the ball. I believe I touched the ball, with a Nelaton's 
probe, in this abscess, for the porcelain became leaded, showed the marks of lead 
upon it. I would have removed the ball, but for the exhausted condition of my 
patient, compelling me to stop instantly. 
I established, however, excellent drainage for the brain pus, and gave the patient 
another chance for life. The ball could have gravitated near this last opening. My 
surgical interference certainly prolonged Miss Anderson's life about four weeks, and 
as an important fact, when she regained consciousness, in the most distinct manner, 
she stated who shot her, and where. On the post-mortem, the tract of the ball was 
found as we had diagnosed. The ball had traversed the brain obliquely backward, 
piercing the Falx major cerebri, in which it had left a hole. In the preparations by 
the undertaker, the body was disturbed and shaken, contrary to my directions. The 
ball had consequently gravitated through the slushy, decomposed brain matter, and 
was found at the base, just behind and below the first clinoid processes of the 
sphenoid, resting upon the membranes. 
I have used with advantage, as other surgeons have, the new topographical and 
physiological knowledge of the brain in cases when it has been injured. 
There are some anatomical points I would like to bring to your notice. I do not 
think that anatomists make sufficiently distinct that all muscles arising from one 
bone, and passing over the articulation to the bone below, are articular muscles. 
Hence, if any one of these is paralyzed, the articular surfaces separate, as far as the 
white, fibrous ligaments around them will permit. This is notably shown in the 
paralysis of the deltoid, making a simulated luxation. The white, fibrous ligaments 
around the joint, while they have some representative fibres of elastic tissue, are not 
made to stretch, and do not stretch in health. They are made to hold the opposing 
articular surfaces a certain distance apart, so as to permit motion by the muscles, 
and to prevent too wide a separation of the articular surfaces. The definition of 
a movable joint, as I teach, is that normal solution or division of the skeleton, to 
deaden shock and permit motion ; as in all the diarthrodial joints. The ligaments 
are made flexible to permit the motion, and strong, inelastic, so as not to stretch and 
allow the articulations to separate but a certain distance. As the muscles contract 
intermittingly and so variously, if the ligaments did not strongly hold the bones of 
the movable articulations together, we could not stand erect. The enlargement of 
the ligaments that we see in pathological conditions of the diarthrodial joints, as 
hydrops artieuli, white swelling or synovitis, is not immediate, as it would be if the 
ligaments were elastic, and stretched immediately, but is a slow, progressive enlarge- 
ment or expansion, under the maceration of the tissue, during the inflammation ; 
and the reduction is equally slow and tedious, often requiring the alterative impres- 
sion of the iron at a white heat. Like a sponge which swells when soaked with 
water, and becomes smaller when the water is removed. It does not stretch, it 
swells and shrinks. Surgeons make anatomical mistakes, when they say that the 
non-elastic ligaments stretch. When stretching or elasticity is needed, then we 
have the preponderance of yellow, elastic tissue, and we call this tissue yellow, SECTION VII ANATOMY. 
125 
elastic, fibrous tissue. How could a man stand on his toes if the tendo-Achillis 
stretched ? 
In regard to movable joints, again, while as histologists we recognize the low 
grade of inflammation that the articular cartilages are liable to, with the accom- 
panying infiltration into their lymph spaces; in joint inflammations, as coxalgia, 
white swelling, it is the synovial membrane which, when inflamed, does the mischief, 
and gives the agonizing pain. The articular cartilages slowly macerate, become 
opaque and dirty colored, and can be scraped off with a groove director without giving 
pain ; their organization is so low. This I have tested in two cases of knee-joint 
amputation, where I could scrape off the articular cartilage without the patient 
knowing it. Beneath this macerated cartilage was red, injected and inflamed bone. 
The synovial membrane is so highly organized, that inflammation of it causes agon- 
izing pain, and the sufferer instinctively holds the joint steady by his muscles. 
When inflamed, it becomes vascular and loses its polished, transparent appearance. 
In health we never find it between the articular surfaces, because it is too highly 
organized to bear the pressure. Admitting Toynbee's statement, that in the early 
stages of fœtal life it is a closed sac between the joints, and then covers the articular 
surfaces when motion of the joints commences, then the intervening synovial mem- 
brane is absorbed, for we never find it on the articular cartilage in the new-born. In 
inflammation of joints lined by synovial membrane, it is this membrane that gives 
the pain and causes the destruction of the joint. If this inflammation is not arrested, 
then nature makes her own cure, which is anchylosis. The synovial membrane grows 
and spreads over the articular cartilage, which has now become macerated ; sucks it 
up in its lymphatics, and leaves bare bone against bare bone, vascular and inflamed, 
when blood vessels throw out callus and solidify the joint. Using the finest ether 
and vermilion injections, I have never been able to inject the articular cartilages in 
the adult, new-born cadavera, or in fœtal calves. I have dissected several joints 
amputated as a result of synovitis, and have found this the invariable condition. 
The anatomical teaching has great practical value in surgery. Many who use 
extension and counter-extension in joints, think that they are doing good, by forcibly 
separating the joint surfaces, and taking off pressure from the articular surfaces. I 
have been called in consultation frequently, where I found that the extension and 
counter-extension was causing pain, unrest, and doing harm. When it is recognized 
that it is the synovial membrane that must be treated, and not irritated, and not the 
articular cartilage, then the importance of rest is recognized, and the extension and 
counter-extension are used judiciously and only for rest. That is the requisite for 
curing joint inflammation. Rest, so as not to increase the synovitis ; sufficient fixation 
to prevent the inflamed synovial membrane from being rubbed against, and then the 
proper lotions, or counter-irritants, aided by constitutional treatment, to cure the 
inflammation. Extension and counter-extension are often abused. 
I would like to bring to your notice that I believe there are only four metacarpal 
bones in each hand and foot. I do not think the anatomical teaching is correct, that 
says there are five metacarpal bones in each. A metacarpal bone is developed by 
two centres-one for the shaft and one for the head ; a phalanx, one for the shaft 
and one for its base. The thumb has, therefore, by this explanation of development, 
three phalanges. The first, or upper phalanx, is one, and is not a metacarpal bone, 
by anatomical definition. It is the same way in the foot ; hence, the great mobility 
of the big toes, as well as the thumbs, and the facility with which some people, born 
without hands, can use their feet. In looking at the hand, it is made up of two 
solid triangles, each having for its base line of junction, one drawn from the index 126 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
finger to each pisiform bone. As a practical deduction from this, I have always 
found it necessary to use a different treatment for fractures and dislocations involving 
the metacarpus and the thumb. Again, the metacarpus can be all removed, with 
its adjacent phalanges, in cases of injury, and, if the thumb is intact, it can be moved 
over, and its so-called metacarpal bone, or first phalanx, takes position against the 
carpal row. This I first saw done by my father, when the result was a useful and 
active thumb at the end of the, stump on the carpus. I have also had the same good 
result in a like amputation. 
Among the anomalies of muscles there is an interesting and important one, in 
which I have several times found an unequal development, and hence contraction of 
the soleus and gastrocnemius muscle. That is, the soleus will be hard and tense, 
while the gastrocnemius will be too long apparently, and will be loose and movable ; 
can be moved to and fro on the soleus beneath. This was first pointed out by my 
father, and he explained, by this, how certain cases of talipes equinus were not 
benefited by cutting the tendo-Achillis. After the tendon united, the same deformity 
recurred, because the gastrocnemius and soleus being inserted into the tendo-Achillis, 
the same tenseness of the soleus and relaxation of the superficial gastrocnemius 
occurred. This he met practically by slipping a knife between the gastrocnemius SECTION VII-ANATOMY. 
127 
and soleus and cutting the soleus loose, by shaving it oft' flatwise from the tendo- 
Achillis. This operation I have repeated several times, and have made a long, 
sabre-shaped myotome to do it with facility. A simple puncture is made, and I 
then push the myotome flatwise between the gastrocnemius and soleus, and shave 
off the latter in the same way. By keeping your knife flat, cutting in this way, you 
are in no danger of injuring the deeper-lying tibial artery, and the hemorrhage is 
slight and easily controlled. I think an additional teaching might be emphasized 
with regard to some of the deep fascias, as of the hand and foot. They not only 
protect the deeper structures, but they act in some places as cords or ligatures. 
This I have noticed in deep cicatrices and club deformities of hand and foot. As an 
illustration, in talipes varus or valgus, the pathology, I think, is that the plantar 
ligaments, long and short, are not sufficiently developed, and, from the same cause, 
or as a consequence, the deep or plantar fascia is not long enough. Hence, when 
the bones grow they are restrained or compressed on the undeveloped side, and 
become proportionately large on the opposite-the convex side. Hence, in operations 
for talipes varus, or valgus, I always cut subcutaneously the deep fascia, to lessen its 
tenseness. Again, if it is an old deformity, the bones have been forced to grow in 
the manner I have just mentioned. In such cases I have found I could not correct 
the deformity without cutting out the projecting bones on the outside of the foot. 
This I have done, producing the best results. 
In regard to the coronoid process of the ulna, there is a point that seems worth 
mentioning. Surgeons have often spoken of the fracture of this process as the 
result of muscular contraction. This, I think, is partly the fault of an anatomical 
teaching and works on anatomy, because it is not sufficiently emphasized that the 
coronoid process is covered by the anterior ligament of the elbow, so that its summit 
is always within the ligamentous covering of the joint. The projecting eminence 
which this process makes can thus never be broken off by the contraction of the 
brachialis anticus. This muscle is inserted at the base of the process, into a rough 
depression on its anterior surface. As it is thus inserted into the anterior surface of 
the very base it cannot pull off the upper portion of the process. The tendon of 
insertion lies entirely outside of the ligaments surrounding the elbow joint, on the 
surface of the anterior ligament, while the free articular tip of the process is within 
the joint, covered completely by the ligaments, and grasping by its concavity the 
anterior part of the trochlear surface of the lower articular end of the humerus. I 
don't believe that the coronoid process is ever broken off by muscular contraction. 
I have seen this fracture occur very often in injuries to the elbow joint, and always 
from direct violence, such as a fall. In falling, the arm being outstretched for pro- 
tection, the violence is applied to the open palm or to the wrist, and thus the forearm 
is driven so forcibly up against the humerus that the coronoid process is broken off 
in the joint. I believe that this very often happens, and is not recognized, on 
account of the subsequent and almost immediate swelling. As a consequence, the 
joint is not treated so as to place this fractured process in the best position for a 
cure. It may get between the articular surfaces, or in such a position as to inflame 
the synovial membrane, and thus produce, as we often see, a permanent deformity . 
of the joint, impairing its usefulness. 
Among some smaller points of interest, that time will not permit me to refer to, 
I would like to mention to you anatomists how constantly misused is the term anasto- 
mosis, when applied to the description of the nerves, by surgeons and other scientists; 
even by anatomists. 
The derivation of anastomosis is from ana, stoma and osis. Meaning, the appli- 128 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cation of one mouth to another mouth, for the purpose of facilitating the circulation 
of a fluid. This term is well adapted to the vascular apparatus, where one vessel 
connects with its open mouth to the mouth of another, as is so well shown in the 
circle of Willis at the base of the brain. But it is not applicable to the nervous 
system. We know that the nerves are cords, and that the nervous fluid circulates 
along these cords, delicate as so many of them are, in a manner similar to the pas- 
sage of the electric current along a wire. The nerves are continuous cords, from their 
origin to their termination. One nerve may join, side by side, with another, and 
both run to their destination, but in no case do we find them to inosculate, or join 
end to end with open mouths. Nerves do not anastomose, and, according to my 
judgment, it is a great misnomer to so state. To say so is an anatomical mistake, 
as precision is a most important point in anatomical teaching. By accurate teaching 
and nomenclature we prepare the way for the subsequent elucidation of physiological 
truths. 
In reporting to you what has recently been done for the advancement of our 
department of medical knowledge, it may be well to mention the inauguration of the 
Anatomical Institute of Vienna, within the past twelve months.* Although but 
one division, the erection of several buildings for allied sciences being contemplated, 
it is admirable in its appointments. It has two lecture-rooms, each with a seating 
capacity of 300. Rich in museums and material; a most complete library of anato- 
mical work. Working rooms for professors and students. The dissecting rooms are 
two grand halls furnished with marble tables, electric lights, marble floors and water 
appliances that stand unrivaled. The whole building can be flushed with water, 
and thus be guarded against miasmatic influences. 
In reviewing the practical work that has lately been accomplished, we must bear 
in mind that but little can be added to the details of human anatomy, except in 
histology; but much remains to be done in the way of rational explanation and 
elucidation. While the material at hand for the purpose is inexhaustible, the 
labors we have to record, although by no means small, make but little impression 
upon it. 
Upon the researches in regard to the osseous system, I will first record to you the 
result of the investigations of Mr. J. Bland Sutton, f He has found that the ossi- 
fication of the superior maxilla in the mammalia proceeds from four centres, of 
which the originally separate parts are :- 
(1) The premaxilla : the innermost part of this is of cartilaginous origin ; being 
formed in the anterior extremity of the ethmo-vomerian plate. If anything inter- 
fere to prevent the premaxillary bone from meeting the ethmo-vomerian plate, the tip 
of this cartilage ossifies independently, and the double premaxillary bones, described 
by Albrecht in cases of cleft palate and hare lip, are thus explained. 
(2) The prepalatine portion, comprising the palate plate and a considerable portion 
of the inner wall of the antrum. 
(3) The maxillary centre, including all the facial and orbital parts of the bone, 
internal to the infra-orbital canal. 
(4) The malar piece, situated external to the infra-orbital canal. 
He has also found that in the early life of the human fœtus, a cartilaginous bar 
is given off from the upper end of Meckel's cartilage, subsequently the malleus, to 
* Reports in many German Journals, for 1886. 
f Proceeding* of the Zoological Society of London, 1886; Journal of American Medical 
Sciences, 1886. SECTION VII-ANATOMY. 
129 
near the extremity of the fronto-nasal cartilage, and which undergoes the following 
metamorphosis :- 
(а) The anterior portion ossifies as the pterygoid bone, the internal pterygoid 
plate of human anatomy. 
(б) The middle part remains throughout life as the cartilaginous portion of the 
Eustachian tube. 
(c) The posterior extremity degenerates into fibrous tissue, and becomes the 
anterior ligament of the malleus. The number of centres given by him agree with 
other descriptions, but there exists some difference in the dates of their appearance 
and junction. 
Mr. W. Kitchen Parker* has made the structure and development of the skull 
a special study, and during the past year has published two monographs upon the 
subject, one upon the skull of the edentata, and the other upon the skull of the 
insectivora. Another contribution is that of Mr. Herman Weicker, "The Capacity 
of the Encephalon in the various Nations." Although of much smaller scope than 
the former monographs, we may refer to that series which are published by my 
friend, Prof. Macalister,f of Cambridge University, England, upon the cranial bones. 
It is to be regretted that they are so little available to the ordinary student. 
Dr. Benedict. J of Vienna, has completed his instruments for the craniometric 
and cephalometric method. It is unquestionable that, by this method, much will 
be accomplished toward bringing anatomy to a fixed science. Such instruments as 
these are of the utmost value in the study of our department of the medical science. 
I firmly agree with Benedict when he says : "If anatomy shall become a fixed science, 
it can none too soon be reduced to mathematical morphology. ' ' 
The axial skeleton has had its attention at the hands of Prof. Cunningham,! who 
has discussed embryologically the connection of the os odontoidum with the body of 
the axis vertebrae. 
Turner || has shown that a difference exists in the spinal curvature in the skeletons 
of the various races, which if not compensated for in the living by an equivalent in 
the intervertebral discs the appearance would be marked, as the lumbar spine is less 
curved in the Negroes, Andamanese, and especially Australians. To express the 
relation of the anterior and posterior depths, a lumbar index is calculated, the anterior 
vertical diameter being taken as a standard-100. The average index of the five 
lumbar vertebrae in 12 Europeans is 95; in 2 Esquimaux, 98 ; in 3 Negroes, 98.9; 
in 2 Sandwich Islanders, 104.7 ; in 5 Australians, 105.8. The lowest was 84.8 in a 
Chinese skeleton, and the highest 106 in a Bushman. 
Prof. has given further data to the ethnological classification which uses 
the pelvic brim as a basis, and proposed one similar to that in use for the various 
forms of the cranium. The base of operation was in all cases the male pelvis, as the 
female basin showed a greater similarity of form in the different races. 
In the researches which have the brain and nervous system and its development 
as a basis, we first refer to the work that great student, Herr His,** has contributed 
* British Medical Journal, 1886. Transactions of the Royal Irish Academy, for 1886. 
J Wiener Medicinische Blatter, 1887. $ British Medical Journal, 1886. 
|| Journal of Anatomy and Physiology, April, 1886. 
Journal of Anatomy and Physiology, 1885. 
** Report of the Fifty-ninth Congress of German Scientists, Section of Anatomy-Archiv für 
Anatomie, 1886. 
Vol. Ill-9 130 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to the origin and development of nerve fibres. He has demonstrated that after the 
closure of the spinal canal an apposition forms between an inner and dense, and outer 
and somewhat less compact layer of cells (the inner plate and the enveloping layer). 
From the cells of the former a superstructure is developed, the myelo-spongium, 
which with its outer covering tops the nucleated cell tubes, and delivers the founda- 
tion for the future white fibres of the spinal cord. The development of nerve fibres 
in the human embryo is begun with the fourth week. The cells of the enveloping 
layer develop into a primary conical process, a prolongation of the axis cylinder, and 
which from its incipiency shows fibrillar markings. The fibres developed from the 
anterior half of the enveloping layer leave the spinal cord as motor roots. The 
posterior half are given off in a saggital manner, and develop circularly toward the 
anterior (formatio arcuta). A part of these fibres go over to the anterior commissure, 
which, in the beginning, contains but few strands; coincidently with the latter 
longitudinal fibres appear which are the commencement of the anterior columns. 
Branched sprouts appear from the enveloping layer of cells, the anterior motor 
horn cells, later, as the prolongations of the axis cylinder. 
The foundation for the ganglions are divided and become completely separated 
from the spinal marrow, their cells spread and originate two roots, one of which 
enters the spinal cord as the posterior, the other develops toward the periphery. 
The nucleus of the spinal ganglia moves eccentrically to the side, and thus allows 
the building of the "T" formed fibres. These forms are readily recognizable in an 
embryo of four or five weeks, as the cells do not yet possess the endothelial division. 
The root fibres encroaching on the spinal marrow collect in thin, and later on, in 
heavier oval bundles; subsequent fibres can pierce these bundles and make their way 
between the cells. The peripheral branches burrow their way through the loose 
connective tissue, and in the beginning have a relatively enormous power. The 
central fibres find their way out in the meshes of the myelo-spongium. The primary 
conduct is in every case a free development of the divided and undivided fibres; just 
how far secondary combinations can begin between the cells, centrally as well as at 
the periphery must, for the present, remain an open question. He positively asserts 
that motor fibres always appear before the sensory. 
Prof. W. Bechterew* has pointed out a region of the lateral column of the 
spinal cord, immediately in front of the posterior nerve roots, between these and the 
crossed pyramidal tract. The fibres differ from those of the neighboring parts by 
their small size ; they begin to acquire their medullary sheath when the fœtus is 
about thirty-three centimetres in length, at a time when the posterior columns are 
completely medullated, and while the pyramidal tracts still consist entirely of pale 
fibres. The name posterior root-area of the lateral column is given to this region, 
since it is composed of the small fibres of the posterior roots, which ascend for a 
short distance at the outer part of the substantia gelatinosa, and then turn inward to 
the posterior horn. Bechterew's observations on the fœtal cord confirm Lessauer's, 
who found this area degenerated in tabes dorsalis. The fibres of the ascending root 
of the fifth nerve are medullated in foetuses from twenty-five to twenty-eight centi- 
metres long. They can be seen arising from the lower part of the medulla oblongata, 
from the cells of the base of the posterior horn, being placed internal and anterior to 
the gelatinous substance of Rolando. They pass outward through the latter to gain 
its outward surface, along which they ascend. They have no origin from the 
substantia gelatinosa. 
* Archiv für Anatomie, 1886. SECTION VII ANATOMY. 
131 
The same observer, in his study of the development of the restiform body, from 
various periods of fœtal life, finds it is made up of five constituents, which are 
enumerated in the order of acquiring their medullary sheath.* 
1. The direct cerebellar tract of the cord. 
2. Fibres sprouting from the nucleus of funiculi cunextus of the same side. 
3. Fibres springing from the lateral nucleus of the same side. 
4. Fibres issuing from the nuclei of the funiculi graciles of both sides. The set 
derived from the nucleus of the same side ascend to the restiform body as the 
posterior superficial arcuate fibres ; while those from the opposite nucleus pass forward 
in the inter-olivary layer and emerge on the inner side of and through the pyramid, 
as well as between the pyramid and the olive, and from the anterior superficial 
arcuate fibres. 
5. Fibres from the lower olive of the opposite side. Neither the formatio reticu- 
laris nor the pyramid of the medulla oblongata has any relation to the restiform 
body ; nor does the latter receive any fibres from the fifth and eighth nerves, as 
Edinger states. The auditory nerve is connected to the cerebellum by a special 
bundle, which ascends to the middle peduncle. The fifth nerve has no connection 
with the cerebellum. The restiform body is distributed in three distinct bundles 
within the cerebellum. 1st, containing fibres from the direct cerebellar tract of the 
cord, from the nucleus of the funiculus cunextus, and from the lateral nucleus 
passes to the cortex of the forepart of the upper worm ; 2d, composed of the fibres 
from the nuclei of the funiculi graciles to the middle portion of the upper worm 
on the same side ; and, 3d, comprising the fibres from the opposite olive, to the 
gray substance of the corpus dentatum, and in part, perhaps, to the cortex of the 
hemisphere. 
Baginsky f has devised a unique operation by which he has demonstrated the 
origin and central course of the auditory portion of the eighth nerve. The resulting 
degenerative changes affected only the posterior root of the nerve. The anterior 
root in all cases remained unchanged. It was thus shown that in the posterior root 
no connection existed with the inner and outer auditory nuclei, but that it sprang, 
in part, from the accessory auditory nucleus and the tuberculum laterale of Stieda, 
and in part to course round the restiform body into the arcuate fibres of the medulla 
oblongata. Some of the other fibres appeared to pass through the corpus trapezoides 
to the superior olive of the same side. Having crossed the mesial plain, the auditory 
fibres are found in the lower fillet of the opposite side, running to the inferior 
quadrigeminal and interior geniculate bodies, which are believed to be related to 
the auditory nerve in the same way that the superior quadrigeminal and exterior 
geniculate bodies are to the optic nerve. No changes when found above the meso- 
•cephalon in the cerebrum, or in the cerebellum and its inferior peduncle. 
Prof. Hamilton J has continued his researches upon the corpus callosum, the 
result of which he has published in his paper, ' ' Is the Commissural Theory of the 
Corpus Callosum Correct?" Our own anatomist, H. F. Osborn,| has also given an 
excellent account upon the same subject. The lectures of Alex. Hill, in which he 
pointed out an interesting similarity in the minute structure of the sense organs- 
the eye, the ear and the nose-and his ingenious arguments of various abstruse 
points is, doubtlessly, familiar to all. Dr. Herringham, in a paper on the brachial 
plexus, can claim to have placed this difficult subject upon a more rational basis. A. 
•» Archiv für Anatomie, 1887. 
j- VtrcÄow'» für 1886. 
J Transactions of Royal Society, 1886. 
§ Journal American Medical Sciences, 1886. 132 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
M. Patterson* lias, by dissections, been enabled to show that the construction of the 
sacral plexus agrees in principle with that of the brachial. He deduces that, in the 
primitive condition of the limbs, the nerves passing into them are divided into dorsal 
and ventral branches, which supply corresponding surfaces, and that indications of 
this arrangement are retained in the mode of origin of the nerves and their distri- 
bution to the structures of the limb. 
F. II. Hooper,f in his study of the recurrent laryngeal nerve, has shown that 
their recurrence is due to certain changes in the brachial arches and the descent of 
the heart into the thorax. At one time in the period of development the laryngeal 
nerves are straight, but, as the heart descends, they are brought down. The proof 
of this is found in the abnormal condition of the nerve in cases of irregularity of the 
great vessels which branch from the aorta. These nerves (at least in dogs and cats) 
contain no sensory fibres. The larynx possesses three functions controlled by three 
distinct sets of muscles, all innervated by the recurrent nerves. These functions 
are: 1st, respiration; 2d, sphincter action, which closes the larynx and prevents 
the entrance of foreign bodies, and plays an important rôle in expulsive acts ; 3d, 
phonotory action. 
The results of the extensive researches of Braune and Stahl J upon the calibre of 
the large air tubes, in relation to the capacity Of the lungs, are an admirable addition 
to our knowledge upon this subject. They have found that the trachea is smallest 
immediately below the larynx, increasing its calibre to about the middle of its length, 
and then diminishing to about three centimetres above the bifurcation ; from whence 
it enlarges to its end. The sum of the sections of the two bronchi at their beginning 
is greater than the section of the trachea three centimetres above the bifurcation. 
The calibre of the right bronchus at its origin to that of the left is, on an average, 
as 100 : 77.9. The calibre of the left diminishes from its origin to its termination. 
The right bronchus is too short to allow of observation being made upon it. The 
section of each bronchus at its origin is normally greater than the sum of the 
sections of its primary branches. There is a constant relation between the weight 
of the lung and the calibre of its bronchus. A definite relation between the 
calibre of the bronchi and the capacity of the lungs is also shown in patho- 
logical conditions. The calibre of a bronchus depends upon the volume of air 
that traverses it. 
To our knowledge of the organs, some excellent contributions have been added, 
notably by Dr. Schieffendecker,? who gives the position of the duodenum, the ileo- 
colic junction, and of the sigmoid flexure, after some two hundred dissections, and 
the results of his observations are as follows : The only deviation in the duodenum 
is in the length of the second part. This changes the level at which the third p irt 
crosses the spine, and which may be as high as the disk between the second and 
third lumbar, or as low as the top of the fifth lumbar vertebra. The site of the 
duodeno-jejunal junction is constant. The opening of the ilium into the large intes- 
tine is on a level with the sacro-iliac articulation. It may be lower, and we have 
found it in the cavity of the true pelvis; only two cases were found in which the 
ending of the ileum was higher; in one it was opposite the third lumbar vertebra, in 
the other in front of the second lumbar vertebra; so there was practically no ascending 
colon. 
* Journal of Anatomy, 1887. 
f Transactions of American Laryngological Association. New York Medical Journal, July 
23d, 30th. 1887. J Archiv für Anatomie, 1886. § Archiv für Anatomie, 1887. SECTION VII-ANATOMY. 
133 
The position of the sigmoid flexure was found to be very variable, and the different 
forms are collected into groups as follows :- 
I. When the flexure lies to the inner side of the descending colon. 
(а) The loop hangs down in the pelvic cavity. This is regarded as the normal 
position. 
(б) The loop is turned upward and applied to the posterior abdominal wall. 
(c) The loop is directed upward, but the other parts of intestine intervene 
between it and the posterior wall, and it may come into more or less contact 
the anterior wall. 
II. When the flexure lies to the outer side of the descending colon. 
There was only one example of this met with. 
Waldemayer* describes the normal position of the pelvic organs in the female, 
and from observation on some twenty nulliparæ between the ages of fifteen and 
thirty, shows that His's and Schulte's description is accurate. He goes further and 
states that the contracted bladder in the adult is entirely behind the symphysis pubis, 
and is much flatter on its upper aspect than the male organ. The ureters lie against 
the side wall of the pelvis, close below the ovaries, very near to the hilus. The pro- 
jecting fold of peritoneum which runs across from side to side over the empty 
bladder, and which is shown to exist also in the adult female, is named by him plica 
vesicalis transversa. 
Symington f has made observations from frozen sections, and his views are coinci- 
dent with the former. He states that it is erroneous to suppose the uterus to be 
normally antiflexed, and that it is less antiverted in the child than in the adult. The 
ovary they have both pointed out is not normally fixed, but possesses a large range 
of mobility; alterations are mainly due to change in uterine position. The uterus 
does not undergo any marked increase in size between infancy and puberty. The 
period at which the arbor vitæ disappears from the uterine body is variable. In one 
of the cases it was well marked at thirteen years. 
Mr. F. Trevis has also given his attention to the alimentary canal and peritoneum. 
He has systematically dissected and described the appearances found in two hundred 
mammalia. Pillet and Bonlart $ have contributed a valuable paper, bearing upon 
the same subject. 
A. in an elaborate article, furnishes us with some points in the 
anatomy of the thyroid gland. He found a pyramidal process, including cases of a 
superior accessory gland, in seventy-nine per cent, of one hundred and fifty-three 
cases examined. In the majority of cases it sprang from one of the lateral lobes, 
no variation being found in favor of the right or left, but rarely from the isthmus. 
The superior accessory gland, he says, arises from the separation of the pyramidal 
process, either before or after birth. It is nearly always connected to the hyoid bone 
by continuous gland substance, by connective tissue, or by a special muscle. 
A musculus glanditlæ thyroidæ occurs in nearly forty per cent, of subjects. It is 
connected with the pyramidal process, or with the body of the gland. The muscle 
may be a hyo-pyramidalis, derived from the thyro-hyoid or from the sterno-hyoid, 
or a thyro-pyramidalis, derived from the sterno-thyroid ; in rare cases a muscular 
bundle was found running transversely from the lower edge of the thyroid cartilage 
to the pyramidal process. Accessory fasciculi may be found attached to the body of 
Anatomischer Anzeiger, 1886. 
f Edinburgh Medical Journal, 1886. 
J Journal de l'Anatomie et de la Phys., 1886. 
§ Virchow's Archiv, 1886. NINTH INTERNATIONAL MEDICAL CONGRESS. 
134 
the gland and coming from the crico-thyroid, thyro hyoid, or the inferior constrictor 
of the pharynx. 
Anastomoses between the arteries of the right and left side are scanty. Out of 
one hundred and twenty subjects examined, in twelve an arteria thyroidea ima was 
found twelve times. Its origin was from the innominate in six cases, from the right 
common carotid in two, and from the right subclavian in four. 
He found that accessory glands were of very frequent occurrence in the neigh- 
borhood of the hyoid bone, and classified them into four groups according to their 
site :- a 
1. Pre-hyoid glands, superficial to the mylo-hyoid muscle. 
2. Supra-hyoid glands, between or in the substance of the genio-hyoid muscles. 
3. Epi-hyoid glands, above the genio-hyoid muscles. 
4. Intra-hyoid glands, lodged in the hollows of the hyoid bone. 
In one case a duct was found leading from the foramen cæcum of the tongue to 
the epi-hyoid gland. The author concludes that the foramen cæcum indicates the 
spot where the diverticulum leaves the pharynx. Accessory glands near the great 
cornu are much rarer than the others, although they are derived in the same way 
from the lateral diverticula which forms the lobes of the main gland. 
That much-abused adenoid tissue of the nasal mucous membrane has been described 
by Zuckerhandl* as a normal, although largely variable, constituent in man. The 
adenoid tissue is found most abundantly in the respiratory division of the nose, and 
especially in the posterior region. In the olfactory part, the connective tissue of the 
mucous membrane contains interspersed lymphoid cells, but no follicles. Adenoid 
tissue, both of diffuse and forming follicles, is w'ell developed in the pituitary mem- 
brane of the domestic animals, and in all of them the follicles are more numerous 
and constant than in man. 
E. Kaufmann t has demonstrated that the prominences seen in frontal sections 
of the meatus auditores are caused by fine ridges of the cutis, running transversely 
,to the axis of the canal and parallel to the margin of the tympanic membrane. The 
ridges are found in greatest profusion in the floor of the canal, and less frequently in 
the roof, and make their disappearance on the anterior and posterior walls. It is 
only exceptionally that one can find a few small papillæ projecting from the ridges. 
The ridges first make their appearance in the fourth and fifth month of fœtal 
life, and become less marked in old age. This corrects the usual statement which 
describes the skin covering the deeper part of the canal as presenting papillæ disposed 
more or less regularly in longitudinal rows. 
Schwabach, J in view of the conflicting statements of F. J. C. Mayer, Luschka, 
Ganghofner and Trautmann, undertook fifty-three dissections to determine the bursa 
pharyngea. He finds no such pouch normally, but states that when it is present it 
is of pathological significance. 
The curious phenomena of migratory testis has again received its usual attention, 
and the paper of Messieurs Debierre and Pravase? places the transition of the testis 
upon a better footing. They recognize that the internal cremaster is an upward 
prolongation of the gubernaculum. Lockwood has forestalled them, and treats of 
the same subject in his paper on "Infantile Hernia." Lockwood attributes an 
important pathological function to the cremaster fibres, and considers them com- 
* Wiener Jahrbuch, 1886. 
f Wiener Jahrbuch, 1886. 
+ Archiv für Microekopieche Anatomie, 1887. 
£ Lyon Médicale, 1886. SECTION VII ANATOMY. 
135 
petent to its production, because of the migration of the cæcum and the production 
of the sac of an infantile hernia. 
Dr. Dalia Rosa * has pointed out to the Vienna Society the growth of the tem- 
poral muscle, and has formulated the following laws : There is a regular progressive 
surface growth, from birth to the end of the first dentition; from thence to the end 
of the second dentition, there is a regular increase with the appearances of each 
molar tooth ; while in the interval which elapses between the first and second denti- 
tion, as well as the periods between the appearance of the molar teeth, there is a 
relatively small surface growth of the muscle. He further shows how, through 
extension of its attachment, it produces the characteristic markings on the bony 
surface, and finally points to some pathological value this knowledge gives. 
David Wallace, f of Edinburgh, describes a case in which the musculus sternalis 
occurred on the right side of a female subject, and was well marked, being about an 
inch wide and six and a half long, with a tendon of two inches. Its origin was the 
costal cartilage of the sixth rib, and it received slips from the third, fourth and fifth 
ribs, and also from the right half the anterior aspect of the sternum, between the 
fifth rib and the manubrium sterni. Its fibres passed upward, and became continuous 
with the sternal origin of the right sterno-mastoid, giving a few fibres to the great 
pectoral muscle. The muscle was supplied by a nerve which was traced to the 
external anterior thoracic nerve. This differs from former observations. In the 
cases reported by Shyhard, Cunningham and Abrams, the nerve supply was reported 
from the internal anterior thoracic nerve. 
H. St. John Brooks, + in an elaborate essay, has communicated that the outer 
head of the flexor brevis pollicis muscle most frequently receives branches from both 
ulnar and median nerves. In thirty-one dissections he has seen the following varia- 
tions : The outer head, in five cases, was supplied by the ulnar nerve alone ; by the 
ulnar and median in nineteen cases ; the outer head by the median, the inner by the 
ulnar, in five cases ; the outer head by the median, the inner by the median and 
ulnar, in two cases. He has also shown that the muscle known as the flexor brevis 
minimi digiti, in human anatomy, and the larger part of the opponeus minimi digiti 
are derived from Cunningham's adductor layer, while the ulnar head of the true 
flexor brevis is only represented by that part of the opponeus beneath the deep 
branch of the ulnar nerve ; the radial head of the flexor brevis forms the third pal- 
mar interosseous muscle. The so-called deep head of the flexor brevis pollicis is 
really a part of the adductor, and the proper ulnar head of the short flexor is the 
first palmar interosseous of Henley. The separation and reduction of some of their 
parts, shown by their muscles, is attributed to the pressure of the more developed 
long flexor tendons. 
Dr. Adolph Ott,£ in three hundred sections of the heart of a five-mouth embryo, 
demonstrated that no ganglion cells were found in the ventricular walls below the 
aperture of the pulmonary artery and aorta. From the semilunar valves upward 
they regularly increased in number. Particularly profuse were they in the septum 
atriorum or auricularum cordis. Taking his clue from these observations, he demon- 
strated ganglion cells in the corresponding sites in the adult heart. 
Fleming || has attempted to show that in the rabbit the Wolfian duct originates 
* Wiener Medicinisehe Blätter, Nov. 24th, 1886. f Journal Anatomy and Physiology, 1887. 
J Journal Anatomy, 1886. § Prager Medicinisehe Wochenschrift, 1886. 
|| Quarterly Journal of Microscopical Society, 1886. 136 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
from the epiblast. If this observation could be clearly proven, it would reconcile 
many discrepancies ; but it is so out of accord with what occurs in other vertebrates, 
that, without doubt, even after Speer's paper showing like origin in the dolphin, 
more evidence will be demanded upon this point before its acceptance. 
Bailey and Lockwood's valuable researches upon the fascia, muscles and ligaments 
of the orbit have excited the interest which they deserve. 
I regret that complete translations of the work of Hennum, of Christiana, are 
not extant, for in his experimental research he has formulated some new anatomical 
laws. He applied pressure to variously-formed elastic globes, and showed that they 
conformed to strictly geometric crystallographic figures. He could demonstrate that 
similar relations result in the developments of all formations in the various organs, 
and particularly in the epithelial. 
Mr. W. Balten Spencer, in a study of the pineal body, attributed to De Graaf 
the merit of having clearly shown that in one particular animal the pineal gland 
is actually modified into a structure comparable to the invertebrate eye. Mr. Spencer 
carries the researches much further, and shows that in many lizards the invertebrate 
eye possesses a cornea, lens and retina of unanticipated perfection. 
Much had, of course, to be omitted, owing to the limited time at my disposal, but 
I have endeavored to give you, in concise language, the results of recent labors of 
anatomical workers in our field. Time only prevents me from mentioning to you 
some of the numerous anomalies that have been reported. 
With this modest introduction to our work, the Chair, which is your executive 
only, gentlemen, is ready, if the Section is, for the first paper in order. 
THE DEVELOPMENT OF THE TORUS LONGITUDINALIS IN TELE- 
OSTIANS AND ITS HOMOLOGY IN HIGHER VERTEBRATES. 
DU DÉVELOPPEMENT DU TORUS LONGITUDINALIS DANS LES TELEOSTIENS ET 
SON HOMOLOGIE DANS LES PLUS HAUTS VERTÉBRÉS. 
DIE ENTWICKLUNG DES TORUS LONGITUDINALIS IN DEN TELEOSTIERN UND SEINE 
HOMOLOGIE IN HÖHEREN WIRBELTHIEREN. 
BY PROFESSOR H. RABB-RICKHARD, 
Berlin. 
In a series of former publications, I succeeded in proving that the different parts of the 
brain of Teleostian fishes in no way essentially differ from what anatomy and embry- 
ology teach us on the higher classes of vertebrates. All previous authors had overlooked 
the existence of a pallium or rind of the hemispheres, taking the rounded hills which 
are found just in front of the lobi optici (or mesencephalon), and which are separated 
from each other by a median fissure, for a solid cerebrum without anything comparable 
to a cortex. This, however, I discovered, in the form of a very thin epithelial mem- 
brane, enveloping the hemispheres from above. I succeeded in removing this membrane, 
which is always destroyed by breaking off the skull from above, and therefore con- 
stantly escaped the notice of former investigators, by cutting the brain together with 
the skull, after having softened the boues. I had previously made out, by studying 
the embryology of the Salmonidés, that the hemispheres were composed of a pallium 
(cortex) and a corpus striatum, both separated by an ample cavity, which is the SECTION VII-ANATOMY. 
137 
homologue of the united lateral and median ventricles, and which I proposed to call 
ventriculus communis. What till then was supposed to be the whole hemisphere, 
turned out to be only the corpus striatum (Insula-Stammlappen of German authors). 
The brain of a mammal, of a mouse or rabbit, for instance, may be transformed to the 
appearance of a Teleostian brain by breaking off the dorsal cortex of the hemispheres, 
and thereby laying open the ventricular surface of the corpora striata. 
I only hinted at the interesting fact that in the Teleostian fishes that part of the 
brain which in higher vertebrates is the seat of the highest psychical functions, 
namely, the cortex cerebri, with its innumerable ganglion cells, is reduced to a simple 
layer of ciliated epithelial cells. A localization of the different cerebral functions in 
highet vertebrates, according to the experiments of Fritsch, Hitzig, Ferrier, Munk and 
others, is impossible in the Teleostians, simply by the absence of any nervous tissue in 
the cortex. 
I am glad to state that this view of the brain of fishes is now almost universally 
accepted by anatomists. At the same time, it is proved that no homology whatever is 
possible between parts found in the lobi optici of the Teleostians and the hemispheres of 
higher vertebrates. The lobi are homologous to the mid-brain (mesencephalon, corpora 
quadrigemina) of the mammalia, and, when looking for equivalent parts in both, we 
are restricted to those found in the latter. Now it happens that the lobi optici of 
Teleostian fishes present a seemingly much more complicated structure than the mid- 
brain of the other vertebrates. There is a folded mass projecting in the cavity of the 
lobi from behind, which is nothing else than a mighty valvula cerebelli. But there are 
other parts, not less complicated, we find no equal of in the mid-brain of higher 
vertebrates. 
First of all, there exists the Torus longitudinalis, a double protuberance of a longi- 
tudinal stripe immediately beneath the dorsal roof of the lobi optici (tectum loborum), 
which was found by Carns in Clupea hazengus, and declared to be the fornix. A few 
years ago Professor Fritsch, of Berlin, to whom we are indebted for a splendid mono- 
graph on the brain ot Teleostian fishes, accepted this view, trying to corroborate it by 
minute investigations. It needs no further proof that this opinion is perfectly errone- 
ous. The fornix is a part of the hemispheres of higher vertebrates, and must not be 
sought for in a region of the fish brain, which is homologous to the mid-brain. But the 
fact that there was not a vestige of a part comparable to the Torus longitudinalis to be 
found in the mid-brain of higher vertebrates excuses Carus and Fritsch for seeking an 
homology in other regions of the brain. Neither was the development of the Torus 
known. 
I hope the following paper will cast a light on both points :- 
As to the development of the Torus, studied in the Salmonidés, I found that the 
roof of the lobi optici in an early period is represented by a simple layer of tissue, 
attenuated in the median line, without even a trace of the Torus. Consequently the 
roof on either side of the median line is very much thickened, whereas the thin 
median part does not undergo any change for awhile. Then there begins a prolifera- 
tion of the inner cells, producing a double longitudinal stripe, which, protruding in 
the ventricle, is gradually transformed to the Torus longitudinalis of adult fishes. 
One must, before all, bear in mind this development of the torus as a proliferation 
of the inner cells, which form the ependyme in higher vertebrates. When seeking 
for an homologous formation in the latter, we are obliged to look for the innermost 
epithelial layers covering the walls of the Aquæductus Sylvii, which is the reduced 
ventricle of the lobi optici of fishes. 
In examining the mid-brain of Rana esculenta, Lacerta ocellata, Psammosaurus 
terrestris, Iguana tuberculata, Chamæleon, Chelonia midas. Alligator mississip- 
piensis, I was struck by the fact that the epithelial ependyme is not equally developed 138 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in all parts of the ventricle. There exists a locality immediately behind the commis- 
sura posterior, beneath the roof of the mid-brain, where the cells show a quite extra- 
ordinary lengthening, forming a sort of double longitudinal fringes, which are most 
remarkable in the mid-brain of Chelonia, Alligator and the bigger Saurii. By their 
symmetrical disposition on both sides of the median line, they resemble the embryonic 
stage of the Torus in Teleostians. 
On further investigation I stated the existence of the same fringes in the brains of 
birds (Columba domestica), and I am sure they will also be found in mammalia in the 
same place. As to mammalian embryos, I made sure of their existence, they being 
beautifully developed in the Edentata (Xenurus gymnurus). 
I am therefore compelled to conclude that the Torus longitudinalis of the Teleos- 
tians, hitherto unknown in all the other classes of vertebrates, is represented in the 
latter by a singular and constant proliferation of the ependyme cells beneath the roof 
of the corpora quadrigemina, immediately behind the commissura posterior. 
Thus, the Torus longitudinalis is deprived of its isolated existence in fishes, and 
demonstrated as a rudimental formation, even in the highest vertebrata. 
ON THE CEREBRAL VESICLE IN THE HUMAN EMBRYO. 
SUR LE VESICULE CEREBRAL DE L'EMBRYON HUMAIN. 
ÜBER DIE GROSSHIRNBLASE DES MENSCHLICHEN EMBRYOS. 
PROFESSOR VON GERLACH, M.D. 
In the previous century Vicq d'Azyr observed on the medial surface in the gray 
substance of the convolutions of the occipital lobes a white stripe, by which stripe the 
gray layer of these convolutions was divided into an external dark gray stratum, a 
middle white one-the stripe of Vicq d'Azyr-and an internal light gray stratum. 
Baillarger described, in the first half of the present century, a second white stripe in 
the gray substance of the cerebral convolutions, by which the number of strata was 
thus increased to five ; an external gray, an external white, a middle gray, an internal 
white and an internal gray layer. 
Through Meynert, a more scientific microscopical basis for these five strata of the 
cerebral convolutions was obtained. 
About the year 1857, while I was studying the effect of stains on animal tissues, 
the magnificent colored spectra obtained from sections of the convolutions of the cere- 
bellum engaged my attention to a high degree. Sections of the cerebellum of even 
1 mm. in thickness were stained so beautifully after a short treatment with ammonia- 
carmine, that single strata gave a picture sharply enough outlined in their different 
shadings to have served as samples in any calico printing or wall paper manufactory. 
I was much surprised that the same results could not be obtained upon staining 
sections of the convolutions of the cerebrum. 
In most of the sections which had been prepared for staining in the same manner 
as those of the'cerebellum, the white substance was but slightly stained, the gray 
peripheral more intensely. In the brain of the newborn only were the two stripes of 
Baillarger faintly but distinctly visible, absorbing less pigment than the three other 
strata of the gray substance separated by them. SECTION VII-ANATOMY. 
139 
A fortunate circumstance enabled me to obtain a quite fresh human embryo, three 
cm. long, from head to nates. This specimen I treated with chromic acid, and for a 
short time with dilute alcohol, my usual procedure with the convolutions of the cere- 
brum and the cerebellum. 
In eight days the specimen was ready for dissection. I cut through the middle of 
the body, the neck and the head, and made from the latter sagittal sections. Upon 
examining these after staining with ammonia-carmine, I was surprised at the sharp 
differences of color presented-intensely red where there were cells only, less red where 
there were both cells and interstitial formations, and a very light red where there were 
but few cells. My interest was especially awakened by the examination of the cere- 
brum, which really consisted of the anterior cerebral vesicle only. The cerebral vesicle 
Figs. 1,2. 
Section through the cerebral vesicle of a human embryo, 3 cm. long from head to nates (Enlarged 
200 times.) 
1. Gray substance. 2. White substance. 1, 2, 3, 4, 5. The five gray layers of the gray substance. 
was sharply divided into two layers (Figs. 1 and 2), which can hardly be explained in 
any other manner than that they were the gray and the white substance of the cere- 
brum. The external layer, that is, the gray substance, was nearly twice as thick as 
the internal ; and in it the stratification appeared with the same distinctness as in the 
convolutions of the cerebellum, in the adult. A very thin external cellular layer was 
separated from a middle thicker one, and that in turn from a still thicker internal 
layer, by the two stripes of Baillarger, which were almost destitute of cells and were 
of a pale red color. All three cell layers were characterized by an intense red, forming 
a color spectrum unsurpassed for representing the layer in the gray substance of the 
convolutions of the cerebrum. I have used them only in my lectures on the anatomy of 140 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the brain, when demonstrating to the students, by means of a projecting apparatus, the 
stratification of the gray substance of the cerebrum. The white substance of the 
cerebral convolutions appeared quite different from that of the adult, which, as is 
known, consists only of fibres in cylinders, surrounded by medullary sheaths, radiating 
like a fountain to the gray substance. 
I once noticed, in a section of an older embryo, that the chief mass of the white sub- 
stance consisted of oblong cells, on account of which it gave an intensely red color. 
My assistant, Dr. Herrmann, who was occupying himself particularly with nucleus 
segmentations, observed in these cells of the white substance a striking number of 
nucleus divisions, which could not be ascertained in the cells of the gray substance. 
In all older embryos, in which the convolutions of the cerebrum were more or less 
perfectly developed, I could demonstrate the stratification of the gray substance, after 
preparation with ammonia-carmine; but the difference between the five layers appeared 
the more distinct, the younger the embryo was. 
In an embryo still younger than that described above, but which, unfortunately, I 
did not receive when quite fresh, and which was less satisfactory for staining on account 
of the beginning maceration, in consequence of the hardening in chromic acid and alco- 
hol, I could still ascertain that the white substance of the cerebral vesicles, compared 
with the gray, existed in a less proportion than in the embryo three cm. long. 
I think that the following conclusions may fairly be drawn from what has been 
said : The stratification of the gray substance of the cerebrum, after preparation with 
ammonia-carmine, appears the more distinct the younger the embryo. The destruction 
of color decreases with the advancing development preceding birth, and still more 
after birth. In an adult, it is hardly possible to show the five layers of the gray sub- 
stance of the cerebral convolutions, after preparation with ammonia-carmine. The 
first rudiment of the cerebral vesicle is to be considered as morphologically equiva- 
lent to the gray substance of the convolutions of the cerebrum. The white substance 
of the primary rudiment is only minimum, but increases its ratio to the gray along 
with the development of the embryo. 
THE ANATOMY OF THE RECTUM IN RELATION TO THE 
REFLEXES. 
L'ANATOMIE DU RECTUM PAR RAPPORT AUX REFLEXES. 
DIE ANATOMIE DES MASTDARMS MIT BEZIEHUNG AUF DIE REFLEXE. 
BY JOSEPH M. MATTHEWS, M.D., 
Louisville, Ky. 
It is a matter of every-day occurrence that diseases are observed with a history of 
reflex symptoms. The organs and tissues of the body are so intimately connected by 
sympathy, which is made manifest in disease, that it would be a wonder indeed if they 
could be overlooked. And yet we are constantly meeting with cases which have been 
misunderstood, for the reason that the reflexes have not been properly considered. 
Perhaps the field of gynaecology reveals more evidence of this than any other depart- 
ment, yet, after a number of years in the observation of rectal troubles, I am persuaded 
that this portion of the anatomy is much neglected, not only in relation to the diseases 
that affect it, but also to it as a seat of many of the reflexes. That I may more clearly 
elucidate my subject you will permit me to recall some of its anatomical bearings. I SECTION VII-ANATOMY. 
141 
have had to speak quite recently of the part that the sphincter muscles play in disease, 
and the subject will be touched upon in this paper. The mucous membrane of the rec- 
tum is thicker than that of the colon, and just beneath it is found an increased layer of 
cellular tissue which connects it with the muscular layer beneath. In this membrane 
the follicles of Lieberkuhn are freely distributed. In structure they are very like the 
villi of the small intestine and covered by the same form of epithelium, and in their 
walls is a similar arrangement of capillaries. I shall only refer to the so-called Houston 
valves in the mucous membrane of the rectum, to say that I doubt their existence, and 
if found in some few cases I doubt the* claim that their office is to support the weight 
of faeces. The rectum receives blood from three different sources; the upper part is sup- 
plied only by the superior hemorrhoidal, a branch from the inferior mesenteric, which 
also supplies the lower part of the colon. The terminal branches of the superior 
hemorrhoidal pass to the lower part of the rectum, but the principal blood supply to 
this part comes from the middle and inferior hemorrhoidal, which are primary and 
secondary branches from the internal iliac, which artery affords the principal blood 
supply to all the pelvic viscera. The middle hemorrhoidal is distributed to the pouch 
of the rectum, while the inferior, a branch from the internal pudic, passes across the 
ischio-rectal fossa and reaches the rectum at its lower part. The internal pudic, besides 
giving a large supply of blood to the rectum, supplies blood to the bladder, prostate, 
vagina, perineum, and external organs of generation. The veins which return the blood 
from the rectum are numerous. The hemorrhoidal plexus communicates in front with 
the vesico-prostatie in the male, and the vaginal plexus in the female. While the 
inferior and middle hemorrhoidal arteries supply the principal part of the blood to the 
lower part of the rectum, the corresponding veins return but a small portion of this 
blood. Almost all the blood from the rectum passes through the superior hemorrhoidal 
veins and into the portal system. The nerve supply of the rectum comes from two 
sources. It receives an abundant supply from the hypogastric plexus of the sympathetic 
system. In addition to these, we find a supply direct from the spinal system of nerves, 
those to the rectum coming from the fourth anterior sacral nerve. This is the only part 
of the intestinal canal which receives branches direct from the spinal nerves. The great 
irritability and sensibility of this part can be easily understood. It is a fact that it 
requires deeper anæsthetization to perform operations upon the sphincter than upon the 
eye. Its nerve supply is greater than that of any other muscle of the body. They come 
from three different sources, from the internal pudic, the fourth sacral, and the poste- 
rior sacral nerves. It is a rule in the distribution of nerves that the same nerve supplies 
a muscle and the integument over it. There is no exception here. They pass in 
beneath the external sphincter until they reach the space between the inner border of 
this and the internal sphincter; there they divide into two sets of branches, ascending 
and descending. The ascending branches are distributed to the mucous membrane 
crossing the internal sphincter, the descending to the integument. The principal one 
of the nerve branches to this part comes from the internal pudic, a branch from the 
lower part of the sacral plexus. The pudic nerve is distributed to the muscles and 
integument of the perineum, to the penis, and integument of the scrotum in the male, 
and to the corresponding part in the female. Hence, the relation and great sympathy 
between the lower rectum and all parts of the perineum, and external organs of genera- 
tion. The sphincter ani and sphincter urethral muscles are supplied by the same nerve. 
We have also traced branches from the fourth sacral nerve to the bladder, prostate and 
vagina. Tracing all these nerves to their origin, we find that the spinal nerves, sup- 
plying all the pelvic viscera, all the structures forming the perineum, and external 
organs of generation, are given off from the same point in the spinal cord. Hence, it is 
easy to understand that the rectum can irritate and be irritated in return, from many 
sources and by many conditions. It is not within the scope of this paper to speak of 142 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
all the reflexes that have their origin in the rectum, but I wish to refer to a few of the 
most important. Because of the abundant blood supply of the rectum it is natural, in 
the exercise of its peculiar office, that its blood vessels should often be in a state of con- 
gestion, and this alone excites to many reflexes. Constipation is a great breeder of 
disease, for this reason. When there is no response to the daily call of nature to go to 
stool, the anti-peristaltic action of the gut causes a portion of the faeces to pass back 
into the sigmoid and leaves a portion in the rectum proper. This is added to each day, 
and the liquids of the fecal mass being absorbed leaves the mass in a hardened and 
dried condition, which acts as a foreign substance, irritating and congesting the parts. 
As a result, we frequently find, in women, the reflexes producing pain in the bladder, 
mouth of the urethra, womb, back, thighs, ovaries, vagina, perineum, etc.; in men, 
pain in the bladder, penis, urethra, scrotum, prostate, etc. Many of these troubles are 
directly traceable to the rectum as their source, and just as often is the origin 
overlooked. 
The relation of the rectum with the peritoneum is so close that oftentimes abdominal 
pain is but a reflex from these parts. The meso-rectum, dipping as it does within a 
finger's length of the outlet, is contiguous enough to take on inflammatory trouble 
from many conditions that may exist in the rectum. I have had occasion to point out, 
for this reason, the dangers that might arise from injecting internal hemorrhoids with 
carbolic acid. We have seen how easy it is for the rectum to become congested because 
of its inmost blood supply and dependent position. Being equally supplied with 
nerves, this congested state causes great reflex action to every part to which their fila- 
ments extend. It is my observation that when the rectum is congested, from whatever 
cause, the discharge of mucus is often taken as a symptom of more serious trouble than 
exists. Charlatans are in the habit of parading these symptoms as of the gravest 
importance, and many fall into the trap. The reflex from this congested condition of 
the rectum is usually shown upon the womb and its appendages. 
Case I.-A lady, aged twenty-four, married, was referred to me by a gynaecologist. 
History. Had complained for months of backache, pains in the thighs, general lassi- 
tude, melancholia, bearing-down sensation in both the vagina and rectum; pain over 
seat of both ovaries; constipated habit, leucorrhœa, loss of flesh, irregular menstruation, 
difficulty of urination, a slight discharge of mucus from the bowel. Upon examination 
of the womb the gynaecologist had not seen enough trouble to account for her symp- 
toms. He treated her for several months and advised her to consult me. Upon exam- 
ining the rectum with speculum I found it highly congested, very red and sensitive; a 
discharge of mucus covered the entire circumference for several inches up. The cause 
for this extensive congestion was not discernible. I was satisfied, however, that all the 
symptoms mentioned were purely reflex, and proceeded to treat the rectum. Hot water 
injections were ordered to be taken twice daily for several days, after which the entire 
portion of the congested gut was brushed over with a forty per cent, solution of nitrate 
of silver. After three or four days I began to make application of liquid hydrastis and 
water, equal parts. This was changed for the pure liquid hydrastis. The redness and 
pain gradually disappeared, the discharge ceased, and all reflex trouble vanished. This 
is but a sample case of many that have come under my observation. 
The rectum having a nerve supply direct from the spinal system through the fourth 
anterior sacral nerve, it is often the case that a diseased rectum with reflex to the cord, 
and symptoms simulating grave trouble of the same, may present. 
Case II.-An army officer was referred to me for an examination and treatment for 
a large rectal prolapse. He was then under treatment for supposed locomotor ataxy. 
Upon questioning him concerning his general condition, the following symptoms and 
history were elicited: Pain in both legs, with a decidedly unsteady gait; great nervous- 
ness, weakness of both legs, loss of sexual power, persistent constipation, heavy forcing SECTION VII-ANATOMY. 
143 
pain in the rectum, numbness in feet and legs, melancholia and general restlessness. 
Upon forcing out the rectum, after enema, a very large prolapse was discovered, which 
had existed lor many years. Taking the diagnosis of ataxy as correct, I could not 
promise him much by the operation for prolapse, save to free him from the inconveni- 
ence of the same. The operation was done, however, and as the wounds healed, all 
symptoms here described began to gradually disappear. After two months he pro- 
nounced himself cured of all trouble, rectal, ataxy, etc. He now walks a steady gait 
and great distances; bowels regular, sexual appetite and capacity returned, no pains or 
numbness in legs, and altogether a different man. I am satisfied that the whole train 
of symptoms reflected from the rectum. It is well known that a large number of dis- 
eases of the eye are traceable to disturbances in distant organs through the sympathetic 
system. Instance the sexual apparatus, as in masturbation, stricture of the urethra, 
uterine and ovarian troubles. 
Dr. Joseph A. White, of Richmond, Va., in an excellent article, speaks of hysteria 
being intimately associated with reflexes, and cites such cases as so-called anaesthesia or 
hyperæsthesia of the retina, paralysis or spasm of the ocular muscles producing myosis, 
ptosis, strabismus, etc. In evidence that the rectum is no exception for these same 
reflexes, I would mention that I have under treatment at the present time several 
patients that were referred to me by Drs. Reynolds and Cheatham, of Louisville, in 
which the eye troubles are produced and controlled by rectal trouble. These cases are 
of frequent occurrence. It is an admitted fact that the rectum is the frequent seat of 
gummatous deposit, the result of syphilis. This adds a large list of troubles that are 
reflex, especially so of the cord. In 1877 I had the honor to report a case of this kind 
to the Kentucky State Medical Society. You will permit me to refer to it briefly. A 
young man applied to me for treatment for a most persistent constipation, going, as he 
said, often for weeks without a movement from the bowels. He was put upon the 
usual remedies, without benefit. I had searched for rectal complications but found 
none. He began to present symptoms very like one with locomotor ataxy: weak legs, a 
bad gait, marked strabismus, numbness in lower limbs, violent pain over sacrum. 
These presenting, I sent him to Prof. J. W. Holland for treatment. The treatment 
which was given him for said condition for weeks availed nothing. He again came to 
me, and I resolved to explore the rectum higher up. I did so, and detected a strictured 
surface near the sigmoid flexure, of small calibre. I traced his history and found that 
he had syphilis a year before. I diagnosed his case to be syphilitic stricture of the 
rectum. The obstruction being nearly total, I advised an operation. Colotomy was 
thought of, but the patient being a very large man, with immense belly, it was dis- 
countenanced. The stricture being located so high up precluded all idea of dilating 
with instruments. The patient was chloroformed and I introduced my hand into the 
rectum and carried it up to the site of stricture. Making a cone of my fingers, I gradually 
pushed them through the strictured surface. He suffered great shock after the opera- 
tion, but rallied and was soon able to be up. He was put upon anti-syphilitic medica- 
tion and all the symptoms that I have described cleared up, showing them to have been 
purely reflex. We are all familiar with the reflexes as shown upon the genito-urinary 
organs, the womb, prostate, etc., that are witnessed daily. Of these I will make no 
mention. Neither will I refer to those diseases having their origin elsewhere which 
show themselves by reflex on the rectum. Although these are germane to the subject. 
I would prefer to hear their recital by others. 144 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ON TWIN SUDORIFEROUS GLANDS. 
SUR LES GLANDES JUMELLES SUDORIFERES. 
ÜBER ZWILLINGSSCHWEISSDRÜSEN. 
PROF. LEO GERLACH, 
Of Erlangen, Bavaria. 
In the development and growth of a secreting gland, the spreading of the gland 
epithelium, or, in other words, the secreting surface, may go on in one of two ways: (1) 
Either the tubular cavity enclosed by the gland cells and the membrane proper grow 
lengthwise simply, and upon ceasing this form of growth may at last roll up into a 
coil, thus giving us the tubular or cylindrical form of the gland ; or (2) the layer of 
the gland immediately separates, and this being repeated rapidly in both branches an 
acinous gland is formed, in consequence of the continued ramification and vesicular 
swelling of the blind closed ends of the numerous gland canals. 
In manuals of histology, a sharp distinction is usually made between the tubular 
and the acinous type of gland ; but it must be remembered that there are forms of 
glands, in regard to which one may be in doubt whether to class them with this or 
with that kind of gland tissue. I recall only the pyloric glands of the stomach, in 
which the gland tube ramifies at its end into two short sides, ending in moderate 
swelling. There are, however, intervening transitions between the two kinds of 
glands. 
To those which are usually represented as the prototype of the tubular glands 
belong the sudoriferous glands. But it has also been proved beyond doubt, that in 
rare cases separation of their tubes occurs, so that in their formation, though exception- 
ally and in a limited degree, processes must have taken place similar to those occur- 
ring in the genesis of acinous glands. 
The occurrence of two sudoriferous glands uniting in a common duct was proved in 
the beginning of the fourth decade of this century. In a treatise, excellent for that 
time, on the skin, in R. Wagner's Manual of Physiology (p. 108, Vol. n, 1884), C. 
Krause mentions twin sudoriferous glands, which were rather seldom found, scarcely 
one being observed among sixteen or twenty other sudoriferous glands. But before 
Krause, according to a memorandum of Kölliker's, R. Wagner and Giraldès had 
occasionally seen two-sided sudoriferous glands ; and they were possibly seen by 
Bresihet and Rousset de Vauzème also. This latter observer made the strange state- 
ment that transverse anastomoses existed between the two tubes of sudoriferous glands, 
a mistake caused by seeing dichotomous ramifications of the sudoriferous tubes. 
In the later literature, no attention is paid to this rare form of the sudoriferous 
glands. In manuals of histology and anatomy they are not usually mentioned, or at 
most there is quoted the foregoing statement of C. Krause, to which our scanty knowl- 
edge of this peculiarity is limited. There are also, I believe, no drawings by which 
the relative positions of the two gland-coils, the approximate length of the common 
excretory duct, its thickness as compared with the calibre of its branches, and some 
other interesting points, can be seen. For this reason, some notes on these matters may 
not be undesirable. 
In examining sections from the human scalp, prepared for my microscopical courses, 
I happened to see a twin sudoriferous gland. This induced me to make a closer exam- 
ination, and I searched about eighty sections for more glands, with the result of finding 
a ramification of the excretory duct six times. On an average, each cut contained 
eight excretory ducts. At this rate there must have been in the eighty cuts about six 
hundred sweat glands, among which six twin glands were found. The ratio of the 145 
latter to the former would thus be about one per cent. But I believe that twin glands 
occur more frequently than it would seem from this calculation, for the following cir- 
cumstance was not taken into consideration, and it is one which may have been a 
source of considerable error. In a series of sections made through the scalp, the excre- 
tory duct of the same gland will doubtless occur in several different sections, because 
of the oblique direction of the sudoriferous canals in passing through the skin. It is 
also possible that I missed several of the twin glands in my search, however careful I 
SECTION VII-ANATOMY. 
Fig. 1. 
Part of a section through the haired scalp, in which a sudoriferous gland is shown almost to its full 
extent. K. K. The two gland coils. D. Common excretory duct. d. d. The two branches. A. The 
dilatation. T. Sebaceous gland. H. Hair. E. Epidermis. P. Paniculus adiposus. 
was. For these reasons, I estimate the occurrence of such glands to be about three per 
cent., and I consider them to be of rarer occurrence than stated by C. Krause, who sup- 
posed that the ramifying excretory ducts are about five per cent. 
Another circumstance which seems to favor my opinion is, that Reynold, to whom 
we are indebted for a careful inquiry into the human coil-shaped glands, never noticed 
the undoubtedly dichotomous ramification of the gland-tubes, either in the ordinary 
sudoriferous glands of the skin or in the large coil-shaped glands of the armpit, which 
Vol III-10 146 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
differ from the former in many respects. It is possible, though, that the twin glands 
are more numerous in certain parts of the skin than in others, or that they are of par- 
ticularly frequent occurrence in some individuals. Comparing closely the glands in 
my preparations, I found, as a constant result, that the ramifications of the excretory 
duct into two tubes occurred in all cases at the same height. Dissecting the cutis vera 
into three equal horizontal layers, the plane of ramification always lay in the middle 
half of the upper third. It was nearly on the same level as the inosculation of the 
sebaceous gland with the nearest hair follicle. (Fig. 1.) 
Closely above the dichotomous division, the lower part of the common excretory 
duct was swollen into a pear-shaped dilatation, showing a different expansion ; in one 
case only was a swelling entirely missed. This dilatation of the tube may reach to 
twice the size of the excretory duct. In Fig. 2, I have represented such a case. In 
this gland the expansion was more distinct in form ; it had a diameter of 80 /z and a 
length of 250 /z. It is remarkable that the dilatation ran here with its longitudinal 
Fig. 2. 
Place of ramification of the excretory duct of a twin gland, with a transverse dilatation 
{Hartnack System, vn.) 
diameter in a transverse direction ; in all other cases it was perpendicular to the surface 
of the skin. 
With regard to the thickness of the common excretory duct and its parting branches, 
I find that the diameter of the former is always somewhat greater than that of the 
latter. In the gland the dilatation of which I have copied in Figure 2, the two tubes 
had a thickness of 30 /z-35 p., whereas below the ramification the thickness of the com- 
mon canal was 40 p. A difference of structure in the two portions of the excretory duct 
could not be found, but it appeared to me that the common sudorific canal ran in a 
much straighter course than its two branches. The latter, before entering into the 
proper gland coil, usually curve still more or make short bends, often even forming 
several nearly regular spiral turns ; but the common excretory duct ascends in an 
almost straight line to the epidermis. It shows at most only one or an immediately 
repeated bending immediately above the dilatation, causing, perhaps, a slight stowage 
of secretion, whiph itself may again be the cause of a greater expansion of the dilated 
part. 
From what has been said, it will be seen that the common excretory duct must be SECTION VII ANATOMY. 
147 
shorter than the two gland tubes, which extend from the expansion to their entrance 
into the coiled gland body. But this difference in length is brought about not only by 
the numerous windings of the crural canals, but also by the fact that the ramification 
is in the upper half of the cutis vera, and is therefore nearer to the epidermis than to 
the subcutaneous cellular tissue. 
I did not notice any peculiarity with regard to the sudoriferous canals of the twin 
glands in the epidermis. 
In closing, I will remark briefly on the relative positions of the two gland bodies, 
the excretory ducts of which finally unite. In an examination of the arrector pili, 
made in my laboratory, Diering demonstrates that in the haired scalp the coils of the 
sudoriferous glands are always under the sebaceous glands, which they may approach 
so closely that the muscle arrector pili forms a local septum between the two. From 
the drawing of Diering, it appears, also, that those gland coils which lie near the hair 
sac in the lower beds of the cutis, and partly reach into subcutaneous tissue, are usually 
not round bodies, but are stretched into a longitudinal form. Such oblong gland bodies 
border upon many hair sacs on both sides. In my preparations I noticed a different 
arrangement in the position of the two coils of a twin gland. In one of my cuts the one 
gland body was under the other, both bordering upon one side of a hair sac, as 
shown in Figure 2. In another case, unfortunately, not all the parts of the gland had 
fallen into one section. It appeared to me that the two coils were placed opposite each 
other, at the same height, on both sides of a hair. Finally, it may occur that, under 
the dilatation, the one branch may descend by the side of the nearest hair, bordering 
with a gland body upon its sac, while the other branch runs off obliquely or in a 
transverse direction to a neighboring hair, to form a coil on its side. Therefore, the 
two gland bodies of a twin gland may assume a local relation to two different but 
closely situated hairs. 
THE DIDACTIC TEACHING OF HUMAN ANATOMY. 
L'ENSEIGNEMENT DIDACTIQUE DE L'ANATOMIE HUMAINE. 
DER DIDAKTISCHE UNTERRICHT IN DER MENSCHLICHEN ANATOMIE. 
BY F. W. LANGDON, M.D., 
Professor of Descriptive and Surgical Anatomy in the Miami Medical College of Cincinnati (Medical 
Department University of Cincinnati). 
Anatomy being, by universal consent, the foundation of all rational medicine, the 
methods of presenting the subject to students merit the careful consideration, not only 
of professional teachers, but of physicians in general ; for there are few of the latter 
who are not called upon, at some period of their career, either to act as teachers, or to 
give advice as to methods of study. 
Of the two plans of teaching the subject commonly in vogue, viz : the demonstra- 
tive and didactic, the latter only requires consideration here ; there being no question 
as to the utility of, and necessity for, demonstrations on the cadaver. 
The writer is not of those who believe or profess to believe that no benefit is to be 
derived from text-books or .didactic lectures on Anatomy ; if this be the case in many 
instances, it is rather, in his opinion, the fault of the text-books or lectures than of the 
system itself. 
Perhaps every didactic teacher has held his own views as to the best method of pre- 
senting Anatomy to his classes, and yet there are few, probably, who have not felt, at 148 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
times, that their efforts were, in a measure at least, a failure, so far as assisting the 
student's understanding and progress were concerned. 
An extended experience as a teacher, in both dissecting room and amphitheatre, as 
well as to private pupils, has convinced the writer that not only is there room for 
modification and improvement in existing methods, but that such improvement is 
quickly appreciated by the average student. 
With a desire, therefore, for a comparison of ideas and methods, believing that the 
importance of the subject merits it, the writer ventures to present his own views as to 
the objects, scope, and methods most desirable in a didactic course of lectures on 
anatomy for medical students. 
The primary object, of course, of all teaching, is to impart knowledge. Knowledge 
without understanding, however, is necessarily imperfect, and it will be conceded by 
all in favor of an advanced standard of medical education, that the student should not 
only know, but understand, so far as possible, the human body. That is to say, a mere 
cramming of encyclopaedic facts is not a sufficient education in anatomy to satisfy 
modern requirements in the graduate of medicine. 
Facts are all important as a foundation for principles, and it is with this idea in view, 
that they should be taught. The objects of anatomical study, then, may be presented in 
this order :- 
1. Knowledge of facts. 
2. Knowledge of principles. 
3. Knowledge of application of these facts and principles to the promotion of physio- 
logical processes, the cure of disease, the repair of injury, and the relief of 
deformity. 
As regards the scope of didactic teaching ; what facts, then, should precede the study 
of anatomical principles? I would reply, first, those pertaining to the gross physical 
characters of the various tissues ; secondly, the facts of histology, or cellular anatomy 
-not in the disjointed way often taught, but by the student making, for himself, a 
series of sections of the normal tissues, and familiarizing himself with their micro- 
scopical appearances and actions. 
Only when these are mastered, is the student prepared to grapple with the principles 
of the construction of the human body. 
I have seen students who could give the most minute ramifications of a given artery, 
and repeat the nerve supply of group after group of muscles, completely floored when 
asked to name the tissues entering into the construction of the knee joint ?-and yet 
this is evidently a question involving the practical application of important principles 
in treatment. 
Supposing the groundwork of gross and microscopic histology to be well laid down, 
the scope of the didactic course may be stated as follows :- 
1. A review of the elementary facts of structure, or the study of materials. 
2- The principles of structure, or the study of construction. 
3. Applied anatomy, for physiological and clinical uses. 
Whereas, in the dissecting room and histological laboratory the studies are mainly 
analytical in nature, the didactic course, being more advanced, may profitably assume 
a synthetic direction. Both methods of viewing the subject conduce to a more thorough 
understanding of principles than either method alone. 
This brings us to the consideration of methods, or details of didactic teaching. As 
already indicated, the elementary facts of structure are best studied in the dissecting 
room and histological laboratory, by analytical processes. In the amphitheatre more 
time should be devoted to the principles of anatomical construction. To put the sub- 
ject in another light, we have heretofore studied building materials and now advance 
to the subject of architecture. 149 
SECTION VII-ANATOMY. 
• The architecture of the body, synthetically stated, consists in (1) the union of cells 
to form tissues. (2) The combination of tissues to form organs. (3) The association of 
organs to form systems or apparatuses. 
The systematic arrangement of these topics, so as to be easily retained and referred 
to,-i.e., their classification-has been recognized as a necessity by all writers and 
teachers. 
With respect to anatomical classification for teaching purposes, it may be held that 
the simplest classification is always the best, provided it does no violence to principles 
of structure. Since the main object of classification is convenience for mental retention 
and reference, those classifications of tissues, for instance, which, like Bichat's, recognize 
twenty-one primary types ; or with Frey, eighteen, are too cumbersome for convenience. 
Again that of Gegenbauer, recognizing only four primary tissues, while morphologically 
simple, and therefore commendable, is not applicable to the every-day needs of the 
student and practitioner of medicine. It is this latter application that should be con- 
stantly kept in view, in medical teaching. 
For practical purposes I deem it sufficient to recognize seven primary tissues, 
namely :- 
Epithelial, 
Fluid or nutritive (blood, lymph and chyle), 
Connective, 
Cartilaginous, 
Osseous, 
Muscular, 
Nervous. 
Constituting the connective tissue 
group of Gegenbauer. 
Each of these is recognizable by the naked eye, and to one or the other any »tissue of 
the body may be referred. 
It may be observed that those constituting the connective tissue group of Gegen- 
bauer are so diverse in development, structure and functions, and consequently in 
pathological relations, as to render their recognition as distinct classes extremely 
desirable from a practical point of view. 
In the classification of organs, we likewise find great diversity of views. While one 
author adopts a topographical classification, a second resorts to nerve supply as a basis ; 
while a third selects similarity of structure as a guide, thus giving us glandular organs, 
vascular organs, muscular organs, etc. 
Now, it would seem to the writer that either of these methods loses sight of the 
main object of anatomical knowledge, viz. : its application to clinical phenomena :- 
When we consider that the diagnosis of disease during life depends mainly on dis- 
ordered function, it certainly seems more rational to study organs with reference to 
their actions and uses in the economy-in other words, to adopt a physiological classi- 
fication, which is the one finally resorted to in practice. 
Pursuing this system we find the organs falling naturally under eight heads, corre- 
sponding with their sequence and uses : viz. : Organs of- 
1. The Tegumentary system (or apparatus) comprising the skin and subcutaneous 
connective tissue, with their appendages-hair and nails. 
2. The Locomotory system, comprising all the bones, joints and voluntary 
muscles. 
To the possible objection that some of these, e. g., those of the upper extremity and 
head, are not properly locomotory organs in man, it is sufficient to refer to their use in 
swimming, and, in the infant, in creeping ; while all know that restriction of the 
movements of the muscles and joints of the head or neck will produce marked loco- 
motory changes. 150 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
3. The Nervous system, including the nerve-centres, cerebro-spinal and sympa- 
thetic, with their branches, and inter-communications ; also the organs of 
special sense. 
4. The Circulatory system, embracing the heart, arteries, veins, capillaries and the 
lymphatics with their glands, together with the spleen and all ductless 
glands. 
5. The Respiratory system-nasal passages, pharynx, larynx and lungs. 
6. The Digestive system-from lips to anus, with its appendages. 
7. The Urinary system-kidneys, ureters, bladder, urethra. 
8. The Generative system. 
That anatomical knowledge classified in this way is eminently applicable to clinical 
needs may be illustrated by supposing the student or practitioner be asked to make 
an examination of an unconscious patient with a view to diagnosis.» 
1st. The skin presents itself, with its variations of texture, temperature, color, 
moisture, etc., and the presence or absence of oedema in the subcutaneous tissue is 
noted. 
2d. The locomotory apparatus is examined, with reference to fracture or dislocation, 
contusion, etc. 
3d. The nervous system is interrogated, with a view to the presence of paralysis, 
motor or sensory, reflex irritability, as manifested by the pupils and other phenomena ; 
organs of special sense (e. y., the eyes) may also furnish an index to the condition of 
the intracranial circulation and pressure. 
4th. The condition of the circulation is noted-the pulse, color, presence or absence 
of cardiac murmur ; condition of lymphatic glands, splenic enlargement, indications of 
plethora or anaemia, and so on. 
5th. The respiratory organs are investigated-the action of the alæ nasi, laryngeal 
sounds, if any, stertor ; the rate, depth and rhythm of the respirations, râles, etc. 
6th. The digestive system receives attention-from the lips, tongue and teeth, char- 
acter of matters vomited, if any, presence of hernia, distention or enlargement of 
abdominal organs, etc. 
Finally, the condition of the urinary and generative organs having been ascertained, 
how much greater is the probability of an accurate diagnosis from some such system 
of investigation, than from the hap-hazard or irregular investigation of various organs 
without reference to their physiological relations. 
This applicability of anatomical system to clinical work is, in the writer's opinion, 
a most important matter to keep in view. 
The fallacy that anatomical knowledge is applicable chiefly to surgical diagnosis 
and procedures, is one that is largely due to faulty teaching, and should be vigor- 
ously combated. To be even a safe "fever doctor," a knowledge of anatomy is 
essential. 
The writer's views respecting the teaching of anatomy may be briefly summarized 
as follows :- 
The anatomical curriculum should embrace three main divisions :- 
1. Analytical work in the dissecting room and histological laboratory. 
2. The synthesis of the body ; a study of materials and principles of construction- 
the didactic course proper. 
(a) The composition, structure and functions of the cell, considered as the 
anatomical unit. 
(ö) The variations in the primary cell (ovum) and its progeny, from which 
result the (seven) primary tissues. 
(c) The study of these tissues with respect to their development, structure, 
destination and uses. SECTION VII-ANATOMY. 
151 
(d) The formation of organs by combination of tissues, and their classifica- 
tion with reference to function. 
(e) A course in the elements of comparative anatomy might be added with 
advantage. 
3. Applied Anatomy : a topographical study of the location of organs, with especial 
reference to the interpretation of symptoms and medical and surgical proce- 
dures in general. 
In short, facts must precede principles, and principles lead up to practice, as in 
other branches of knowledge. It cannot be too strongly insisted upon that the mean- 
ing of education, as the derivation of the word implies, is " to draw out," i. e., to 
develope the faculties-not merely to crowd them with facts. Hence, the true teacher 
cannot be satisfied with a mere recital of facts. His higher office is to point out 
methods of study, to encourage the observation of facts, and the deduction and appli- 
cation of principles. 
The teaching of anatomy in America is largely a labor of love, since in few of our 
medical colleges is the compensation of the chair at all commensurate with the time 
and labor required ; nor does it bring with it the pecuniary emoluments which accom- 
pany chairs of practice. 
Hence, the need which exists for special endowments in this department. 
ON SOME OF THE PHASES OF EMBRYONIC BONE DEVELOPMENT. 
SUR QUELQUES-UNES DES PHASES DU DEVELOPPEMENT DE L'OS EMBRYONIQUE. 
ÜBER EINIGE PHASEN DER EMBRYONALEN KNOCHENENTWICKLUNG. 
BY W. XAVIER SUDDUTH, M. D., D. D. S., F. R. M. S., 
Director of the Physiological and Pathological Laboratory, Medico-Chirurgical College of Philadelphia. 
In accordance with the title of our paper, we shall confine our remarks simply to 
the embryonic development of bone. 
There exists in the literature of the present day three well-defined processes by 
which bone is formed, viz. : intra-cartilaginous, intra-membranous and subperiosteal. 
Bones are also divided into two classes: cartilage and membrane bones. Cartilage bones 
are the product of both intra-cartilaginous and subperiosteal ossification. In length 
they increase by intra-cartilaginous, and in girth by subperiosteal, formàtion. Mem- 
brane bones, although beginning as such, complete their ossification finally by subperi- 
osteal deposition. From the foregoing statement it will be seen that intra-cartilaginous 
and subperiosteal ossification persist throughout the ossifie process. 
Intra-membranous ossification occupies only a transitory stage in embryonic life, 
soon passing into subperiosteal. The process of intra-membranous ossification, though 
belonging to the class of embryonic bone formation, is too well known to require more 
than a mere notice. I desire to call your attention to-day to another process which 
precedes intra-membranous ossification in the development of the embryo, and which, 
to my knowledge, had not been described in literature until I brought it out in an 
article in the "American System of Dentistry, " in 1885. 
To the development of bone in the embryonic connective tissue, uninfluenced by 
either membrane or cartilage, I gave the name of " Interstitial ' ' ossification. Excep- 
tion has been taken to the term interstitial as applied to ossifie products, on the ground 152 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
that it had previously been used to designate the supposed process by which bones 
increased in size after birth, especially the inferior maxilla. But since it has been 
conclusively shown that bones do not grow " interstitially, " as the word was then 
understood, and since the term has fallen into disuse in that connection, I see no impro- 
priety in adopting it in this instance, especially as it so aptly explains the process herein 
described. 
Intra-membranous aud interstitial bones play only a temporary rôle in the develop- 
mental process, the latter having, perhaps, a shorter duration than the former ; yet in 
the study of embryology they perform as important a part as does cartilage. That 
they have but little practical bearing upon the general subject of anatomy I am well 
aware-confined as they are to embryonic and to foetal life. 
For general classification, the two terms membrane and cartilaginous bones are suf- 
ficient ; but for the student who would enter into the nicer study of foetal anatomy 
other classifications are necessary. 
Intra-membranous ossification is most typically shown in the development of the 
embryonic skull cap, and it has been fully described in existing literature. Interstitial 
ossification is a previous expression of bone formation, and may be said to be pro- 
visional in character, resembling cartilage in that respect. 
Cartilage is the matrix, or mould, which serves as the antetype of the mature pro- 
duct, and the same can also be said of the interstitial bones. The foetal jaw, the best 
defined example of the latter process, is as truly the antetype of the mature jaw as the 
foetal femur, preformed in cartilage, is the pattern or matrix that shapes the mature 
femur. In the foetal jaw even the form of the alveoli, microscopic in size, can be made 
out, enclosing a microscopic dental follicle-the mature product in miniature. The 
malar bones and the clavicle are developed in a manner similar to that of the maxillæ, 
and for each there forms a matrix, around which the mature bone is developed. It is 
to the special manner of development of the maxillæ, the clavicle, and the malar bones 
that I desire to call your attention. The malar, pre-maxillæ, and the superior maxilla 
are not prefigured in cartilage, and ossification begins in them prior to the formation of 
membrane or cartilage in other parts of the body. The inferior maxilla and the clav- 
icle are prefigured in cartilage, but the cartilage plays little or no part in the ossification 
of their bodies, although their articulating ends are developed by intra-cartilaginous 
ossification. 
While studying the development of the jaws, my attention was first directed to the 
need of an additional classification, and I was surprised, upon looking up the literature on 
the subject, to find almost no reference made to the manner of development of these 
bones. 
In " Elements of Embryology," by Foster aud Balfour (p. 405), the ossification of 
the human clavicle is dismissed in the following manner: " The clavicle in man is pro- 
vided with a central axis of cartilage, and its ossification is intermediate between that 
of true cartilage bone and membrane bone." 
Regarding the ossification of the inferior maxilla, there is, so far as I am acquainted 
with the literature on the subject, only one illustration which has been published with 
a view of showing simply the earliest stages of maxillary ossification. That illustra- 
tion is to be found in Klein's " Elements of Histology," and it is taken from an almost 
mature foetus. Judging from the paucity of literature and illustration on the subject, 
one is naturally led to infer that the earliest steps in bone formation have not been so 
thoroughly worked up as the later forms of ossification. 
In describing the process, I shall confine myself to the bones of the face, premising 
that ossification in the human clavicle is analogous to, and concomitant with, ossifica- 
tion in the inferior maxilla. 
The first indication of bone formation in the body is found in the clavicle and the SECTION VII-ANATOMY. 
153 
malar bones. In man this occurs about the beginning of the second month, sometimes 
a little earlier. Ossification in the maxillæ follows shortly afterward, the inferior max- 
illa slightly preceding the superior. Next in order the membrane bones of the skull 
develop; then the intra-cartilaginous and the subperiosteal bones develop. The con- 
nective tissue of the mesoblastic layer, when ossification in the clavicle and the malar 
bones first makes an appearance, is still decidedly embryonic in character. There has 
been no attempt on the part of nature to differentiate periosteum or membranes. My 
most satisfactory work has been done on fœtal pigs, for which I have constituted the 
following table of lengths, comparing their development with the development of other 
embryos which I have studied: A fœtal pig 1 cm. in length compares histologically 
with a four-weeks human embryo, a twelve-days fœtal rabbit, and a forty-eight-hours 
chick; a IJ cm. fœtal pig to a six-weeks human embryo; and a 2| cm. fœtal pig to a 
two-months human embryo and a four-days chick. The cells in the mesoblastic 
layer of a 1 cm. fœtal pig have not assumed a fibrillated character, the somites are only 
in process of formation, and no true cartilage has as yet been differentiated. Develop- 
ment now progresses very rapidly, and by the time another centimetre has been added to 
the length, plates of cartilage are seen and ossifie points make their appearance in the 
positions to be occupied by the clavicle and the malar bones, respectively. 
The youngest well-preserved human embryo which I have had the pleasure of study- 
ing, was probably about two months old. In it I found the clavicle considerably devel- 
oped and ossification in the inferior maxilla already begun. 
I have had younger embryos, but they were not sufficiently well preserved to use 
for fine histological work. My best work on ossification has been done on fœtal pigs. 
They more closely resemble human embryos than do rabbits or chicks, upon which I 
have also done considerable work. 
I obtain fœtal pigs fresh, and while they are yet warm, I place them in Muller's 
fluid, to harden, for several days, after which I finish the hardening process in alcohol. 
In this way I am enabled to get magnificent preparations. I use Prof. Delafield's 
hæmatoxylon and eosin, for a double stain, also alum carmine, picro-carmine, alone or 
in combination with iodine green, and this latter makes a very beautiful stain for 
developing bone. I find that for general embryological work, hæmatoxylon and eosin 
make about as good a double stain as is needed. Eosin is especially good for the 
demonstration of blood corpuscles. 
In this article, our study of developing bone is made from sections of fœtal pigs, 
stained with hæmatoxylon and eosin. The illustrations are photo-lithograph, made from 
photo-micrographs. 
Our description begins -with a fœtal pig, 1 cm. in length, which compares histologi- 
cally, as regards development, with a four-weeks human embryo. At this age no ossifie 
points are to be seen. The epiblast is composed of one or two layers of embryonic 
cells, the bioplasts of Beale, lying in a bed of protoplasm. They present no histologi- 
cal difference from the mesoblastic cells lying underneath, except that they are arranged 
in a layer and lie more closely together, giving the layer a denser appearance in stained 
preparations. This row of cells constitutes the deepest layer of the rete Malpighii, or 
what I have termed the " infant layer." (See Fig. 1.) 
The mesoblast is composed of nucleated bioplasmic bodies, oval or round in form, 
also lying in a bed of protoplasm, with which substances they are constantly bathed, 
and from which they derive their nourishment. 
They present no cell body, and hence have no "cell-wall," in the strict sense in 
which that term is used. They are simply nuclei, and as they advance in age they 
accumulate around themselves formed material, which constitutes the cell body. They 
thus assume distinctive and characteristic forms. The connective tissue cells of the 154 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
mesoblast become fibrillated, their processes gradually thicken and elongate until they 
are distinctly visible, even with low powers. 
Fibrillation is more or less marked in a pig 2j cm. in length (see Fig. 2). It is at 
Fig. L 
ct, connective tissue of mesoblast ; ep, epiblast (single layer of cells). The epiblast is separated from the 
mesoblast mechanically. 
Fig. 2. 
Porcine Embryo (2% cm. X 250) : et, embryonic connective tissue of mesoblast. 
this age that ossification first makes its appearance in the clavicle and the malar 
bones of the human embryo, and in the inferior maxilla of the porcine embryo. 
At this stage of development the blood vessels are seen as mere channels in the 
embryonic connective tissue, the corpuscles staining with eosin. SECTION VII ANATOMY. 
155 
The walls of the capillaries are first formed by the more or less fibrillated connec- 
tive tissue cells; in some instances arranged longitudinally in the direction of the 
blood current, in others they appear to wind around the current of blood. No mus- 
cular tissue has as yet been differentiated. 
The inferior maxilla is composed of two lateral halves, united in the median line. 
It consists of an outer single layer of epiblast covering a solid band of embryonic con- 
nective tissue. At the anterior portion the tongue and the inferior maxilla are united 
into one solid body, and are both covered by the in-dipping epiblastic layer. The 
mucous membrane of the mouth is derived from the same layer of the blastoderm as 
the skin, and differs from it, even in adult life, only in the fact that from being con- 
stantly bathed in the fluids of the mouth, it consequently does not present the corneous 
appearance found in the skin-an appearance due simply to desiccation. The central 
portion of the inferior maxilla, shortly after the union of the two lateral processes, 
becomes differentiated into a cartilaginous cord, which serves to strengthen the jaw. 
To this band or cord the name of its discoverer, Meckel, has been given. It is formed 
in two separate parts (see Fig. 3), arising from the middle of either side. These unite, 
as do the lateral processes of the jaw, at the symphysis mentis. 
The cartilaginous matrices of the bones of the ear become directly ossified, as do 
also the articular ends of the cartilage of the jaw. 
Fig. 3. 
Meckel's Cartilage, from Human Embyro of Forty to Forty-two days, and before the appearance of the 
maxillary bone (magnified ten diameters). A, enlargement of cartilage near its union with the 
neck of malleus; D, union with cartilage of opnosite side; M, head of malleus; N, handle of mal- 
leus; E, cartilage of the incus; i, cartilage of the stapes; O, cartilage of the os lenticulare. The out- 
lines of a jaw have been added to the figure, to show the relative position occupied by the cartilage in 
the jaw. 
Surrounding the central cartilage is seen the now more or less fibrillated embryonic 
connective tissue, deeply stained in well-prepared specimens. The proportion of con- 
nective tissue to cartilage is ten to one. 
The cartilaginous band does not increase in size, but the connective tissue develops 
very rapidly. 
In the central part of the connective tissue of the inferior maxilla, on the outer side 
of Meckel's cartilage, the ossifie points first make their appearance. These are seen in 
specimens stained with hæmatoxylon and eosin, as groups of oval or round cells, that 
are more deeply stained than the remainder of the embryonic connective tissue cells. 
Except for the darker stain taken and their somewhat larger size, they fail to present any 
points which under a lower power will differentiate them from the other surrounding 
cells. Under high powers, however, they do not show the same fibrillated appearance 
seen in the ordinary connective tissue cells, and in this latter respect they more nearly 
resemble the plasma cells of older tissue. 
It is a well-known fact that those cells which are younger stain more deeply than 
older cells, and this is also true of the younger portions of the same cell. And, again, 
cells, when actively functionizing, stain more deeply than do the same cells when qui- 156 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
escent. Just what property such cells possess at the one time, and not at the other, 
which causes this difference, we have not been able to determine, butthat such a differ- 
ence exists there can be no doubt. 
These groups of cells under consideration, by this peculiar property of selection of 
stain, differentiate themselves and stand out in strong contrast to the other cells in 
double-stained specimens. This variation in shade I have reproduced by means of 
photo-micrographs, and it is well shown in the accompanying figure. (Fig. 4.) 
By following out serial lines of studies, in sizes ranging from this stage, 2J cm. in 
length to 3 cm., 4 cm. and upward, I have been enabled to constitute a progressive series 
of steps in the development of bone, and can say that these groups of cells are osteoblasts. 
They soon form themselves into double layers, and the process of trabeculae building is 
begun. 
Fig. 4. 
Inferior Maxilla, Porcine Embryo cm. X 240) : o, osteoblasts grouped together, surrounded by 
embryonal connective tissue, ct. 
Now, at this stage of development no bone formation has occurred in the skull cap, 
neither has intra-cartilaginous ossification begun. The development of provisional 
bone seems to be concomitant with the formation of the supporting cartilaginous 
structures, and to play nearly as evanescent a part in the further growth of the 
embryo as does cartilage. That the osteoblasts found in this character of ossification 
arise from the ordinary connective tissue, I think there can be no doubt. They are simply 
modified mesoblastic cells, which are endowed with special functionizing power. Sec- 
tions through the face of a two-mouths human embryo show the process of bone 
formation in the region of the malar bones somewhat more advanced. Here some of 
the osteoblasts are enclosed in shells of forming bone, which at first have the appear- 
ance of being spiculæ, but upon closer observation, it will be seen that each osteoblast 
lies imbedded in a bony matrix, which it has secreted around itself. (See Fig. 5.) SECTION VII ANATOMY. 
157 
The form that depositing bone assumes depends largely upon the character of the 
tissue into which the salts of calcium are deposited. In intra-membranous ossification 
bone is developed in long, narrow spiculæ. In subperiosteal ossification bone is deposited 
in layers, which, in turn, enclose successive layers of osteoblasts. 
In the development of provisional bone, occurring, as it does, in the central portion 
of the tissue, the secreted lime salts are deposited around the spherical osteoblasts, 
more or less in the form of spheres. 
The apparent spiculæ, if examined closely with a high power, will reveal as many 
cup-shaped excavations upon their sides as there are osteoblasts in line. 
* " Under the superintendency of the osteoblasts, a crescentic layer of true bone is 
deposited upon the side of the osteoblast in apposition with a similar crescentic layer 
formed by an osteoblast located on the opposite side of the line. The sides of each 
crescent join similar crescents formed by fellow-workmen on either side. As deposition 
progresses, the osteoblast becomes encircled by a shell of lime. As the trabecula widens, 
by enclosing the osteoblasts which lie upon its sides, new layers of osteoblasts are found 
Fig. 5. 
Human Fœtus (2 months ; X 250): o, osteoblasts (the dark lines which come to the edge of the figure at 
6 represent bands of forming bone); c. sp, calco-spherule surrounding an osteoblast ; ct, embryonal con- 
nective tissue. 
arranging themselves on the walls, which, in turn, become enclosed in a layer of bone. 
Thus, by the accumulation of successive layers of calco-spherules, the broadening of 
the bands of bone tissue is accomplished. As the osteoblasts build themselves into the 
wall, their places are taken by fresh recruits. When each osteoblast, by secreting its 
calco-spherule, completes its life-work as a bone builder, it becomes a bone cell, and 
from that time on occupies the house it has builded. (See Fig. 6.) 
" The crescentic nature of the first part of the layer secreted by the oesteoblasts is 
plainly shown when they (the osteoblasts) are displaced or where they are consider- 
ably shrunken. As the process of secretion proceeds, the osteoblast becomes enclosed 
in a thin spherule of formed material, designated by Mr. Rainey as calco-globulin. This 
shell of bone is pierced here and there by the fibres of the osteoblast which are left as 
the latter shrinks. The deposition of bone is really in the meshes of the fibres. 
* Sudduth, in " American System of Dentistry." 158 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
' ' The body of the cell is spheroidal, hence the deposition assumes a spheroidal form ; 
accordingly, we denominate it a calco-spherulc. 
' ' As the process of secretion goes on depositing from the circumference toward the 
centre, the fine processes before mentioned continue to be united with the osteoblasts. 
Their terminal fibrillæ anastomose with those of other osteoblasts, and these again with 
others ; those which lie nearest the capillary vessels connect with them, thereby receiv- 
ing nourishment, which they, in turn, give to the outer layer of bone cells. The office 
of these processes, then, is to supply the nutrient matter needed to support life in the 
bone cells. 
" Bone cells are nothing more or less than encapsuled osteoblasts, which are occupy- 
ing the homes which they have builded themselves. The cavities which they occupy 
Fig. 6. 
Porcine Embryo (5 cm. long, X 250): osteoblasts situated at the ends of the 
lamellæ of bone; db, developing lamella of bone containing bone cells ; ci, cl, em- 
bryonal connective tissue. 
are the lacunæ of the old writers, the canals in which their processes lie are the canali- 
culi, and the capillary vessels the Haversian system. These lacunæ and their canaliculi, 
together with the Haversian canals, are occupied in living hone by the above-described 
organic element." 
Having thus accounted for the ossification of the inferior maxilla, without the direct 
aid and influence of Meckel's cartilage, it yet remains to explain the method by which 
it disappears. The cartilage becomes enclosed in a sheath of bone, which is developed 
in the surrounding embryonal connective tissue. As the deposition progresses, the car- 
tilage is encroached upon, is broken down under the influence of the osteoblasts, and 
becomes incorporated into the substance of the maxilla. 
The changes are plainly shown in the accompanying cut. (Fig. 7.) 159 
SECTION VII ANATOMY. 
There is no proliferation of the cells, as in the head of the femur, nor does Meckel's 
cartilage increase in size after the process of bone formation begins. The process of 
ossification differs from that known as inter-cartilaginous ; in the latter case there is rapid 
proliferation of the cartilage cells, the cartilaginous head (femur) increasing in size in 
proportion to the encroachment of the ossification zone. This does not occur in ossifi- 
cation of Meckel's cartilage. There is no increase of cartilage cells, except at the points 
of articulation, where true inter-cartilaginous ossification occurs. In the body of the jaw 
the cartilage simply becomes calcified, and afterward ossified and incorporated into the 
substance of the maxilla, as before stated. It entirely disappears before the fifth month 
-not by wasting away, but by ossification. This change begins, as we have seen, at 
two and a half months ; at three months it is almost complete, and at four months, in 
Fig. 7. 
Meckel's Cartilage, from jaw of two-and-a-half-months human fœtus, undergoing 
ossification, a, normal cartilage cells ; c, enlarged cells containing calcific material ; 
db, db, developing bone ; cl, connective tissue ( X 250). 
nearly every case which I have examined, no trace of the cartilage remains. In the 
pig it persists much longer, and is unaffected by ossifie processes in embiyos ten centi- 
metres in length. 
Such is a brief description of the process in the inferior maxilla, which also answers 
for the superior maxilla, the malar bone and the clavicle. With the differentiation of 
a periosteum, cortical bone formation begins, and this is soon followed by internal 
absorption of such bone as has been interstitially developed. The space occupied by the 
first developed bone in the fœtal jaw will constitute the canal of the dental nerves in 
the mature jaw. 
Lengthening of the jaws is by intra-cartilaginous ossification at the condyles. 160 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A CURIOUS CONGENITAL DEFORMITY OF THE SPINAL COLUMN 
PROBABLY DUE TO MATERNAL IMPRESSION ON THE FŒTUS. 
UNE DEFFORMITÉ CONGENITALE DE LA COLONNE VERTEBRALE DUE PRO- 
BABLEMENT À L'IMPRESSION MATERNELLE SUR LE FŒTUS. 
EINE MERKWÜRDIGE ANGEBORENE MISSBILDUNG DER WIRBELSÄULE, WAHRSCHEINLICH 
DURCH MÜTTERLICHEN EINDRUCK AUF DEN FÖTUS BEDINGT. 
BENJAMIN LEE, A.M., M.D., PH.D., 
The question of the influence of maternal impressions on the fœtus has recently been 
brought prominently before the minds of the profession, in consequence of the reading 
of an elaborate and learned paper on the subject by Dr. Fordyce Barker, before the 
American Gynaecological Society, followed by a discussion of great interest, opened by 
Dr. S. C. Busey, of Washington. 
Both of these distinguished gynaecologists expressed the conviction that the con- 
veyance of such impressions is possible, and adduced thoroughly authenticated cases in 
proof of the theory. Dr. Barker, after a careful résumé of the arguments which have 
been advanced on both sides of the question, says : "I think the weight of authority 
must be conceded to be in favor of the doctrine that maternal impressions may affect 
the development, form and character of the fœtus." Among the names which he 
adduces as committed to such a belief are those of Montgomery, Rokitansky, Carpenter, 
Dalton, Flint, Grimaud de Caux, Martin St. Ange, Devay and Hammond. Dr. 
Busey expresses the "belief that there is some relation of cause and effect between the 
mental impressions of mothers and fœtal deformities," and supports it by several well 
considered propositions and a long list of collected cases. 
Dr. Goodell stated that while he scouted the extravagant statements made by the 
laity on this subject, yet he was inclined to believe that " there was more in it than 
physiologists are willing to concede." In the course of the paper and discussion fifty- 
one cases were related, more or less at length, corroborative of the truth of the theory. 
The majority of them are either of the nature of nævi or of arrest of development result- 
ing in deficiency of a portion of a limb or of soft tissues. That which I am about to 
relate does not partake of those characteristics, but seems more distinctly mimetic, and 
is, I think, quite unique. 
HISTORY. 
Daniel Paul Neil er, aged one year and nine months, was brought to me on the 26th 
of April, 1886. His parents reside at Chestnut Hill, Philadelphia. He was pale and 
ill-nourished, and had frequent attacks of pain, usually on awakening from his nap 
during the day. His gait was irregular and tottering. He was wearing a very heavy 
plaster jacket, which he had had on for a year. When this was removed his attitude 
was that of lordosis, but a projection of the last dorsal vertebra could be seen on 
sitting. As a young infant, his health was vigorous, and he was quite free from any 
unusual pain. The only thing that attracted his mother's notice was that when held on 
the arm he had a constant tendency to throw himself backward, and that he showed 
little disposition to walk as he arrived at the age when her other children had done so. 
About a year ago she observed a little lump on the back, and called the attention of 
the family physician to it. He pronounced it a case of spinal disease, and ordered the 
spinal jacket. Two days after the jacket was applied, he walked for the first time. He 
was then ten months old. On examining the spine I was at once struck with its extra- 
ordinary flexibility. Instead of the rigidity which one always expects to find at the 
seat of disease in spinal caries, especially when it has existed for so long a period as a 
year, there was unusual mobility at that point, and there was an entire absence of that 
Of Philadelphia. SECTION VII ANATOMY. 
161 
careful holding of the shoulders, awkward gait and turning in of one or both toes, which 
are such characteristic symptoms of an acute inflammatory condition in the course of 
the spinal column. Anchylosis evidently did not exist, nor were there any symptoms 
of ulcerative action, and yet, when in the sitting posture, there was a distinct protu- 
berant knuckle, just such as one would see in a case of Pott's disease. Over this 
knuckle of bone there was a well-developed bursa, which increased the apparent 
deformity. When he stood up, the back arched in, the knuckle disappeared, and the 
hand, held closely against it during the change of attitude, felt the vertebræ glide 
over one another, as though there were a free articulation, with cartilages and synovia at 
that point in the spine. 
My conclusion, therefore, was that this was a congenital malformation, that there 
had never been any inflammatory or ulcerative action, that the irregularities of 
locomotion proceeded entirely from difficulty of preserving the equilibrium, owing to 
the abnormal mobility of the spine. I believed that the screaming spells on awaken- 
ing from sleep were due to the pressure of the jacket upon the spinous process at the 
seat of deformity, of the severity of which the bursa spoken of was a sufficient proof. 
The irritation thus produced and the weight of the plaster combined would account 
for his loss of appetite, languor and emaciation. 
Acting on this belief, I removed the jacket, and substituted for it an extremely 
light spinal corset. The result was an immediate amelioration of all the symptoms. 
He at once walked with more ease and steadiness, his appetite returned, and his 
screaming spells ceased. He has continued to improve up to the present time. On 
inquiry of the mother as to whether she had received any injury during gestation, she 
said that she had not, but that almost every day during that period she was obliged 
to see a little girl who was much deformed with spinal curvature, the disease being in 
the middle of the back. She was full of pity for the unfortunate child, and, as she 
expressedit, " couldn't keep her eyes off of her " when she was near. This appeared to 
me to afford a solution of the peculiarities of the case. It was the first one of the 
kind that I had met in a somewhat extended experience, and I have thought it of 
sufficient interest to bring it to the notice of the distinguished men composing this 
Section, and obtain an expression of opinion in regard to it. If my understanding of 
the case is correct, it simply constitutes the substitution of a diarthrodial tbr a 
synarthrodial articulation, under the influence of a powerful and constant maternal 
impression, producing an imitation of the deformity which aroused the mother's 
interest and excited her pity. 
THE ANATOMY OF STRICTURE. 
L'ANATOMIE DU RETRECISSEMENT DE L'URETHRE. 
DIE ANATOMIE DER HARNRÖHRENSTRIKTUREN. 
BY J. NEELY RHOADS, M.D., 
Assistant in the Gynaecological Department of Jefferson Medical College Hospital. 
Before entering upon the anatomy of stricture of the urethra, let us glance at the 
anatomy of the normal urethra. 
First, allow me to say that the male urethra is not a canal of uniform diameter, 
for, if we begin with the meatus urinarius, we have the two labiæ thrown edge to edge 
vertically, forming a narrow, slit-like opening, which is invariably (in its normal con- 
dition) the smallest part of the entire urethral tube. Directly behind the meatus the 
Vol. Ill-11 162 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
urethra widens out, under the name of the fossa navieularis, to twice the size of the 
meatus, returning again, one and a half inches from the meatus, to a much smaller 
canal. This portion of the urethra contains the glands of Littré, the openings of which 
are directed forward, and vary in size from openings that can scarcely he discerned, to 
large pouch-like openings, as the lacuna magna, that renders unskilled instrumentation 
troublesome. 
One and a half inches behind the meatus the urethra contracts into an uniform 
canal one-quarter of an inch in diameter, and continues so for about four and a half 
inches, when it again widens in the bulbous portion, to be again reduced, about six 
inches from the meatus, into the smallest calibre of the tube, except the meatus urina 
rius. This part is called the spongy portion. Continuous with the spongy portion, 
about three-quarters of an inch, is the membranous; this, as was inferred above, is the 
smallest part of the entire canal, except the orifice, and terminates at the apex of the 
prostate gland. This part of the urethra is embraced by the compressor urethræ muscle 
and triangular ligament. Directly following and continuous with the membranous 
part of the canal is the prostatic urethra, the widest and most irregular part of the whole 
canal. Upon the floor of this portion is a septum-like band or ridge of erectile tissue, 
called veru montanum, which is supposed to prevent the semen from flowing backward 
into the bladder; on either side of this ridge are the orifices of the prostatic ducts and 
all the prostatic sinuses. In part of the veru montanum is a sinus called vesicula 
prostatica, which contains the longitudinal openings of the ejaculatory ducts. The 
prostatic urethra is another stumbling block to the unskilled in instrument passing. 
The urethra of the female is an uniform canal about one-quarter of an inch in 
diameter, except at the meatus, approximating one inch in length. The triangular 
ligament embraces the female urethra in a similar way as it does the male, and is also 
embraced by the compressor urethræ muscle in a similar manner. 
Both the male and female urethra are made up of three coats: muscular, erectile 
and mucus. Like the male, the female urinary meatus is always the smallest, and is 
also always the most sensitive part of the entire canal, causing nearly all the pain inci- 
dental to the passing of bougies, catheters and other urethral instruments. 
Stricture of the urethra is divided by most authors into two forms, namely, spas- 
modic, or those that are always temporary, and organic, or those that are always perma- 
nent. 
Spasmodic stricture of the urethra is an occlusion of its calibre, which may be 
either abrupt or gradual, and may be seated in any part of the urethra, from the neck 
of the bladder to the meatus; spasmodic stricture is generally of short duration, last- 
ing from a few minutes to six or eight hours, or longer, and is caused by contractions 
of the muscular coat of the urethra, and is generally reflex, as from adjacent inflam- 
mation ; for instance, a man falls astraddle of a fence or log ; a few hours after he may 
have spasmodic retention of urine, passing off in a few hours ; the same thing may 
occur after operation upon the perineum or testicles, and may also follow operations 
upon the penis itself, as the removal of a redundant prepuce. An acute attack of 
hemorrhoids is likely to be accompanied with the same trouble, as is also an operation 
upon them. Pressure, in the female, is a common cause, as the passage of a large head 
in childbirth in a protracted labor, or packing the vagina for gynaecological purposes, 
and from wearing an improperly constructed or inserted pessary. The passage of a 
sound or other instrument, the passage of a calculus through the ureters or urethra, an 
organic stricture in the anterior portion of the canal, acute gonorrhoea, gleet, excessive 
venery, indulgences in drinks, especially acid wine, and excessive shock, are all reflex 
sources of spasmodic strictures. 
Spasmodic strictures may be annular, and may involve any or all portions of the 
urethra. SECTION VII ANATOMY. 
163 
Organic stricture is the result of an effusion of lymph into and surrounding the 
membranous lining of the urethra, generally submucous, and having a great variety of 
shapes, ranging from the contraction of a single muscular fibre to the hardening of the 
entire penis, and, when followed by fistulas, even the perineum may become gristly. 
The most common form of organic stricture is the annular or thread-like, which can 
be well simulated by tying a string around an intestine. This form of stricture is fre- 
quently multiple; sometimes as many as eight, rarely ten, are found in one urethra, 
and may be associated with all or any of the other forms, and may also have a calibre 
so small as to be impenetrable, or so large and resilient as to escape detection; the 
threads or bands forming the annular stricture may sometimes split on one side, thus 
forming two strictures on one side of the canal, and only one on the other. 
Stricture, or contraction of the meatus, is generally described with the annular 
form, and is very common. Contraction of the orifice, after amputation of portions of 
the penis, is a rare form that might be classed under the same head. 
Longitudinal strictures sometimes exist, running like a septum along nearly the 
entire canal; this form may be twisted upon itself, forming a spiral stricture, or there 
may be two or more ridges making the urethra seem to be corrugated, as seen after 
several internal urethrotomies. Certain strictures have been described by some 
authors and are very seldom met with, and are generally seated near the meatus, 
stretching sometimes more than half-way across the urethra, and consisting of a thin 
membranous fold. 
Nodular strictures are also recorded, being really epitheliomas, and vary with the 
changes of that disease, especially their shape. 
Gummatous strictures are also seldom found, are very irregular, and may be found in 
any part of the urethra. 
Sarcomas sometimes seem to be stricture-like constructions, and are rare. 
Chancroidal strictures, due to chancres at the meatus or within the urethra, occa- 
sionally occur. 
Traumatic strictures may be of any imaginable shape, and in any part of the 
urethra. 
Organic strictures are generally made up of scar tissue, hard and gristly, but may 
be quite soft and flexible (the resilient form). 
The most common cause of organic stricture is masturbation ; the next, irritating 
injections, and the next most common, in my judgment, as in the order mentioned 
below. Injuries, surgical operations, chancre (primary syphilis), passing of calculus, 
cancer and gumma (secondary syphilis). 
I would like to call the attention of the Congress to an invention of mine, in the 
shape of a bulbous bougie, which can be made extemporaneously by taking a small- 
sized bougie and melting solder upon it, smoothing it off nicely ; and each time it is 
used either melting a little more upon it or cut a little off with your pocket knife, 
as the case may require, always smoothing it off nicely with a small piece of emery 
paper. 
From this idea, I have had constructed, by Mr. Snowden, of Philadelphia, a pocket 
bougie, which is made of steel, nickel-plated, and, as shown in the accompanying cut, 
consists of ten 2|-inch bulbs (being only the alternate sizes) and an universal handle. 
(A) represents a Gouley, or tunneled-sound point; (B) a bladder sound, or stone-searcher 
point; (C) a curved bougie point, and (D) a straight bougie point. This case, including 
a few whalebone filiform bougies, contains a complete set of urethral dilating instru- 
ments. 
This pocket instrument is entirely equivalent to forty separate bougies, for when 
the curved beak is adjusted, twenty curved bougies can be formed, that will take the 
place of about six pounds of steel, and can be used for dilating strictures in any portion 164 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of the male urethra, and by simply adjusting the straight beak, which weighs j ust one- 
quarter of an ounce, twenty straight or meatus bougies are formed, suitable for dilat- 
ing strictures without disturbing the bladder (in the male), for dilating the female 
urethra in any part, for stricture, or for dilating the entire female tube, to allow digital 
cystic exploration for stone or ribbed bladder, and is also an excellent instrument for 
dilating the uterus, either gradually, that is, day unto day, or at once. 
Allow me to repeat that this little point, weighing just one-quarter of an ounce, 
takes the place of twenty bougies, that would weigh several pounds. I have found, 
in using my instrument and the ordinary bougie alternately, that patients at once 
remark the painless, bulbous one. This, I think, is very natural ; the meatus, being 
the most sensitive, and always the smallest part of the urethra, receives the most 
stretching ; by using the ordinary bougie, which increases gradually in size from the 
beak to the handle, a stricture four inches from the orifice receives less stretching than 
the meatus, by one or two sizes, while by the use of the bulbous instrument, only the 
same size passes the meatus, and its passage, being momentary, is nearly painless, and 
when the bulb engages the stricture, it may remain in position several minutes without 
giving much pain, as the small staff near the handle has allowed the meatus to relax. 
One of the best recommendations of this instrument is its remarkable compactness, as 
it can readily be carried in the coat pocket and into a patient's house without exciting 
the curiosity of the neighbors or the rest of the family, and last, but not least, is its 
cheapness. A full set of regular steel bougies, cased, will cost twenty dollars and take 
a large case to hold them, and a full set of straight or meatus bougies will cost more 
than half as much, and need a box more than half as large, making a large, imposing 
and cumbersome package to carry into a sensitive patient's presence. 165 
SECTION VII ANATOMY. 
AN ANOMALOUS MIDDLE THYROID ARTERY, WITH PRESENTA- 
TION OF SPECIMEN. 
UNE ARTÈRE THYROÏDE MOYENNE ANORMALE AVEC PRESENTATION DE 
SPECIMEN. 
EINE ABNORME ARTERIA THYREOIDEA MEDIA, MIT DEMONSTRATION DERSELBEN. 
BY DR. MAX J. STERN, 
Instructor in Laryngology at the Medico-Chirurgical College of Philadelphia. 
The preparation that I present for your notice is a dissection, made by myself, at 
the Philadelphia School of Anatomy, and presented to my friend and teacher, your 
worthy President, Prof. Pancoast, by whose courtesy I am enabled to bring it before 
you. The subject was a woman, aged thirty-four, and the cause of her death, accord- 
ing to the certificate, general paralysis. 
In the specimen you will please notice the ligature on the left carotid artery; it was 
cast around it in the injection of the body. Originally, I intended injecting through 
the aorta, but on reaching the heart, and not finding its situation normal, I cut down 
on the carotid and injected through it. 
The first striking feature that will be noticed is the aorta arising on the left side, 
6 cm. from the median line, passing obliquely upward, forward and outward, then 
arching backward and downward, but at no time touching the median line, the nearest 
approach being at the commencement of the transverse aorta and it being one and one- 
half centimetres from it. The left common carotid and subclavian arteries arose nor- 
mally from the aorta and were normal in their distribution. The slight alteration in 
the course of the left carotid is due to the handling and cutting of it preparatory to the 
injection. 
The arteria innominata is given off at the commencement of the aorta transversence, 
passes obliquely upward, then transversely over the trachea, two and a half centimetres 
above its bifurcation, dividing, immediately after crossing it, into the subclavian and 
common carotid arteries. The subclavian was throughout normal in its distribution. 
The common carotid pursued a normal course, bifurcating into the external and internal 
carotid arteries on a level with the superior border of the thyroid cartilage. The first 
branch of the external carotid artery, usually the superior thyroid, is the branch to 
which I wish to call your particular attention. It will be seen that, leaving the external 
carotid artery immediately above its bifurcation, it pursues first a transverse and then 
a downward course until reaching the superior border of the thyroid gland, and here 
dichotomizing into a superior thyroid artery and the anomalous artery, for the demon- 
stration of which the preparation now before you has been made. 
The course of this artery is obliquely downward and inward until reaching the 
crico-thyroidean membrane, then, traversing it, it passes downward and over the isth- 
mus of the thyroid gland, nearing the inferior border of which, it divides and subdivides 
into minute arteries, which are lost in the substance of the gland. On cutting through 
the skin, it was found intimately associated with the gland and just peeping between 
the ribbon muscles directly in the median line. 
The significance of such an artery as a complication in the operation of tracheotomy 
can readily be understood. My friend, Dr. J. Solis Cohen, informed me that, operating 
in 1865, with the assistance of Dr. D. Hayes Agnew, a frightful hemorrhage -was 
encountered shortly after the skin was incised and while in the deep connective tissue. 
Neither he nor Dr. Agnew could ever locate the artery that had been divided, although 
both were positive it was not the artery of Neubauer. Dr. Cohen is strongly of the 
opinion that it was the one which I have described to you. NINTH INTERNATIONAL MEDICAL CONGRESS. 
166 
In examining some sixty or seventy specimens, I have met with three or four like 
arteries, although, compared with this, they seem simply rudimentary. In my 
researches into the literature of the subject I can find no mention of such an artery, 
and believe this the first time it has been described. 
SKIN GRAFTING UPON THE CRANIUM. 
PEAU GREFFEE SUR LE CRÂNE. 
HAUTTRANSPLANTATION AUF DEN SCHÄDEL. 
Professor of Anatomy of the Chicago Medical College ; Member of the American Medical Association. 
FREDERICK CHRISTIAN SCHAEFER, M. D., 
My object in introducing an old subject is twofold :- 
1st. On account of the paucity of statistics of injuries of this nature, to place a case 
upon record before the profession. 
2d. To report results of observations in skin grafting over the bones of the cranium. 
Since the subject of skin grafting was first introduced by MM. Reverdin and 
Frank Hamilton, innumerable and varied trials have been made to close wounds by this 
procedure, with variable degrees of success, all over the civilized world, but an exten- 
sive search of the medical literature gives very meagre information concerning skin 
grafting upon the cranium. 
Case I.-The patient, a young lady, twenty-four years of age, was at work in a 
laundry under a revolving shaft, July 9th, 1886. The shaft was between four and five 
cm. below a heavy beam, and about twenty-five dm. above the floor; it was making 225 
revolutions a minute, as computed by the engineer. The girl was said to have reached 
up for something on the wall, when the wind blew her hair toward the shaft. Instantly 
she was drawn against the beam and shaft, and fell back to the floor without her scalp. 
The narrow space between the shaft and beam doubtless saved her life. She then 
walked upstairs (the accident occurring in a basement), where I found her sitting in a 
chair, moaning piteously, presenting a most ghastly, heart-rending appearance. 
THE WOUND. 
The entire skull was laid bare, from the margin of the eyelids to the neck. The nasal 
bones were uncovered and broken, exposing the superior nasal meatuses. The skin of 
the eyelids was removed from within three mm. of their edges; the border of the wound 
was traceable from the lower portion of the left external angular process of the frontal 
bone and margin of the left upper eyelid, downward and backward below the left ear, 
which was entirely removed; thence the wound extended across the neck, five cm. 
below the superior curved line of the occipital bone, and could be traced forward 
through the lower third of the right auricle to the right external angular process of 
the frontal bone and margin of the right upper eyelid, across the right lid, nose and the 
left lid to the point of commencement. The superior border of the left zygomatic 
process was broken, exposing the cavity within the process. Every vessel and nerve 
supplying the scalp was torn off, and the pericranium was lost in three places; one spot, 
corresponding to the centre of the forehead, was oval in contour and measured 5x7 
cm. The other exposed surfaces of the bones were located on either side of the calva- 
rium, on the corresponding parietal and temporal bones; were elliptical, eight cm. long, SECTION VII-ANATOMY. 
167 
six cm. wide. The neck flap of the wound fell away from the muscular structures 
beneath it, exposing the trapezius muscle almost half-way to the shoulder blade. The 
trachelo and sterno-mastoid muscles were also uncovered, the latter to the extent of 
seven cm. The right ear was torn through its lower third, and hung at the side of the 
neck by an isthmus of skin less than five mm. in width. The exposed surface of the 
wound measured 40 cm. in length from before backward, and 34 cm. in width near its 
central portion. The sutures of the cranium were distinctly seen at several places. 
There were only a few muscular fibres left upon the head-a portion of the temporal 
muscles on either side, and the levator palpebræ muscle in the orbits. Hemorrhage was 
profuse; the temporal, occipital and posterior auricular arteries had to be tied. 
Treatment.-I came to the patient within three-fourths of an hour after the accident 
occurred. Controlled hemorrhage, examined the scalp, wrapped the head up in car- 168 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bolized gauze. The scalp was thoroughly mangled and covered with fragments of hair 
on its inner surface, which had to be removed. In order to save time, I sent for my 
friend and neighbor, Dr. J. D. Skeer, to assist in the immediate treatment of the case. 
Dipped the scalp in warm carbolized water, picked off the broken hairs from its inner 
surface, and cut off the hair from the outer surface, while Dr. Skeer prepared the 
head for the reception of the scalp. Together we freshened the edges of the wound, 
stitched the scalp back by continuous suture, and sewed the right ear in its position. 
Applied iodoform over the entire suture, and coiled small, narrow sacks filled with 
warm sand about the head to keep the scalp warm. After three days, uncovered the 
head and cut through the scalp in several places to let out the pus which had accumu- 
lated beneath it. On the seventh day removed all dressings. The scalp was now per- 
meated with gases of decomposition, and baked firmly against the calvarium in many 
places. Removed it. The right ear was warm and joined at the sutures. During the 
first three weeks we had little hope for the patient's life. Her pulse varied from 90 to SECTION VII ANATOMY. 
169 
130 per minute, while the temperature fluctuated between 100° and 104° F. Was 
delirious about three weeks, having lucid intervals. Her face was swollen beyond 
recognition. She was unable to lie down; had to be propped up with pillows. After 
the second week her neck became stiff, the muscles were rigid, neck turning to one 
side. To overcome this tendency, had the bed turned so that it became necessary for 
the patient to move her neck in the opposite direction. Also had her exercise the neck 
hy rotating and bending it. The optic nerves were extremely sensitive. Vision weak 170 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
at 2%. She complained of noises in both ears. Hearing distance, right ear, left ear 
watch c. During the fourth week she left her bed and walked about the room. 
Dr. Skeer now withdrew from the case, as it was unnecessary for two physicians to 
attend her. Six weeks from the day the accident occurred, I concluded that skin graft- 
ing might be most promising of satisfactory results. Suppuration was very free at this 
time, and the patient was too feeble to permit of any treatment requiring extensive SECTION VII ANATOMY. 
171 
operative procedure. I therefore, on the 15th day of August, took thirteen epidermal 
grafts from the flexor side of her sister's arm and placed them upon the patient's head 
four mm. apart. By way of experiment, four of them were placed upon the centre of the 
cranium in direct contact with the granulation tissue; the others near the edge of the 
wound upon the eyelids where there was the least suppuration. The head at this time 
was covered with granulations from the pericranium, excepting in places where the 
periosteum was lost; these were gradually covering in also, from their margins. The 
grafts were held in place with fish skin, and the handages were permitted to remain in 
position forty-eight hours, when the four grafts upon the vertex presented a pink color, 
and five of the grafts over the eyelids were washed away hy the pus. I then attached 
eighteen grafts, eight upon the top and ten near the margin, as before. After another 
forty-eight hours all on the top of the head were pink, the four previously planted were 
spreading. Those near the margin of the wound remained also, but did not look as 
good. The constant accumulation of pus interfered with the growth of the marginal 
grafts. I was therefore lured on to place the greater portion of them near the vertex 
in semicircles, coming forward to meet those which were growing over the lids. 
October 12th, my notes say there is a piece of transparent skin, 13 cm. long and 7 
cm. wide, extending from the eyelids backward, besides twenty pieces, varying in size 
from a ten-cent piece to a quarter of a dollar, upon the sides. On the 15th of October 
noticed that the new skin began to liquefy in spots. October 17th, 10 o'clock, A.M., a 
copious hemorrhage occurred from one of the venous channels between the tables of the 
right parietal bone; the blood ran forward and to the left side, beneath the front half of 
the new skin, which was thus destroyed. A few days later the other half was per- 
forated by many small ulcers. In ten days more it also disappeared. Over two months' 
work was destroyed in as many weeks. The amount lost would be represented in one 
piece by an oval measuring 15 cm. by 11 cm., to produce which 915 grafts were 
required. 
Although somewhat discouraged by this disaster, we were not dismayed, but endeav- 
ored to retrieve our loss by vigorous grafting. Having noticed that the skin derived 
from the epidermis, chiefly, was very thin, immovable and short lived, I now resorted 
to dermal grafting, picking up each time, also, a few fibres of subcutaneous connective 
tissue. Suppuration having greatly diminished, all of them were placed about the cir- 
cumference of the wound. About 65 per cent, lived. During this month, November, 
two irregular pieces of bone, measuring 3x2 cm., were removed from the outer table, 
where the pericranium was gone. December 1st there was an irregular band of skin 
around the entire head, six cm. wide in front and four cm., wide at the back and sides. 
The last two series of grafts did not thrive. Up to this time heterodermal grafts only 
were brought into requisition, from her sister and three brothers. As the patient was 
now able to walk out of doors, she gained in strength, and the thought occurred to us 
(Dr. Skeer, who called to see her at this time, and myself) that tissue taken from her 
own person might do better than the heterodermal material. On the 24th of November 
commenced taking grafts from her left arm. The rapidity of the growth of her own 
grafts was simply marvelous. For example : one day thirty were placed in a double 
row, set three mm. apart. In thirty-six hours they put on a pink color. Three days 
later they were joined in one piece. The connecting parts were slightly depressed and, 
of course, quite thin. By the eighteenth day a few hair-like vessels were detected in 
the new tissue. 
Eight times after our first misfortune, numerous ulcers started at different places. 
At one time there were eighteen of them. They were evidently caused by the contrac- 
tion of the subcutaneous tissue, whereby the fine vessels were broken. 
(Many of the ulcers healed of themselves, but the larger ones were assisted by auto- 
plastic grafts. 4500 grafts were planted, of which the patient supplied 1800.) 172 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
May 1st (10th month), there remained uncovered four spots, each a trifle larger than 
a silver dollar. I expected to complete the scalp in four weeks, when suddenly her 
strength gave out. She took a severe cold, suppurative inflammation of the left middle 
ear followed, the mastoid process became very tender, and a dozen new ulcers appeared ; 
two large ones, each about twelve cm. long and from one to three cm. wide. The com- 
bined area of all might have been represented by a circle sixteen cm. in diameter. The 
patient was almost disheartened; she slept only three hours of a night for three weeks; 
her head ached, sight grew dim, and I feared meningitis was setting in. Gave her 
opiates and tonics. After three weeks' depression she reacted, when grafting was 
resumed. Occasional discouragements have been met with since, but now she feels 
good; says the head and eyes seem as strong as before the accident occurred. Her 
hearing has greatly improved also. There remain uncovered only two spots, each meas- 
uring less than a quarter of a dollar. One over the left ear, the other on back of head, 
which will doubtless heal over in two or three weeks. 
NOTES. 
From the beginning the entire wound was treated antiseptically with carbolic acid, 
iodoform, and corrosive sublimate. It was dressed, at the suggestion of my colleague, 
with strips of carbolized gauze prepared with 2| per cent, solution. The strips were 
6 cm. wide, 30 to 35 cm. long. A layer of them, which came in direct contact with the 
granulations, was anointed with vaseline, so that it could be readily removed; then a 
series of strips was superimposed upon each other ; next a piece of lint covered on one 
side with vaseline was placed over these and external to the lint; a roller bandage made 
of cheese cloth was wrapped about the head. This formed a convenient and serviceable 
dressing. The lint and strips were easily removed. The interstices of the gauze, by 
capillary attraction, drew the pus from the wound's surface ; the lint prevented too 
rapid evaporation, whereby the dressings were prevented from baking against the 
wound. The outer bandage retained the other parts in place. Thinking the lint 
heated the head, by way of experiment it was left off ; but each time the dressings were 
stuck against the cranium, so that they were removed with difficulty, therefore con- 
tinued using it. 
At first the grafts were held in place by means of a piece of fish skin, which after 
thirty-six hours began to liquefy and could be removed with a sponge. Repeated exper- 
iments caused me to discard this. The fish skin would break down, commingle with 
the pus and help to macerate the grafts. Next tried McIntosh dressing. This heated 
the tissue too much, and the grafts were often found floating in the pus beneath it. 
Having observed that the pus always clung to the gauze dressing ; that, as a rule, the 
thicker the layer of gauze used the less pus remained upon the wound's surface, I con- 
cluded to place a pad of oiled carbolized gauze upon the grafts instead of the rubber 
or fish skin. This worked remarkably well. Six or eight thicknesses of gauze, extend- 
ing two or three cm. beyond the grafts in all directions, were applied. This had the 
desired effect of absorbing the pus, reducing the heat to the minimum, while the 
grafts generally remained in place. 
The grafts usually assumed a pinkish appearance in forty-eight hours. Occasionally, 
a series of the autoplastic grafts, when the patient felt exceptionally good, would be 
almost pink in twenty-four hours. Many of them, however, gave no evidence of being 
alive until after seventy-two hours. Several times grafts which hung to the dressings, 
covered with pus, after forty-eight hours, being replaced, took hold and lived. 
The progress of the growth of the new skin was similar to the description of M. 
Reverdin. A narrow (one mm.) zone of hyaline tissue, somewhat depressed, surrounded 
the grafts in ninety-six hours ; this grew with variable degrees of rapidity until the 
grafts were joined, then it grew thicker and thicker. After three weeks, sometimes a SECTION VII ANATOMY. 
173 
few days earlier or later, fine vessels were traceable in this new tissue ; these increased 
in size and number until the skin was literally a network of vessels. As they con- 
tinued developing, it was noticed that the larger ones were directed upward. Later, 
some of them assumed very nearly the position of the normal arteries, like the temporal, 
occipital, etc. Now many of them have a bluish color, being evidently veins. 
The grafts were derived from her sister, three brothers and herself, aged respectively 
17, 19, 27, 30 and 24 years. They varied in size, averaging about 4x3 mm., the cen- 
tral portion consisting of dermis with subcutaneous connective tissue ; the marginal 
portion comprised epidermis only. Simply a fold of the skin was lifted with sclerotica 
forceps and hastily snipped with iris scissors. When removed their under surfaces 
curved inward. They were then spread out and Zaid in direct contact with the granula- 
tions. The peculiar form of the grafts seemed to exert a favorable influence upon them. 
Their inward curvature caused them to cling closely to the granulations and an imme- 
diate suction action took place. The patient said she could feel them draw as soon as 
they rested upon the head. I have no doubt that the empty vessels in the grafts 
expedited this process. Many times grafts 6x7 cm. were tried without success. Tissue 
with hair was also applied ; but the hair bulbs died. 10 to 100 grafts were planted at 
a sitting. Most of the time 20 to 30 only were used. Usually two days intervened 
between the graftings. Frequently, however, several weeks' rest had to be given the 
patient, on account of her weak condition. 
Anatomy.-All of the skin from the margin of the superior eyelids upward presents 
the characteristics of the normal skin. It is pliable, soft and movable. The lower half 
can be pinched up in folds. It imparts a velvety sensation to the fingers when touched. 
Furrows with pores opening into them are plainly seen with the hand glass. Follicles 
are abundantly present. Her head sweats freely, and much of the new skin feels to the 
patient Hke the skin in other portions of her body. The eyelids are somewhat retracted, 
less, however, than they were four months ago. The younger pqrtion of the new tissue 
appears quite red; myriads of small vessels can be seen in it. As the skin grows older 
the smaller vessels gradually disappear from view, others appear larger; the integument 
assumes a more normal appearance as to color and consistency. It also becomes more 
movable, owing to the development of subcutaneous connective tissue. One cannot 
see where the new skin begins upon the eyelids. The lids close perfectly, so that the 
lady sleeps with closed eyes. 
STATISTICS. 
Our works on Surgery give no statistics, although at different times such accidents 
have occurred in the manufacturing States of our country. After having written many 
letters to physicians for information concerning cases which came under their observa- 
tion or treatment, I received responses from two only. I have imperfect reports to give 
of six cases :- 
Case I.-A girl, nineteen years of age, lost her scalp, fourteen years ago, in the Elgin 
Watch Factory, Elgin, Ill. Dr. E. Powell, of Chicago, informed me that the wocpid 
extended across the forehead above the eyebrows, and that her ears were not touched. 
Skin grafting was tried repeatedly in this case, with no results. Was told by a surgeon 
who saw her more recently that one of her eyes was lost since by exposure, occasioned 
by retraction of the eyelids. 
Case ii.-Gross' "Surgery," last edition, makes mention of a young lady who lost 
her scalp in a factory in Philadelphia, in 1869. He simply says the wound cicatrized 
over. 
Case hi.-Reported in the " Surgical History of the War," Part I, p. 315. A con- 
ductor on the Union Pacific Railroad was scalped by the Sioux Indians, near Cheyenne, 
in 1869. Wound, as indicated by the illustration given, was elliptical; measured about 174 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
10 x 8 cm. A portion of the outer table of the cranium was removed. The wound 
healed over. 
Case iv.-Reported by her employer, Mr. E. F. Smith. Miss Hattie Thomas, at 
Union City, Conn., March 29th, 1871, in a button factory, placed her head under a 
swift-running shaft to pick up a button, when her hair was caught by the shaft and her 
scalp taken off from the nape of her neck to her eyebrows. Her physician was Dr. S. C. 
Bartlett, now deceased. He cleaned the scalp and placed it upon the head about two 
hours after it was torn off, but it did not stay. Then commenced skin planting. Had 
the head almost covered twice. Each time it was lost. A third effort proved success- 
ful in healing the wound, so that she was able to work after two years. 
Case v.-Miss Neuman, Bristol, Conn. Had her scalp torn off by her hair catch- 
ing in the machinery in a mill where she was at work during the past winter. The 
entire scalp was gone, an eyelid and an ear slightly torn. She was treated by Drs. 
Wilson and W. E. Way, of Bristol. Result of treatment not given. The Hartford 
Times, of last July, contained an advertisement for volunteers to furnish skin for 
grafting. 
Case VI.-Reported by Dr. W. W. Horton, of Unionville, Conn. " June 12th, 1885, 
Rosa Flynn had her entire scalp torn off by her hair catching in the shafting of a paper 
mill, in Unionville, Conn. The scalp was torn from the back of the neck around, just 
above each ear to the nose, taking the eyebrows. There was also a flap torn down the 
right side of the face nearly to the mouth. ... I treated her for one month, then 
sent her to the Hartford Hospital, where skin grafting was tried. Both human and 
rabbit skin was used. It was a failure. Lids are retracted. The wound is still open. 
Hemorrhage occurs from the capillaries when her head gets on a lower level than her 
body. Expect the wound will cicatrize over in another year." 
It will be noticed that in none of these cases was the wound as extensive as in the 
one under consideratipn. 
DEDUCTIONS FROM EXPERIENCE IN THIS CASE. 
I. When grafts are set within five mm. of each other, a stronger skin is produced 
than when they are placed further apart. 
II. A graft will grow to many times its own dimensions, so that a circular graft 
three mm. in diameter will form a piece of skin eighteen mm. wide, but the skin 
will not be as strong or of as good quality as when the grafts are closer together. 
III. Dermal grafts with a few fibres of connective tissue form a smooth, soft, pliable, 
movable skin, presenting the characteristics of normal integument. 
IV. Epidermis placed upon the cranium produces only a thin film, which is immova- 
ble, and ulcerates readily. 
V. Autodermal grafts are more reliable than heterodermal grafts, providing the 
subject is healthy. 
VI. Grafts from a person near the patient's own age do better than from one much 
older or younger. 
VII. With dermal grafts the follicles are preserved, whereby the patient is made 
more comfortable, the skin produced is more natural, hence more durable. 
VIII. The most reliable skin is formed by grafting about the circumference of the 
wound, say one or two rows, producing a narrow strip one cm. wide, and waiting until 
the blood vessels are well developed in it, then plant another series close to the last 
ones. By this plan, contraction in the marginal tissue takes place in advance of the 
subsequent graftings, diminishing the liability for the ulcerative process to occur by 
reason of such contraction. 
IX. The new skin is fed first by the tissue upon which it rests, probably by osmosis, 
but depends for its permanent sustenance upon the vessels growing into it from the SECTION VII ANATOMY. 
175 
circumferential tissue. This fact is thoroughly established in my mind, as it was 
frequently demonstrated by the death of patches of new skin removed from the 
marginal tissue. Time and material can therefore be saved by constantly grafting from 
the circumference in large wounds. 
X. All things considered, grafts will grow better in a new wound than in an old 
one, and the more recent the wound the more certain are they to thrive. In the present 
case, during the last three months, notwithstanding the improved physical condition 
of the patient, only twenty per cent, of the autodermal grafts took, while six months 
ago eighty-five per cent, could be depended upon. 
THE RETRO-CALCANEAN BURSÆ IN REFERENCE TO AMPUTA- 
TIONS THROUGH THE ANKLE JOINT. 
LES BOURSES SETRO CALCANEENNES PAR RAPPORT À L'AMPUTATION DANS 
L'ARTICULATION TIBIO TARSIENNE. 
DIE BURSÄ RETRO-CALCANEÄ MIT RÜCKSICHT AUF AMPUTATION DURCH DAS 
FUSSGELENK. 
BY JOSEPH N. DICKSON, A. M., M. D., 
Pittsburgh, Pa. 
Mr. President and Gentlemen :-Various methods have been proposed in per- 
forming this very important amputation; viz., the circular incision; the long dorsal flap 
(Baudin's); the lateral flaps; the single lateral flap (Roux, Seiddillote, Mackenzie); 
the inferior posterior or heel flap (Syme, 1843); and various modifications of Prof. 
Syme's method. 
I propose to set before you the plan of operation as detailed by Dr. W. R. Hamilton, 
of Pittsburgh, Pa., in 1881, in a paper entitled "A New Method of Performing the 
Amputation of the Ankle-joint." He describes his method thus :- 
Amputation at the ankle-joint, as heretofore performed, has been difficult in 
execution and frequently followed by unfavorable results. It is an operation frequently 
required here (Pittsburgh), on account of injury, a larger proportion of our popula- 
tion being engaged in railroad service, mining and mechanical occupations dangerous 
to life and limb, than in any other part of this country. 
A new method of performing this operation is given as applicable to cases of injury, 
admitting the ordinary regular operation, but which may be varied as cases of injury or 
disease may require. 
It is as follows : The foot being held at right angles to the leg, the point of a large 
scalpel should be introduced immediately below the tip of either malleolus, and an 
incision made through the soft parts directly across the sole and terminating at the top 
of the opposite malleolus. The ends of this incision should be joined by another 
directly across the front of the ankle joint. All these incisions should be made down 
to the bones by the first application of the knife. The ankle joint should now be 
opened by dividing the ligaments and the dissection of the flap commenced from above 
downward. The thinness, softness and flexibility of the tissues at this part facilitate 
the operation. The dissection at the sides of the os calcis should be kept in advance 
of that at the posterior part, which enables the attachment of the tendo-Achillis to 
be easily divided. The separation of the flap from the plantar surface of the os calcis 
then becomes the least troublesome part of the operation. The dissection should be 176 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
carried so close to the osseous surface as to include the periosteum. No vessel should be 
divided after the first incisions, except the nutrient vessels of the bone, as every touch 
of the knife can be plainly seen by the operator. The soft tissues, together with the 
periosteum, should be separated from the outer side of each malleolus to about one- 
third of an inch beyond its base, and the malleoli theji sawn off obliquely. The saw 
should be applied on the articular surface of the bone and the direction of the cut be 
upward and outward. The articular surface of the tibia should be left uninjured. 
The anterior tibial artery may now be seen and easily secured by torsion. The Esmarch 
bandage should be suddenly removed and the limb elevated. The external plantar 
artery, which may be found near the middle of the anterior border of the flap, may 
require attention, and as it is desirable to avoid the use of ligatures in this operation, 
the artery may be caught and twisted, but as this is difficult on account of the tissues 
which surround it, a needle, carrying a silver wire, should be passed from the outside 
of the flap through it, alongside of the artery and returned on its opposite side, thus 
including it in a loop which may be tightened. This loop may be removed in twenty- 
four hours. 
If the lines of incision have been made as directed, when the flap is pressed firmly 
against the bones it will be found to fit admirably, and the hard integument of the flap 
will be pressed against the cut edge of the skin on the front of the leg, which will be 
found drawn above the plane of the articular surface of the tibia, and the end of the 
stump will be covered by the firm cushion of skin and other tissues from over the os 
calcis. 
While the flap is held firmly in position, silver wire sutures should be inserted about 
three-quarters of an inch apart, after which a strip of adhesive plaster half an inch wide 
and sixteen inches long should be applied transversely between each suture, and its free 
ends so attached to the leg above as to press the flaps firmly against the bones. The 
skin of the flap and leg should be placed in close apposition, and as the integument of 
the flap is much thicker than that of the leg, the sutures should be introduced deeper 
in the latter than in the former, so as to approximate the edges of the true skin in each. 
A compress, secured by a bandage, applied firmly over the end of the stump, so as to 
compress the flap against the end of the bones, and leave no cavity for the accumulation 
of blood, etc., completes the dressing. 
At the end of five or six days the sutures can be withdrawn without disturbing the 
adhesive plasters, if everything is progressing favorably. 
In favorable cases, absolute "healing by immediate union" may be expected in the 
greater part of the wound, and " healing by adhesive union " in the remainder, without 
suppuration within the flap. 
In the preceding part of this article the term ' ' flap ' ' has not been applied to the tissues 
above the line of incision in front of the ankle, which is usually drawn up above the 
plane of the articulation of the tibia. The term "flap" has only been applied to the 
tissues dissected from the foot. When the incision is carried across the sole of the foot, 
as directed by Prof. Syme, the dissection of the flap is exceedingly difficult. Owing to 
the thickness and unyielding character of the tissues, it cannot be pushed back without 
considerable force and wrenching, and owing to the os calcis, the plantar surface of 
which rises rapidly toward the anterior extremity, the blade of the scalpel cannot be 
kept parallel with the osseous surface, and, in the language of Lister, "It becomes a 
most troublesome task to turn back the integument over the prominence of the heel, 
the knife being thrust the operator knows not where. The subcutaneous tissue on 
which the skin depends for its nourishment is punctured and scored, and perhaps the 
point of the instrument appears occasionally through the skin itself, while the flap is 
subject to violent wrenching in the effort to draw it back over the bony projection." 
It is entirely foreign to the purpose of the author to detract any credit from Prof. SECTION VII-ANATOMY. 
177 
Syme for his original operation, or to lessen the credit due any of the many surgeons 
who have offered modifications of this operation. Nor do we claim priority for this 
method in all its details. The method of dissection was first pointed out by Dr. W. R. 
Hamilton, in an article read before the Pennsylvania State Medical Society, in 1875. 
The manner of dressing has been developed since that date. 
Others have recommended the removal of the malleoli obliquely without disturbing 
the articular surface. Should the articular surface of the tibia be damaged, either by 
disease or injury, it should be removed, although this has the objection that the end of 
the stump, after removal of the articular surface, resembles the large end of the ftus- 
trum of a cone, which renders the stump tender until it is rounded off by absorption. 
William Stokes, in " Heath's Dictionary of Practical Surgery," recommends the use 
of Von Langeubeck's periosteal raspatory for detaching the periosteum and other tissues 
from the os calcis. Some objections have been raised against this method, on account of 
the possibility of spicula of bone being developed from the periosteum in the flap, but 
this has never occurred in any case we have observed. Macleod, of Glasgow, and J. 
Bell, of Edinburgh, preserve the periosteal covering whenever it is possible to do so. 
It will be seen that the operation as described above differs in many important 
details from that of the original operation as described by Prof. Syme. The malleoli 
are removed obliquely, but the articular surface is left intact, forming a concave sur- 
face, which is filled up by the tissues of the flap and the retro-calcanean bursae, which 
will be described later on. The advantages of sawing off the malleoli obliquely are 
obvious, as it permits of the adaptation of a lighter and better artificial foot. We are 
informed by J. W. Thompson, of the Artificial Limb Manufacturing Company, of Pitts- 
burgh, Pa., that the stumps after this operation are the very best that his firm have 
any knowledge of, as all the patients are able to walk without apparent lameness. 
Some are even able to dance. He also told us of a man who works at his trade as a 
stone mason, in a shop where his fellow-workmen do not know that he has an artificial 
foot. 
The lines of incision in this amputation also differ from Syme's, as the plantar inci- 
sion is carried further forward, making a longer plantar flap, while the dorsal incision 
is carried further upward, so that when the stump has healed the cicatrix is higher in 
the limb, and, consequently, less liable to irritation than in Syme's operation. 
As regards the circulation in this long plantar flap, J. A. Wyeth, of New York, has 
proved, by a large number of dissections, that the principal blood supply is derived from 
the calcanean branches of the external plantar artery. Hence, the propriety of a long 
plantar flap. 
On the other hand, Erichsen, Lister and Spruce do not consider the division of the 
posterior tibial artery an accident of serious moment. In one case operated upon in 
the Western Pennsylvania Hospital, with the assistance of Dr. W. R. Hamilton, we 
found the posterior tibial artery badly damaged, as well as the soft tissues surrounding 
it. This case did equally as well as others. 
Perhaps the most important step of all is the preservation of the retro-calcanean 
bursa. This bursa is thus decribed by Nancrede: " Its anatomy differs somewhat from 
that of other bursæ, in that cartilage forms part of two of its walls, viz. : the anterior 
and posterior, for the vertical portion of the os calcis beneath the tendo-Achillis, and 
the portion of the tendon that faces that part of the bone are both coated with a thin 
layer of cartilage. This bursa is small and heart-shaped, with its apex upward, thus 
forming two pouches, one on either side of the tendon. These lateral pouches have a 
few bridles of connective tissue traversing them, although not of enough bulk to form 
even partial partitions. A vascular and fatty fold is usually found in each pouch." 
The preservation of this bursa is an important consideration, for several reasons: it 
fills up the concavity of the articular surface of the tibia, thus rounding the stump: it 
Vol. in-12 178 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
also acts as a cushion, deadening shock and permitting mobility of the integument over 
the stump. By preserving this bursa intact, the danger of bursitis with consequent 
inflammatory exudation and suppuration is obviated. 
The ankle-joint amputation with the bursa retained is analogous to amputation at 
the knee joint, where the bursa is also retained. 
The method of dressing the stump is very important. The pressure on the heel 
portion should be continued all the time the sutures are being placed and the dressing 
and bandages applied. 
As regards the statistics of this operation, fifty-two cases have been collected from 
the practice of various Pittsburgh surgeons; of these there were- 
15 cases operated on by Dr. McCann. 
17 " " " Dr. Hamilton. 
1 " " " Dr. Lemoyne. 
4 " " " Dr. Murdock. 
6 " " " Dr. King. 
1 " " " Dr. Haworth. 
1 " " "Dr. Foster. 
1 " " " Dr. Scott. 
1 " " " Dr. Buchanan. 
5 " " " Dr. Dickson. 
Total, 52 
Of these fifty-two cases only three died, two from internal injuries and the third 
from gangrene. 
Ten of the above cases were double amputations of both lower extremities, and two 
were double amputations where an upper and lower limb were amputated. 
The results that follow this amputation have been more satisfactory than any ampu- 
tation in any other part of the body. 
THE DISPOSAL OF DISSECTING-ROOM OFFAL. 
LA DISPOSITION DES ABATS DE LA CHAMBRE DE DISSECTION. 
FORTSCHAFFUNG DER ABFÄLLE AUS DEM SEKTIONSSAALE. 
BY H. C. BOENNING, 
Of Philadelphia, Pa. 
A question of some importance to those concerned in practical anatomical work is, 
What shall be done with the refuse and offal of our dissecting rooms? As the result of 
some inquiry, I have ascertained that our medical colleges and other institutions 
where the cadaver is in use dispose of their offal in different ways, and generally one 
of the following, and in this order of sequence ; by burial, by storage in vaults or wells, 
by cremation and by alkalies ; but in addition other methods are employed by some ; 
thus, in one answer to a letter of inquiry I read, " We mince our waste and throw it 
into the sewer." Another writes : " Weget away with the stuff, " meaning the refuse, 
' ' by putting it where the buzzards will clean the bones ; ' ' and one charitable institution 
informs me that they "box the offal and send it to Rahjamundy," which place I have 
learned is a mission station in India. Such suggestions are original, somewhat 
startling, perhaps, but on the whole not sufficiently practical. Buzzards, for instance, SECTION VII ANATOMY. 
179 
seldom pass Mason and Dixon's line, and the expressage to India is not a romance. Burial 
seems to be the favorite plan. But the cost of burial, except in rare instances, is con- 
siderable ; thus, to bury the waste at the Philadelphia School of Anatomy for the 
session of '85 and '86, it cost close upon two hundred dollars. But aside from the 
element of cost, burial should be discountenanced, because, to avoid the expense of fre- 
quent handling and hauling the foul and offensive offal, it is allowed to accumulate for 
a week, a month, six months, and in some instances, a year or longer. Such storage 
means decomposition, fermentation and the evolution of gases and vapors favorable to 
the culture and development of all manner of disease germs. Where, however, as in 
the case of some institutions, it is possible to send away the dissecting-room offal 
several times a week, in coffins, at the expense of the city, I think the plan is most 
excellent. As to vaults and wells : Twelve or thirteen years ago, when the old 
University of Pennsylvania buildings were torn down, workmen discovered a num- 
ber of wells into which the waste from the dissecting-room had been thrown. Some 
of the wells had been bricked over, and altogether they held the refuse accumulated in 
that institution for perhaps fifty years. As soon as the laborers broke into the wells 
and discovered the remains of possibly their ancestors, a howl went up that reached 
all over the country, and the University men were dubbed ghouls, whereas they are all 
clever gentlemen, and all of them friends of mine. Vaults and wells are largely used, 
but they are so expensive, if properly constructed, and so offensive if poorly built, that 
I am surprised to learn that so many institutions have provided them for the deposit 
of their dissecting and surgical room refuse. As to alkalies : At least three institu- 
tions in this country destroy their offal by alkalies. One uses lime, the others potash 
and a refuse material or by-product, the result of the manufacture of the cyanide of 
potassium. These alkalies, I am informed, are intimately mixed with the waste and 
allowed to stand, when, in one instance (I now quote from a letter), "it stands until 
liquid, or nearly so, when it is poured into the river," alluding to one of the great 
water highways of the west. This plan is undoubtedly cheap, but again involves 
storage and frequent handling, as well as the formation of noxious gases. Cremation 
stands third upon the list, and is undoubtedly and beyond all controversy the best way 
to destroy the mouldy and maggoty remains of our rooms. But to build a crematory 
means the outlay of a large sum of money ; it means the accumulation and storage of 
a large quantity of refuse ; it means the outlay of a number of dollars, and twelve 
hours to heat the furnaces ; it means untold annoyances, for cracks will occur, the 
gases formed during cremation will escape and appeal to the olfactories of the people 
in the vicinity, and, in general, it means a period of unhappiness, that is dreaded alike 
by the faculty, the college and its neighbors. Such, at least, is the common experience 
of our institutions provided with huge and expensive brick-built crematories. 
Among the correspondence I received is a letter from a western college, in which 
the writer states that their refuse is stored in a well or vault until spring or summer, 
when it is gradually burned in a large stove. Let me narrate my experience in this 
line at the Philadelphia School of Anatomy:- 
I was located at the corner of Tenth and Arch streets, the very centre of the city, and in 
the course of time every one within a radius of half a mile knew where the dissecting 
room was located, and when Mr. Jones, a quarter of a mile away, one day, burned an old 
pair of gum boots, every family residing within the circuit stated sent a representative to 
my room, with orders to investigate our doings. This was of common occurrence, and I 
may say that every mal-odorous condition of the atmosphere in that vicinity brought 
the people to my doors. I cannot deny that occasionally my janitor did feed the 
furnaces with sundry scraps, always, of course, provoking complaints and the visits of 
the Board of Health, but latterly the complaints became decidedly less frequent, although 
more refuse was burned, and I can only account for the falling off of the ' ' complaints ' ' on 180 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the assumption that noses, like palates, are susceptible to a vast deal of cultivation, and 
I believe, gentlemen, that if I had remained in that neighborhood long enough rents 
would have gone up-sure. About six months ago a member of the Franklin Institute 
called my attention to a patent furnace which, to use his vigorous language, would 
"burn up the very devil himself," and upon investigation, I found this furnace was 
constructed, theoretically, in such a manner as to secure absolute and perfect combus- 
tion, and I reasoned that a furnace that would burn wet sawdust and feathers without 
evolving smoke or odor, as was claimed, would burn the waste anatomical material which 
collected in my rooms, and without offence to any one. I wrote to the inventor, Mr. 
Gregory, and at my suggestion he built a furnace of convenient size, which in the 
course of time was placed in the lower dissecting room. I had about 800 pounds of 
refuse, mouldy, stinking, wet stuff, and after a fire was started Mr. Gregory had the 
furnace packed with the worst smelling and foulest of the offal, which was placed in 
strata alternating with sawdust and breeze, which is a waste dust or dirt from the 
coke works. As the dripping mass became heated a destructive distillation began, and 
gradually the consumption proceeded, shortly increasing at such a rate that I calculated 
the capacity of the furnace at not less than 500 pounds of offal a day. During all this 
time the magazine of the furnace was filled with dense smoke, but on top of the house, 
close to the chimney, neither smoke nor odor was perceived, and although we burned 
all the offal at my rooms, and sent to the Jefferson College for 300 pounds more, so as to 
fully and thoroughly test the furnace, no one in the neighborhood perceived the 
slightest odor or smoke, and we ourselves, conscious of the process in progress, could 
not perceive the faintest odor suggestive of the burning of putrid flesh. So much in 
proof of the practical application of the Gregory furnace to the uses of the dissecting 
room. 
One of my many visitors, during the experiments, said to me : " The only objection 
to this furnace that I can imagine is the cost of the fuel it must take." " Yes," I 
answered, " fuel is a costly article, but in this furnace, so far, we have used none, noth- 
ing but coke-yard dirt and sawdust," the cost of which for cremating eleven hundred 
pounds of offal, including wood and kindling, was just sixty cents. Now, let me 
describe this furnace and the principles of its construction, but premise what I have 
further to state by saying that I am in nowise interested in this furnace, except in the 
cause of science, and that I am not paid in any manner for bringing the invention to 
your notice. 
The great merit of this furnace is the only reason why I speak of it, and I predict 
that in a few years it will be used largely, not only to cremate dissecting-room offal, 
but also garbage, and, indeed, in a thousand different ways, in the arts. 
The furnace consists of two cases, one inside the other, and an air space between. 
Just as when we take two boxes, the one smaller than the other, and place the smaller 
within the larger, we have between them an air space. The fire is built in the inside 
box, and heats the air in the air space to an intense degree. At the back part of the 
furnace the inside box has a horizontal slot running the entire width of the furnace, so 
that the heated air can escape from the air space and mingle freely with the smoke and 
gases as they are about to pass out of the furnace. As this intensely heated air comes 
in contact with the smoke, etc., it at once combines with the unconsumed carbon, giv- 
ing an absolutely colorless flame, free from odor, proving, practically, that perfect com- 
bustion has occurred. In the experiments at the Philadelphia School of Anatomy, 
Mr. Gregory effected an arrangement by which the interior of the furnace could be 
seen, and the process of cremation watched, and what, therefore, I have described is 
not fancy, but fact. Of course, I have not given you the details of this furnace. These 
you can ascertain by sending to the Patent Office for specification No. 228,061, dated 
May 25th, 1880. The entire principle of the furnace may be stated to be the supply of SECTION VII ANATOMY. 
181 
superheated air to the partially consumed products or distillations formed during the 
combustion. The heat developed is prodigious-sufficient to melt ordinary fire brick, 
which, I believe liquefies at about 5000° F. A word concerning the ashes left in the pit of 
the furnace: They were carefully collected, and did not quite fill an ordinary wooden 
bucket. I am certain that if the draft of the furnace had been opened and the fire pushed, 
even less ashes would have remained. As the furnace can be readily used for heating pur- 
poses, the waste, as it is formed, day by day, can be gradually consumed, and from a 
strictly economic point of view, serves the purposes of a fuel. These are the advantages, 
gentlemen, I experienced in the use of this furnace : The destruction of my offal as 
soon as it was formed, and without annoyance to any one ; avoidance of expense of 
storage, handling and hauling ; hence, an absence of gases and exhalations, which ordi- 
narily are formed, and which menace the public health ; and, lastly, the economy of this 
plan, which need not be further enlarged upon ; and yet, gentlemen, with all these 
advantages-all these, I say-the successful management of a school of anatomy is not 
a poem. 
FROZEN SECTIONS OF MALE PELVIS, SHOWING THE RELATIONS 
OF THE PERITONEUM TO THE ABDOMINAL WALL, BLADDER 
AND RECTUM, WITH SPECIAL REFERENCE TO SUPRA- 
PUBIC CYSTOTOMY. 
SECTIONS GELÉES DU BASSIN MÂLE MONTRANT LES RAPPORTS DU PERITOINE 
A LA PAROI ABDOMINALE, A LA VESSIE, ET AU RECTUM, AVEC UNE 
ALLUSION SPECIALE A LA CYSTOTOMIE SUS-PUBIENNE. 
GEFRORENE DURCHSCHNITTE DES MÄNNLICHEN BECKENS, DIE BEZIEHUNGEN DES 
BAUCHFELLS ZU BAUCHWAND, BLASE UND MASTDARM DARLEGEND, MIT 
SPECIELLER HINSICHT AUF DEN HOHEN BLASENSCHNITT. 
ALBERT B. STRONG A.M., M.D., 
Demonstrater of Anatomy, Rush Medical College, Chicago, Ill. 
Mr. President and Gentlemen :-In performing supra-pubic cystotomy, to cut 
into the bladder without endangering the peritoneum or doing undue violence to the 
connective tissue back of the pubes, is the important part of the operation. Shall this 
be done with the bladder empty, or partially filled, either alone or in connection with 
a distended rectum, are questions upon which all are not yet fully agreed. 
For the purpose of investigating these mooted points, I have undertaken, with the 
assistance of medical student John S. Perckhan a series of experiments upon a number 
of cadavers. 
The results are shown in these drawings, which are made from photographs of frozen 
sections of the adult male. 
They represent the parts as enlarged to three times their natural size. 
Plate No. I represents a subject forty years of age, weighing 100 pounds. It shows 
the normal relation of the parts, the bladder and rectum being empty. Here we see 
the anterior peritoneal reflection is 1} inches below the crest of the symphysis pubis. 
Plate No. II represents a section of a subject forty years of age, weighing 140 pounds. 
It shows the bladder as empty and the rectum distended with 15 fluid ounces of plaster- 
of-Paris solution. Here we see the anterior peritoneal reflection is one inch below the 
crest of the symphysis pubis. 182 
ninth international medical congress. 
PLATE I-Peritoneal Reflection. 
PLATE IL-Peritoneal Reflection. SECTION VII ANATOMY. 
183 
Plate No. ill represents a section of a subject thirty-five years of age, weighing 110 
pounds. It shows the rectum as empty and the bladder distended with 10 fluid ounces 
of plaster-of-Paris solution. Here we see the anterior peritoneal reflection is one-fourth 
of an inch below the crest of the symphysis pubis. 
Plate No. IV represents a section of a subject forty years of age, weighing 140 
pounds. It shows the rectum as containing 15 and the bladder 10 fluid ounces of 
plaster-of-Paris solution. Here we see the anterior peritoneal reflection is seven-eighths 
of an inch above the crest of the symphysis pubis. 
You observe here this white line running across the bladder, in plates in and IV. 
This indicates the height to which the plaster-of-Paris solution of 10 ounces came. The 
space above contained air, which I think must have been there before the bladders were 
injected. 
Looking at these plates with reference to the relation the anterior peritoneal reflec- 
PLATE III.-Peritoneal Reflection. 
tion bears to the crest of the symphysis pubis, we observe in the normal condition of 
the parts, when the bladder and rectum are empty, it is 1} inches below ; when the 
bladder is empty and the rectum distended with 15 ounces, it is one inch below; when 
the rectum is empty and the bladder distended with 10 ounces, it is one-fourth of an 
inch below ; when the rectum is distended with 15 and the bladder with 10 ounces, 
it is seven-eighths of an inch above. 
Numerous experiments made upon many other subjects, treated without freezing, as 
is seen in each of these drawings, gives the same general results. 
After preparing each cadaver, two lines of investigations were followed. In the 
first, a small opening was made into the abdominal cavity and the parts examined by 
touch and sight. In the second, supra-pubic cystotomy was first made and the parts 
explored by abdominal section afterward. 
To give in detail one case under the first head will be sufficient to show in what 
manner our investigations were conducted. 184 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case No. IV.-Male, fifty years of age, weighing 150 pounds, dead 24 hours; bladder 
empty, rectum washed out, rubber bag placed in the bowel and gradually distended 
with 12 fluid ounces of water. Made a cut into the abdominal cavity in the median 
line below the navel, just large enough to admit the index finger. The anterior peri- 
toneal reflection was found to be at the crest of the symphysis pubis. The rectum was 
only moderately distended, filling up the floor and the posterior wall of the pelvis to 
within an inch of the promontory of the sacrum. Next, 12 fluid ounces of water was 
injected into the bladder, which caused it to rise upward nearly to the base of the 
sacrum, and forward against the abdominal wall, dragging the peritoneum with it to a 
height of three-quarters of an inch above the crest of the symphysis pubis. 
PLATE IV.-Peritoneal Reflection. 
Next the water was let out of the bladder, which immediately settled down until the 
peritoneum was even with the crest. 
Then the water in the rectal bag was increased from 12 to 18, then to 24 fluid ounces. 
In neither case was the anterior peritoneal fold elevated. 
All the fluid was contained in the rectum proper. It did not ascend to a higher 
point than one inch below the promontory of the sacrum. 
Next enlarged the abdominal opening and inspected the parts. Rectum very much 
distended; no rupture of its fibres. 
The following table gives a brief summary of this series of cases :- SECTION VII-ANATOMY. 
185 
TABLE NO. 1. 
Subject. 
Sex. 
Weight. 
No. of Fluid 
Ounces in 
Rectal Bag. 
No. of Fluid 
Ounces in 
Bladder. 
Relation of Anterior Peritoneal 
Reflection to the Crest of Sym- 
physis Pubis, in inches or frac- 
tions thereof. 
Relation of Upper 
Dilated End of Rec- 
tum to the Promon- 
tory of the Sacrum, 
by inch measure- 
ment. 
1 
F. 
112 
12 
10 
*4 below. 
44 
22 
10 
Even. 
2 below. 
44 
22 
22 
*4 above. 
2 below. 
2 
M. 
160 
12 
10 
Even. 
44 
12 
14 
2 above. 
4* 
0 
Air. 
3 above. 
3 
M. 
220 
15 
10 
4 above. 
44 
15 
16 
6 above. 
Even. 
•4 
18 
16 
6 above. 
2 above. 
4 
M. 
150 
12 
0 
Even. 
1 below. 
44 
12 
12 
% above. 
1 below. 
4< 
18 
0 
Even. 
1 below. 
44 
24 
0 
Even. 
1 below. 
5 
M. 
150 
6 
0 
*4 below. 
'4 
12 
0 
*4 below. 
Even. 
44 
18 
0 
*4 below. 
2 above. 
6 
M. 
150 
0 
12 
% below. 
44 
6 
12 
Even. 
4* 
12 
12 
Even. 
1 below. 
16 
12 
*4 above 
Even. 
44 
16 
15 
% above. 
44 
16 
21 
2 above. 
44 
0 
Air. 
2*4 above. 
44 
10 
10 
1 above. 
44 
10 
6 
% above. 
44 
10 
10 
1% above. 
7 
F. 
190 
0 
Air. 
1*4 above. 
S 
F. 
130 
12 
12 
1*4 above. 
*4 below. 
0 
Air. 
2*4 above. 
0 
12 
1*4 above. 
'4 
0 
18 
21 
M. 
125 
12 
0 
Even. 
*4 
15 
0 
2 above. 
44 
15 
12 
2*4 above. 
23 
0 
3 above ; burst rectum. 
In the second series of cases, supra-pubic cystotomy was first made and the parts 
examined afterward. 
The following case is offered in illustration : August 9th; subject No. 13; male, of 
good muscular development, forty years of age, weighing 160 pounds; bladder empty, 
rectum washed out. Injected 12 fluid ounces of water into the rectal bag and ten ounces 
into the bladder; made supra-pubic cystotomy without seeing or injuring the perito- 
neum, also without disturbing the space between the bladder and pubes. 
The manner of operating was as follows : Carried an incision from the crest of the 
pubes upward in the median line three inches; exposed the linea alba; cut between the 
pyramidales muscles; exposed the transversalis fascia; made a small nick into this oppo- 
site to the crest of the pubes, enlarged it upward an inch, put the end of the index 
finger into the wound and hooked up the underlying fatty tissue; a little scraping below 
the finger revealed the bluish appearing bladder. The apex of the bladder could be 
felt two and a half inches above the crest; the bladder was only moderately distended; 
easily picked it up with common dissecting forceps, made an incision, an inch in length, 
into the anterior surface; there escaped about one ounce of fluid; left index finger 
hooked into the bladder and felt its apex one inch above the upper end of the cut 
into it. 
The following table is a brief summary of the cases operated upon without seeing or 
injuring the peritoneum :- 186 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Subject. 
Sex. 
Age. 
Weight. 
Fluid Ounces 
in Rectal Bag. 
Fluid Ounces 
in Bladder. 
Relation of the Apex of the Bladder 
to the Crest of the Pubes, in 
inches and fractions thereof. 
9 
M. 
45 
160 
0 
10 
% below. 
10 
M. 
28 
150 
0 
0 
% below. 
11 
M. 
50 
175 
0 
Air; 103. 
above. 
1% above. 
12 
F. 
30 
110 
14 
8 
13 
M. 
40 
160 
12 
10 
2l/2 above. 
14 
M. 
25 
160 
0 
Air; 103. 
2 above. 
15 
M. 
35 
125 
12 
6 
above. 
22 
M. 
40 
160 
12 
8 
1 above. 
23 
F. 
50 
110 
15 
12 
3 above. 
24 
M. 
40 
120 
12 
8 
3 above. 
TABLE NO. 2. 
In the last table we give the relation of the apex of the bladder to the crest of the 
pubes, in the first the relation of the anterior peritoneal reflection to the same point. 
It must be remembered that the apex of the bladder and the peritoneal reflection are 
not always on the same level. In moderate distention of the bladder, the peritoneum 
passes down on its anterior surface a variable distance, depending upon the degree of 
distention and the firmness with which the bladder is pressed against the abdominal 
wall. 
When the apex of the bladder is two inches above the crest and the bladder pressed 
firmly against the abdominal wall, the peritoneal reflection is not more than three- 
quarters of an inch above the same point. 
With this degree of distention, however, the peritoneum is so loosely attached that 
it and its subjacent fatty layer can easily be slipped up without doing violence to either. 
Rectal Bag. 
The rectal bag used and which you see here, is made of pure rubber with rather 
thin walls. When empty it is six inches in length by two and a half inches in width. 
One end is somewhat rounded; to the other is attached, as part of it, a rubber tube 
twelve inches long, for convenience in filling. 
To introduce the bag, it is first oiled, then bunched together and folded over the index 
finger, when it is easily introduced just within the internal sphincter. A measured 
quantity of water is gradually and slowly injected with a bulb syringe. 
As the result of these investigations, the following conclusions are submitted:- 
I. In the normal condition, the bladder and rectum being empty, the apex of the 
bladder and the peritoneal reflection are a little above the arch of the pubes. 
II. In moderate distention of the bladder, the anterior peritoneal reflection is below 
the apex; with the same degree of distention, and the bladder pressed against the 
abdominal wall, the peritoneum ascends higher. 
in. Supra-pubic cystotomy can be most easily and safely performed when the blad- 
der is lifted from the pelvic floor and moderately distended against the abdominal 
wall. SECTION VII-ANATOMY. 
187 
IV. Distention of the rectum alone elevates the base of the empty bladder, but does 
not raise materially the vesico-abdominal fold of peritoneum. 
V. Distention of the bladder alone, in thin subjects particularly, requires relatively 
a greater amount of fluid to elevate the peritoneal reflection. The bladder is not 
crowded against the abdominal wall, but rather falls away from it. 
VI. Moderate distention of both rectum and bladder meets the indication the best; 
from ten to fifteen fluid ounces in the rectal bag, and eight to ten in the bladder is 
generally enough, and seems to be a safe quantity to use. 
VII. Dilatation of the rectum first and the bladder afterward lifts the peritoneal 
reflection the highest. 
Vin. The object of the rectal bag is to elevate the distended bladder and press it 
against the abdominal wall, and so crowd up the peritoneum. 
ix. To meet this indication, the gut should be dilated from the anus to near the 
promontory of the sacrum. 
X. The rectal bag should be sausage-shaped, of thin rubber, rather than pyriform 
and thick. For the thinness enables it to follow up the gut, and the shape makes uni- 
form pressure throughout the entire length. 
xi. In a very fleshy subject with a flabby and pendulous belly, the bladder is rela- 
tively freely movable. In such a case it will easily rise out of the pelvis against the 
abdominal wall, when alone distended •with a moderate quantity of water; the rectal 
bag may be safely dispensed with. 
xii. Air injected into the bladder of a subject lifts the bladder and its peritoneal 
reflection out of the pelvis better than water. (See Cases il, vu, XI and XIV.) 
xiil. In one case the gut was ruptured opposite the promontory of the sacrum, with 
twenty-three ounces in the rectal bag (Case xxi) ; in no case was the bladder ruptured. 
XIV. In the cases reported, twenty-four in number, an average of fourteen ounces 
in the rectal bag and twelve in the bladder elevated the anterior peritoneal reflection 
on an average of one and a half inches above the crest of the pubes ; the apex of the 
bladder was one inch higher. 
In twenty-five cases reported by Dr. Helmuth in his monograph on supra-pubic 
lithotomy, when the bladder alone was injected, the average quantity of water in each 
was twenty-seven ounces; the peritoneum was lifted two, and the apex of the bladder 
four inches above the crest of the pubes. 
In five of these cases rupture of the bladder occurred with an average of 59 fluid 
ounces. 
EXPERIMENTS. 
The first thing done with each subject was to empty the bladder and wash out the 
rectum. Water was used to distend the gut, by means of the rectal bag ; the bladder 
was directly injected; a bulb syringe was used. 
The relation of the anterior peritoneal reflection to the crest of the symphysis 
pubis is given by inches; also the relations of the upper end of the distended rectum to 
the promontory of the sacrum is given by the same measurement. 
The following are the cases operated on :- 
Subject No. i.-June 29th. Female, in good flesh, thirty years of age, weighing 
112 pounds. 
Experiment No. 1.-First injected 12 ounces into the rectal bag, then 10 ounces into 
the bladder. The peritoneal reflection was one-quarter of an inch below the crest; 
bladder only moderately distended. 
Experiment No. 2.-The amount of fluid in the bladder remaining the same, i.e., 10 
ounces, the fluid in rectal bag was increased from 12 to 22 ounces; the peritoneal reflec- 
tion was even with the crest; the upper end of the distended rectum was two inches 
below the promontory of the sacrum. 188 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Experiment No. 3.-The amount of fluid in rectal bag remaining the same, i.e., 22 
ounces, the fluid in the bladder was increased from 10 to 22 ounces; the peritoneal 
reflection was one-quarter of an inch above the crest; both bladder and rectum seemed 
to be distended to their utmost capacity. Neither viscus was ruptured. 
Notwithstanding the unsafe quantity of water in the rectal bag and bladder, 22 
ounces, the peritoneum was lifted only one-quarter of an inch. I think this is explained 
when we see that the rectum was not dilated upward beyond a point two inches below 
the promontory of the sacrum. The bladder bulged backward over the upper end of 
the rectal bag. 
The rectum was not dilated high enough to throw the bladder against the abdominal 
wall. It is not so much the lifting of the base of the bladder that is required, as 
throwing the whole bladder forward; a high dilatation of the rectum does this best. 
Subject No. ii.-June 29th. Male, negro, well-developed, weighing 160 pounds; 
dead 20 hours, from typhoid fever; abdomen considerably bloated and tympanitic; not 
due, however, to post-mortem change. 
Experiment No. 1.-First injected ten ounces into the bladder, then twelve ounces 
into the rectal bag. The peritoneal reflection was even with the crest. 
Experiment No. 2.-The fluid in the rectal bag remaining the same, i. e., twelve 
ounces, the fluid in the bladder was increased from 10 to 14 ounces; peritoneum 
elevated two inches. 
Experiment No. 3.-The bladder and rectum were both emptied, the rectum remain- 
ing empty; the bladder was distended moderately with air. Peritoneum elevated three 
inches. 
Subject No. III.-June 30th. Male, large, very fat, pendulous abdomen, 25 years of 
age, weighing 220 pounds; dead 24 hours. 
Experiment No. 1.-First injected 15 ounces into the rectal bag, then 10 ounces into 
the bladder. Peritoneum elevated four inches, bladder only slightly distended. 
Experiment No. 2.-The quantity of water in the rectal bag remaining the same, 
i. e., 15 ounces, water in the bladder increased from 10 to 16 ounces. Peritoneum 
elevated to the naval, bladder only moderately distended, rectum distended to the 
promontory of the sacrum. 
Experiment No. 3.-The water in the bladder remaining the same, i. e., 16 ounces, 
the water in the rectal bag was increased from 15 to 18 ounces. Rectum dilated to a 
point two inches above the promontory of the sacrum. Rectum not over distended ; no 
fibres ruptured. 
Subject No. iv.-July 12th. Male, 50 years of age, weighing 150 pounds ; dead 
24 hours. 
Experiment No. 1.-Injected 12 ounces into the rectal bag. Peritoneum even with 
the crest. Rectum moderately distended to one inch below the promontory of the 
sacrum. 
Experiment No. 2.-The rectal bag holding 12 ounces, 12 ounces were injected into 
the bladder. Peritoneum elevated three-quarters of an inch. 
• Experiment No. 3.-Bladder emptied; water in rectal bag increased from 12 to 18, 
then to 24 ounces; rectum very much distended up to a point one inch below the pro- 
montory of the sacrum. 
Subject No. v.-July 14th. Male, well developed, forty years of age, weighing 
150 pounds ; dead 24 hours. 
Experiment No. 1.-Injected first six, then 12, then 18 ounces into rectal bag; peri- 
toneum not materially changed in either case; when 12 ounces were in rectal bag the 
rectum was dilated to the promonotory of the sacrum ; when 18 ounces were in it was 
dilated to a point two inches beyond. 
No experiments were made on the bladder, owing to a stricture of the urethra. SECTION VII ANATOMY. 
189 
Subject No. vi.-July 21st. Male, forty years of age, weighing 150 pounds; dead 
36 hours. 
Experiment No. 1.-Injected 12 ounces into the bladder; moderately distended ; peri- 
toneal reflection one-quarter of an inch below crest. 
Experiment No. 2.-12 ounces remaining in the bladder ; six ounces were injected 
into the rectal bag. Peritoneum even with the crest ; six ounces more injected into the 
rectal bag does not materially change the peritoneum ; rectum distended to within one 
inch of the promontory of the sacrum. 
Experiment No. 3.-12 ounces remaining in the bladder ; the water in the rectal 
bag was increased from 12 to 16 ounces ; rectum distended to the promontory of the 
sacrum. Peritoneum elevated one-quarter of an inch above crest. 
Experiment No. J.-16 ounces remaining in the rectal bag ; water in bladder 
increased from 12 to 15 ounces. Peritoneum half an inch above crest. 
Experiment No. 5.-16 ounces remaining in the rectal bag ; water in bladder 
increased from 15 to 21 ounces. Peritoneum elevated two inches. 
Experiment No. 6.-Water let out of the rectal bag ; bladder with its 21 ounces 
sinks into the pelvic cavity. Peritoneum three-quarters of an inch above crest. 
Experiment No. 7.-Both bladder and rectum being empty, bladder was moderately 
distended with air. Peritoneum elevated two and one-quarter inches above crest. 
Experiment No. 8.-Rectum and bladder being empty, ten ounces were injected 
into rectal bag, which distended it to a point one inch below promontory of sacrum. 
No effect on the peritoneal reflection. 
Experiment No. 9.-Ten ounces remaining in the rectum, six ounces -were injected 
into the bladder. Peritoneum elevated three-quarters of an inch above crest ; water in 
bladder increased to ten ounces. Peritoneum elevated one and one-quarter inches. 
Subject No. vii.-July 21st. Female, very fleshy and flabby, with pendulous abdo- 
men, fifty years of age, weighing 190 pounds; dead 40 hours. 
Experiment No. 1.-Rectum empty; bladder moderately distended with air. Peri- 
toneum one and one-half inches above the crest; on attempting to squeeze the air out 
of the bladder through a small opening in the abdominal walls, the bladder was rup- 
tured. It had not been over-distended with air. 
Subject No. viii.-July 22d. Female, twenty years of age, 130 pounds weight, in 
good flesh ; accidentally killed 40 hours before. 
Experiment No. 1.-Injected 12 ounces into the rectal bag, also same amount into 
the bladder. Peritoneum elevated one and one-quarter inches above crest. Rectum 
distended to a point half an inch below promontory of sacrum. 
Experiment No. 2.-Bladder and rectum emptied; bladder distended with air till 
quite resistance was offered to the bulb of a Davidson's syringe. Apex of bladder within 
two inches of navel. Peritoneum lifted two and one-quarter inches above crest. Bladder 
not ruptured. 
Experiment No. 3.-Bladder and rectum emptied ; injected 12 ounces into the 
bladder. Peritoneum lifted one and one-half inches above crest. 
Experiment No. 4--Rectum empty ; 18 ounces injected into the bladder; elevates 
apex of bladder half way to navel ; 30 ounces brings it to %ithin one inch of navel. 
Bladder very tight, not ruptured at 36 ounces. 
Subject No. IX.-July 29th. Male, forty-five years of age, weight 160 pounds ; 
dead 36 hours. 
Experiment No. 1.-Rectum empty; bladder distended with ten ounces; made supra- 
pubic cystotomy without seeing or injuring peritoneum. Apex of bladder half an 
inch below crest; picked up apex of bladder with forceps; when incised there escaped 
not more than two drachms of fluid. Bladder very loosely distended. 190 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Subject No. x.-Aug. 5th. Male, twenty-eight years of age, weighing 150 
pounds; 20 hours dead. 
Experiment No. 1.-Bladder and rectum being empty, made supra-pubic cystotomy 
without seeing or injuring peritoneum; apex of bladder half an inch below crest. In 
operating the cellular tissue in front of the bladder was much more disturbed than 
if the bladder had been distended. 
Subject No. XI.-Aug. 8th. Male, fifty years of age; general anasarca; moderate 
ascites; weighing 175 pounds; fifteen hours dead. 
Experiment No. 1.-Injected into the bladder eight bulbs of air from a Davidson's 
syringe; moderate distention, equivalent to ten ounces of water; made supra-pubic 
cystotomy without seeing or injuring the peritoneum; apex of bladder two and a half 
inches above crest; peritoneum at least one inch above crest. Bladder very loosely 
distended. , 
Subject No. xii.-Aug. 9th. Female, thirty years of age, 110 pounds weight; 
dead 36 hours. 
Experiment No. 1.-Injected 14 ounces into rectal bag, also eight ounces into the 
bladder; made supra-pubic cystotomy without seeing or injuring the peritoneum; apex 
of the bladder one and a half inches above pubes and against the abdominal wall. 
Subject No. xiii.-Aug. 9th.-Male, of good muscular development, forty years of 
age, weighing 160 pounds. 
Experiment No. 1.-Injected 12 ounces into the rectal bag, also ten into the bladder; 
supra-pubic cystotomy in the usual way, without injuring the parts or seeing the peri- 
toneum ; apex of bladder two and a half inches above crest and against the abdominal 
wall ; rectum distended to within one inch of promontory of sacrum. 
Subject No. xiv.-Aug. 15th. Male, twenty-five years of age, good muscular 
development, weighing 160 pounds. 
Experiment No. 1.-Eight bulbs of air from a Davidson's syringe distends the rectal 
bag as much as ten ounces of water. Rectum empty; bladder distended with eight 
bulbs of air; apex of bladder rose two inches above the crest; made supra-pubic cyst- 
otomy without seeing or injuring the peritoneum. The bladder was only moderately 
distended, and opening it disturbed considerably the cellular tissue. Bladder not held 
against the abdominal wall. 
Subject No. xv.-Aug. 18th. Male, thirty-five years of age, rather small, but 
well-developed, weighing 125 pounds. 
Experiment No. 1.-Injected 12 ounces into rectal bag, and six into the bladder. 
Made supra-pubic cystotomy without seeing or injuring the peritoneum; apex of 
bladder two and a half inches above crest and against the abdominal wall; loosely dis- 
tended ; not more than half an ounce of water escaped when it was opened. No dis- 
turbance of the cellular tissue back of the pubes. 
Subject No. xvi.-July 2d. (See plate No. 1.) Male, thirty-five years of age. 
weighing 100 pounds ; bladder emptied ; rectum washed out ; put in the refrigerator 
of Rush Medical College. 
July 9th. Removed to tWe dissecting room, and made a vertical section with a saw; 
anterior peritoneal reflection one and a half inches below crest. 
Subject No. xvu.-July 8th. (See plate No. 3.) Male, thirty-five years of age, 
110 pounds; rectum washed out; bladder emptied; injected into the bladder ten fluid 
ounces of plaster-of-Paris solution and put in the refrigerator. 
July 25th. Made section; anterior peritoneal reflection half an inch below crest. 
Bladder not more than four-fifths full; air chamber above; air must have been there at 
time of injection. SECTION VII ANATOMY. 
191 
Subject No. xviii.-July 8th. (See plate No. 4.) Male, forty years of age, 140 
pounds weight; bladder emptied ; rectum washed out; injected into the rectal bag 15 
and into the bladder 10 fluid ounces of plaster-of-Paris solution; put in refrigerator. 
July 25th. Made section; anterior peritoneal reflection seven-eighths of an inch 
above crest of pubes. Air space above level of plaster. 
Subject No. xix.-July 11th. (See plate No. 2). Male, forty years of age, 140 
pounds weight. Bladder emptied ; rectum washed out ; injected 15 ounces of plaster- 
of-Paris solution into rectal bag; put in refrigerator. 
July 25th. Made section; anterior peritoneal reflection one inch below crest. 
Subject No. xx.-July 2d. Child, five years of age, 30 pounds weight. Bladder 
emptied; rectum washed out; put in a refrigerator. 
July 25th. Made section; anterior peritoneal reflection one-fourth of an inch below 
crest of symphysis pubis. 
Subject No. xxi.-Aug. 22d. Male, forty years of age, 125 pounds weight. 
Experiment No. 1.-Twelve ounces injected into the rectal bag; distended the rectum 
to promontory of sacrum; water increased to 15 ounces; rectum distended to a point two 
inches beyond the promontory of the sacrum. 
Experiment No. 3.-Fifteen ounces remaining in the rectal bag; six ounces were 
injected into the bladder; peritoneum even with the crest; water in the bladder 
increased to 12 ounces; peritoneum elevated two and a half inches. 
Experiment No. 3.-Water in bladder let out; water in rectal bag increased from 15 
to 23 ounces; rectum distended to a point three inches beyond the promontory of the 
sacrum; muscular fibres gave way in a longitudinal direction on each side of the medium 
line of the gut and opposite to the promontory of the sacrum. 
Subject No. xxii.-August 24th. Male, forty years of age, 160 pounds weight. 
Injected 12 ounces into the rectal bag and eight into the bladder; made a cut into the 
bladder without seeing or injuring the peritoneum. Apex of bladder one inch above 
crest ; rectum distended to the promontory of the sacrum. 
In this case had considerable trouble to keep the bag in the rectum, on account of 
the lax and distended anus. When 6 ounces of water were injected, the bag began to 
bulge from the anus, and came out altogether when eight ounces were in. Reintro- 
duced the bag and applied a compress to the perineum while twelve ounces were 
injected, then injected eight ounces into the bladder; when the bladder was exposed it 
was not distended, was very lax and fell away from the abdominal wall. It was 
opened with difficulty and considerable more laceration of the connective tissue back of 
the pubes than was necessary, had the bladder been comfortably filled and pressed 
against the abdominal wall. In the latter condition, as I have frequently observed, the 
bladder and abdominal wall are practically inseparable; the bladder lies at the bottom 
of the wound and bulges into it slightly; when the transversalis fascia is opened abso- 
lutely no separation of the connective tissue about the bladder is made in such a case. 
Let out the water from the bladder; increased the water in the rectal bag to twenty 
ounces, when the bag burst; the rent took place close to where the injecting pipe entered 
the bag; a round piece as large as the little finger nail was completely torn out; was 
holding a compress against the anus at the time, and there was considerable pressure 
felt in the syringe. I was trying to burst the gut; with one hand in the abdomen felt the 
large bowel distending two inches beyond the promontory of the sacrum. The gut was 
not ruptured. 
Subject No. xxiii. August 25th.-Female, fifty years of age, 110 pounds weight; 
dead five hours ; body yet warm. 
Injected fifteen ounces into the rectal bag and twelve ounces into the bladder; cut 
into the bladder without seeing or injuring the peritoneum ; apex of the bladder three 192 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
inches above crest; bladder only moderately distended; lays close against the abdominal 
wall; drew bladder into wound and opened it; there escaped not an ounce of water, 
showing the bladder was not much distended or pressed upon by the dilated rectum. 
Rectum distended to promontory of sacrum and against the arch of the pubes tight 
enough to prevent the water in the bladder from escaping at the urethra. When the 
water was let out of the bladder its base was easily explored with the index finger. 
It was not more than two inches below the cutaneous surface. 
Experiment No. 2.-Put the bag in the vagina and injected six ounces into it; this 
dilated the vagina completely, but would have had no effect on the distended bladder, 
I think, for the distention did not follow up the hollow of the sacrum ; the distention 
did not pass behind the bladder. 
Subject No. xxiv.-August 25th. Male, forty years of age, 120 pounds weight. 
Experiment No. 1.-Injected twelve ounces into the rectal bag and eight into the 
bladder; this caused a slight bulging of the bag from the anus, and the bladder stood 
up well defined ; there was considerable resistance felt in the syringe on filling the bag, 
but little or none on distending the bladder. Cut into the bladder; its apex was three 
inches above the crest; bladder lay close to abdominal wall and seemed to be fully dis- 
tended; on opening the transversalis fascia the bladder bulged into the wound; four 
ounces gushed out when the bladder was opened, showing the bladder had been tightly 
compressed ; rectum distended to promontory of sacrnm. 
ANATOMICAL AND SURGICAL CONSIDERATIONS OF THE SITE 
OF A URINARY FISTULE. 
CONSIDÉRATIONS ANATOMIQUES ET CIIIRURGIQUES DE L'EMPLACEMENT 
D'UNE FISTULE URINAIRE. 
ANATOMISCH-CHIRURGISCHE BETRACHTUNGEN DES SITZES DER HARNFISTEL. 
BY WM. C. WILE, M.D., 
Danbury, Conn. 
In presenting the following paper, I lay myself open to unavoidable criticism ; in 
one sense, it should have been brought within the province of surgery, yet it is not the 
surgeon's but the anatomist's knowledge I seek. These two, that is anatomy and 
surgery, are so closely allied that one is but the other applied ; and when the surgeon's 
skill fails to bring us to the desired goal, we seek the anatomist, and look for enlight- 
enment at the fountain head. So now, where so many differ, let us see if we can glean 
a thought to guide us into the proper path, from those who are so familiar with 
nature's construction. Knowing from experience what these requests portend, I have 
purposely curtailed my article to its utmost limits, hoping the time taken therefrom 
will be devoted to the discussion which may ensue, and sincerely hope that this 
exchange of thought may elaborate lasting results. 
The subject that I seek discussion on is the best site for the construction of an 
artificial urethra when the natural passage way has become impervious through the 
senile changes wrought in the prostatic surrounding of the canal, or occlusion superin- 
duced by malignant growths. I will illustrate the necessity of such a procedure by 
relating a characteristic case. SECTION VII-ANATOMY. 
193 
In the latter part of 1885 I was called to a man, seventy-seven years old, suffering 
from retention of urine. He had been an invalid for a long time, his condition being 
brought about by an enlarged prostate. Despite regular and systematic bougieing, the 
canal had continued slowly and progressively decreasing in calibre until the night 
before I saw him, when he could no longer use his catheter. I finally succeeded in 
introducing my smallest instrument, a number one, and, to my consternation, but the 
slightest amount of fluid escaped. I palpated the abdomen and found a tumor extend- 
ing almost to the umbilicus, which unquestionably was the bladder. A few stringy 
clots could be removed from the urethra, and I was loth to recognize the bladder being 
filled with coagulated blood. After considerable manipulation, which was negative in 
result in so far as draining any of the contents was concerned, I resorted to injections 
of hot water strongly impregnated with pepsin. This succeeded in rendering it soluble, 
and the bladder was finally emptied. It was the last time an instrument could be 
passed through the urethra, which eight or ten hours afterward, despite all medicinal 
treatment, had become absolutely impervious. 
The question now presented itself, What shall I do for the best interests of my 
patient ? There was an immediate need to be alleviated, and a futurity to be borne 
in mind ; suffering to be relieved and permanent benefit to be derived. A horse- 
hair, even, could no longer be passed. The viscus was again filled, and suffering was 
intense ; so great was the latter that I feared the patient might fulfill his threats of 
seeking immunity in death. After much thought, I decided, finally, on perineal sec- 
tion, deeming it best for the patient, despite his almost hopeless condition, and the 
gravity of the operation in one of such an advanced age, in whom all the signs of 
advanced senility were already so well marked, and who, among all the other unfavor- 
able symptoms, presented that grave one of atheromatously degenerated arteries. But 
before me shone the motto : He who risks nothing, will not gain. 
On the following day, with the assistance of my friend, Dr. J. J. Berry, of Ports- 
mouth, New Hampshire, I made a perineal section, without the use of a guide, at the 
left lateral lithotomy site. We cut down until reaching the vesical sphincter ; then 
introducing a dilator, we forcibly stretched the muscle to its utmost limits, hoping thus 
to gain a temporary paralysis, similar to that attained in stretching of the anal sphinc- 
ter, allowing the urine to dribble away, and ensuring the greatest amount of rest to the 
inflamed organ, and hoping that the pressure might exert a benign influence over the 
hypertrophied gland. 
I then made a transverse incision through the urethra, one inch above the superior 
angle of the wound, and dissected the canal out, from the division to its vesical attach- 
ment, dividing the gland and stitching the free end of the divided urethra to the sides 
of the wound. No untoward results were developed after the operation, which lasted 
nearly two hours. The patient fully recovered, the healing of the wound lasting about 
three weeks. The urine was retained in the bladder, and could only be emptied on the 
introduction of a silver female catheter ; the voluntary evacuation of the vesicle had 
passed entirely from will control. The man died just about one year subsequent to the 
operation, from pneumonia. 
The interference we practiced has caused me much thought. Many deem the 
operation inexpedient, owing to its gravity. But is the operation not less grave than 
the disease ? Can suffering be more intense than that superinduced by such an over- 
distended organ and its concomitant inflammatory state? Puncture or aspiration 
promise no lasting help. Were the procedure many times more dangerous than it is, 
I venture to say there would not be a single one of these poor sufferers who would not 
eagerly grasp after the doubtful hope of ulterior relief from their intense agony. 
When we reflect upon the enormous number who have, and will have, enlarged pros- 
tates, we can gain some idea of the relative importance of radical procedures. Yet, 
Vol. Ill-13 194 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
prevalent as the affection is, so divided are opinions as to its relief. Now, cannot the 
anatomist come to our aid, and say, This shall be the way, for it is the nearest 
approach we can attain to the normal condition ? 
I cannot but believe that we can yet arrive at a mode of operating in which the 
patient could obtain voluntary control over the contents of the bladder. The futility of 
this, if a section should be made in the normal state, can, of course, be understood ; but 
where hypertrophy of the gland has for a long time existed, we know what an enormous 
development the muscular coat attains. Now, cannot this be turned to account ? 
Pettigrew, in his exquisite dissections of the muscular fibres of the bladder and 
prostate, has shown how all the fibres are arranged in a figure-of-8 manner, in a long lon- 
gitudinal axis. They usually occupy seven strata and are normally imperfect. They 
become fused with each other, with corresponding or homogeneous fibres, and with 
fibres which are either superimposed or underlie them. The aggregation of these 
fibres toward the apex forms the sphincter vesicæ. Some of them are continued into 
the prostatic urethra, which may be regarded, therefore, as an anterior continuation of 
the bladder. The fibres of the cervix are traceable into the veru montanum, which he 
believes to act as a valve to the urethra, falling into the tube and obstructing it when 
the muscle of the bladder is not acting, and raised up so as to stand erect in the middle 
line, and allow the flow of the urine when the fibres contract. 
Is not this arrangement of the muscular element of the organ analogous to that of 
the uterus? We all know that in the gravid state of the latter, when the exciting 
cause is at hand-that is, fœtal maturity-an expulsive force is developed in the 
organ, which, to not a little extent, can be increased through the agency of the mother's 
will. Now, in the bladder, where hypertrophy and hyperplasia of the muscular element 
sometimes exists to the thickness of an inch, cannot the urethra be transplanted, or a 
new canal formed in such a manner that the control of the vesical contents be under 
the power of the will, which shall make this increased muscularity subservient to it? 
Unhappily, it was not attained in my operation, and, so far as I can ascertain, in no 
other ; but I firmly believe that it can yet be accomplished ; and I ask of you any aid 
that you can give me in arriving at this result. 
ON THE SURGICAL COLLATERAL BRANCHES OF THE MAIN 
ARTERIES. 
SUR LES BRANCHES COLLATÉRALES CHIRURGIQUES DES PRINCIPALES 
ARTÈRES. 
ÜBER DIE CHIRURGISCHEN COLLATERALEN ÄSTE DER HAUPTARTERIEN 
BY EDMOND SOUCHON, M. D., 
Professor of Anatomy and Clinical Surgery, Tulane University of Louisiana, New Orleans, La. 
It is a very remarkable anatomical fact that all the main arteries of the human 
body give off usually but a large collateral branch, which very often presents such 
importance in operative surgery or in surgical pathology, that I will call it the surgical 
branch of that artery. It is most commonly single, but in some few instances we find 
a principal branch and a smaller accessory branch. 
The type of such surgical collateral branch is represented by the deep femoral 
(Profunda). SECTION VII ANATOMY. 
195 
The branch, as a rule, originates from the deep portion of the artery, and is dis- 
tributed to the deeper parts. 
The surgical importance of this collateral branch is not so much because of its size 
when cut, but because it is mostly the great anastomotic medium by which the blood 
is carried to the parts beyond the main trunk when this has been ligated or when the 
circulation has been interrupted through it from any cause. It is, in fact, the safety 
branch of the circulation of the region beyond ; it is, indeed, a remarkable provision of 
nature, which thus insures the nutrition of the distant parts against accidents to the 
main channel. 
A thorough knowledge of these branches is most important in the following 
instances: 1. To properly manage primary and secondary arterial hemorrhages. 2. In 
treating primary and recurrent aneurisms by compression and ligature. A lack of 
the proper knowledge of this surgical branch may be the cause that a ligature for 
primary or secondary hemorrhages, and for primary or recurrent aneurisms, may be 
placed improperly and thus fail to cure the trouble ; it may also be the cause of serious 
operations being performed for recurrent aneurisms, especially such as ligature of a 
.still larger artery, or the extirpation of the sac, whereas the ligature of the surgical 
collateral branch would have effected a cure ; worse than that, death has been caused 
by secondary hemorrhage because the surgeon was ignorant of the important rôle which 
this surgical collateral branch plays. The files of the journals show many such cases. 
3. Also in treating wounds of the large surgical veins, where it sometimes becomes 
necessary, after ligating the wounded vein, to ligate also the main artery below the largest 
collateral, when the limb becomes swollen and blue to an alarming extent, thereby 
diminishing the supply of arterial blood, and equalizing the circulation of the limb. 
In those cases, if the point of ligation is not properly selected, gangrene may follow as 
the result of the arterial ligation itself. 4. The same remarks apply to cases where, 
from some cause or other, a venous hemorrhage cannot be arrested by the ordinary 
means and we must ligate the corresponding artery to arrest the bleeding. 
The most important practical points connected with this branch are the following :-• 
1. The gravity of the ligation of the main artery just above the point of origin of this 
■collateral branch, since the most important anastomotic channel is shut off also, hence, the 
■danger of gangrene. 
2. The great importance of always placing the ligature on the distal side of this col' 
lateral branch, unless it is decidedly impossible. 
3. The necessity in some cases to put a ligature around the collateral branch itself, to 
arrest secondary hemorrhage, or to overcome the return of pulsations in recurrent aneur- 
isms affecting the main artery. 
4. The surgeon should always bear in mind when operating on the main artery of a 
region or on the surgical collateral branch of this artery, that the ligature is not safe 
unless applied at least over one-third of an inch from the point of origin of the surgical col- 
lateral branch. If the ligature is placed on the main artery immediately above, near the 
origin of the collateral artery, the blood passing through the collateral circulation into 
the surgical branch, and thence into the main trunk, will prevent the formation of a 
•clot in the main artery between the ligature and the origin of the surgical branch, and 
the result will be secondary hemorrhage. The same result will follow if the ligature is 
placed on the main artery, beyond the point of origin of the surgical branch, but close to 
it, since the blood from the main artery into the surgical branch will also prevent the 
formation of clots. Again we will run great risk of secondary hemorrhage if we ligate 
the surgical branch too close to its point of origin, since the blood passing in a continuous 
stream will wash out the clots as fast as formed. 
We will now review the main arteries of the body and point out the surgical col- 
lateral branch connected with each and every one of them. In many cases the point 196 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
will be seen and recognized at once ; in others it may at first seem a little strained, but 
upon second thought it will be found that the law holds good all over. 
(A) arch of aorta and divisions. 
1. Truly, the surgical collateral branch of the arch of the aorta is the innominate 
artery. It is more frequently the seat of aneurism than either the first portions of the 
left carotid or the left subclavian ; it is by far more accessible than the first portion of 
the left subclavian ; it has been twice ligated successfully for aneurism of the second or 
third portions of the subclavian, whereas, the ligations of the first portion of the left 
subclavian have all failed. 
The accessory surgical branch here is the right carotid, and because of this it has to be 
ligated also in all cases of ligation of the innominate artery, to prevent the return of the 
blood through the circle of Willis. 
2. The common carotid and the internal carotid form really but one artery, and its sur- 
gical collateral branch is the external carotid. All the remarks made above apply with 
force to this artery. It is of the greatest importance whether the common carotid is 
ligated or the internal or the external. Any ligation applied to cut off the circulation 
of the external carotid will not accomplish its object unless one of two important points 
is attended to most carefully. We may apply the ligature at the bifurcation, but this 
unnecessarily deprives the brain of needed blood. It is therefore best to ligate the 
external carotid, but taking care to ligate at the same time the inferior thyroid, the 
lingual and also the facial if it is near by ; otherwise we will have secondary hemor- 
rhage, either because to avoid tying their branches the ligature should be placed too 
close to the common carotid, or, because if the ligature is applied on the external caro- 
tid at the requisite distance, the inferior thyroid or the lingual will be permeated by 
the current and will prevent the formation of clots. The cases of Dr. Wyeth, of New 
York show this conclusively. 
3. The surgical collateral branch of the external carotid itself is the occipital artery, 
on account of its descending cervical branch which anastomoses with the ascending cer- 
vical branch of the superior intercostal, from the subclavian. This anastomose is second 
in importance to the vertebral in bringing the blood back into an aneurismal sac of the 
third portion of the subclavian artery. 
4. The surgical collateral branches of the internal carotid are the anterior and posterior 
communicating branches ; although they are beyond the reach of the surgeon they play 
such an important part in the surgical pathology of primary and secondary hemorrhages 
and in the return of pulsations in aneurisms, that we must count them among the most 
important collateral surgical branches of the body. 
5. The true surgical collateral branch of the sw&càman artery is unquestionably the 
vertebral artery, because of its size and because of its free anastomoses through the circle 
of Willis, with its fellow, by means of the basilar artery, and with the internal carotid 
through the posterior cerebral and the posterior communicating arteries. 
Clinical experience teaches this most beautifully in the now historical case of the 
man Banks. Secondary hemorrhage having occurred it was arrested and the patient 
practically cured only after the ligation of the vertebral artery. Surgeons are almost 
all so fully impressed with this now that ligation of the vertebral should be performed 
at the same sitting as that of the innominate and of the common carotid if we wish to 
surely cure an aneurism of the third portion of the subclavian. 
Banks was operated on here in 1861, by Dr. A. W. Smith, of this city. This case is 
so instructive that although well known, I will recall its main features. The aneurism 
affected the third portion of the right subclavian ; it was traumatic ; it was of the size 
of a duck's egg. The innominate and the right carotid were ligated with some effect, 
but a few days afterward secondary hemorrhage from the distal end occurred, neces- SECTION VII-ANATOMY. 
197 
sitating the ligation of the vertebral artery. This practically cured the aneurism, 
though there still remained there a pulsating spot no larger than a pigeon's egg. The 
patient remained in this condition for ten years, when having taken to house painting, 
he used his right arm altogether ; this started the tumor to grow again, and he came 
back to Dr. Smyth at the Charity Hospital. The internal mammary was ligated with- 
out any effect. The sac became inflamed, and as it threatened to rupture, it was opened 
and the cavity plugged tightly ; the patient died a few days afterward, of exhaustion 
from loss of blood. The body was dissected by myself, and my report to Dr. Smyth 
published in the New Orleans Medical and Surgical Journal. It was found that the 
innominate, the carotid and the vertebral and mammary were reduced to membranous 
cords ; none of the other branches of the subclavian were perceptibly larger, but the 
perforating branches of the aortic intercostals and the branches of the subscapular were 
much enlarged. 
The internal mammary plays no important part in the surgical pathology of aneurism 
of the subclavian artery. It was ligated by Dr. Smyth in the case of Banks, and it had 
no decidedly perceptible effect on the aneurism. I would say as much of the superior 
intercostal, in spite of its ascending branch anastomosing freely with the occipital, as it 
was not found enlarged upon dissecting the body of Banks. 
The same remarks apply to the other branches of the subclavian artery. 
6. The surgical collateral branch of the axillary artery is the subscapular. It was 
through the anastomoses of this artery with the perforating intercostals from the aorta 
that the blood was carried back into the sac in the ever-so-instructive case of Banks. 
These anastomoses were numerous and large. Dr. Smyth and myself had, of course, 
thought of them as being the channels through which the right arm was nourished, but 
we had never thought that upon striking the axillary artery the blood would divide and 
send a retrograde current back toward the heart into the aneurism. 
Had we ligated the axillary artery above the origin of the subscapular artery, between 
that origin and the sac, it is my firm belief that Banks would have been saved a third 
time and cured permanently. It is important to remember that it would not be proper 
in such cases to ligate the subscapular itself, nor to ligate the axillary below the origin of 
the subscapular, since either procedure would cut off the most important source of sup- 
ply to the arm, and would very likely be followed by gangrene. 
The posterior circumflex may be considered here as the accessory surgical branch of 
the axillary. 
7. The surgical collateral branch of the brachial artery is the superior deep brachial 
(Profunda). Its analogy with the deep femoral is striking. 
The accessory branch is the great anastomotic which insures the collateral circulation 
on the inside of the elbow by anastomosing with the recurrent ulnar and interosseous, 
as the deep brachial insures it on the outside by anastomosing with the recurrent radial. 
8. The surgical collateral branch of the radial artery is the recurrent radial. Its acces- 
sory surgical branch is the v< lar branch to the superficial palmar arch. 
9. The surgical collateral branch of the ulnar artery is the interosseous, because of its 
anastomosis above through its recurrent branch with the great anastomotor, and below 
with the anterior and posterior carpal arteries from the radial and ulna; it is through 
tli is last anastomose mainly that the blood reaches the hand when both the radial and 
tiie ulnar have been ligated in their course. 
10. The accessory surgical branch of the ulnar artery is the deep anastomotic branch 
to the deep palmar arch. 
(b) thoracic aorta. 
11. The surgical branches of the thoracic aorta are the intercostal arteries, because of 
the important part their anastomoses with the subscapular artery play in the surgical 
pathology of subclavian aneurisms, as explained above. 198 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
12. Truly the surgical branch of the abdominal aorta is the cœliac axis, not so much 
on account of its size, since the renal arteries are larger, but because of its anastomoses 
with the superior mesenteric artery. 
13. The only other branches which might play a rôle are the middle sacral and the 
lumbar arteries. 
(d) the iliacs and divisions. 
The arteries of the lower extremities present points which are the analogues of those 
of the upper extremities. 
14. The common iliac and the external iliac form really but one artery, as the common 
and internal carotids. And just as we find that the external carotid is the true surgical 
collateral branch of the carotids, here we find that the true surgical collateral branch 
of the common and external iliacs is the internal iliac. And again, just as we find the 
occipital and its descending cervical branch to be the accessory surgical branch of the 
external iliac, we find that the accessory branch is represented by the ischiatic artery 
because of its anastomoses with the branches of the deep femoral. 
15. The surgical collateral branch of the femoral artery is the deep femoral or pro- 
funda, on account of its anastomoses above with the ischiatic from the internal iliac, 
and below with the articular arteries from the popliteal. It is the typical surgical col- 
lateral branch. It corresponds to the deep brachial in the upper extremity. The 
femoral artery possesses an accessory surgical collateral branch, which is the great anas- 
tomotic. 
16. The surgical collateral branch of the popliteal artery is the anterior tibial, because 
of its anastomoses above, through its recurrent branch, with the articular arteries and 
great anastomotic, and below, through the perforating artery, with the external plantar 
and posterior tibial and the anterior terminal division of the peroneal. It corresponds 
to the interosseous artery with its recurrent branch of the forearm, and plays just as 
important a part in the surgical pathology of the region. 
The following case, reported in the New Orleans Medical and Surgical Journal (1885) r 
by Dr. David Jamison, then Assistant House Surgeon of the Charity Hospital, demon- 
strates this conclusively :- 
"G..B. Narcisse, age twenty-eight years, was admitted into ward 2, August 28th T 
1884. His trouble was a large pulsating tumor on the inner aspect of the right leg, 
about three inches from the knee joint. He received a gunshot wound in the leg two 
years before admission. The tumor made its appearance eighteen months after the 
injury. Aftercareful examination, the diagnosis of ' traumatic aneurism of the ante- 
rior or posterior tibial artery ' was recorded. On September 6th the man was brought 
under the influence of chloroform and a ligature placed around the popliteal artery. 
Pulsation in the tumor immediately ceased ; the wound healed kindly and was com- 
pletely closed by October 1st. Pulsation, however, returned in the tumor in two 
weeks after the ligation of the popliteal, and the tumor commenced again enlarging. 
As the patient suffered a good deal of pain, another effort was made to relieve him. 
Concluding that the collateral circulation had been established through the posterior 
tibial, a ligature was placed on this artery beyond the aneurism. No difference was 
noticed in the tumor. It pulsated as before, and by actual measurement was larger 
and firmer. One week later his condition had not improved. His pains were sharp 
and laminating. The lymphatics in the groin were enlarged and the feet cedematous. 
Large anastomotic vessels were found running into the tumor, which continued slowly 
to increase. The tumor was now examined by Dr. A. W. Smyth, who said that it was 
being supplied through the anterior tibial, and on his suggestion this artery was ligated 
on the distal side. The pulsation in the tumor immediately ceased. For a long time 
(c) ABDOMINAL AORTA. SECTION VII ANATOMY. 
199 
it grew no smaller, but gradually the patient's condition improved, and six months later 
he was discharged from the hospital entirely cured. 
"The instructing feature in this case is the ligation of an artery carrying a retro- 
grade or collateral current of blood to a recurrent aneurism, after the ligation of the 
artery on the proximal or cardiac side had failed to effect a cure. We believe this is 
the only instance in which ligature of the branch carrying the collateral circulation to 
a recurrent aneurism has been successfully practiced." 
17. The surgical collateral branch of the posterior tibial is the peroneal artery, because 
of the anastomoses through its anterior terminal branch with the tarsal arteries from 
the dorsal artery and anterior tibial. It was evidently through this anastomose that 
the blood found its way into the aneurismal sac in the case of the man Narcisse. 
ANATOMICAL POINTS OF VALUE IN DIAGNOSIS AND TREAT- 
MENT OF SOME JOINT AFFECTIONS. 
POINTS ANATOMIQUES DE VALEUR DANS LE DIAGNOSTIQUE ET LE TRAITE- 
MENT DE QUELQUES AFFECTIONS ARTICULAIRES. 
WERTHVOLLE ANATOMISCHE PUNKTE IN DER DIAGNOSE UND BEHANDLUNG EINIGER 
GE LENKK RANK HEITEN. 
BY M. STAMM, M. D., 
Fremont, Ohio. 
In preparing this paper it was not my object to present anything new, but simply to 
collect some scattered facts and arrange them in a manner as they may bear upon the 
diagnosis and treatment of some joint affections. The improvement of late years in 
our methods of treating chronic inflammatory affections of the joints, is of sufficient 
interest, on such a momentous occasion, where the medical profession is represented by 
its best minds, and where the light of their experience may be brought to a focus, to call 
out a discussion and receive the various opinions as to our best measures. I consider it 
of value to speak of the most prominent anatomical points which contribute to our 
diagnosis, and naturally serve as a valuable guide in our treatment. I trust I will not 
meet with too violent an opposition before this enlightened audience, if I designate 
them as chronic forms, which by some authors are described as " fungus articuli," by 
the term " tuberculosis " of the joints. Recent investigations, at least, have accumu- 
lated valuable evidence which will tend to strengthen this view; and among modern 
surgeons there seems to be-a growing disposition to adopt this name. I might farther 
state, that I am not ignorant of the fact that there are some other forms of acute and 
chronic joint affections, as a result of infectious diseases, i. e., measles, scarlatina, 
rheumatism or syphilis. But, as their history generally enables us to make a correct 
diagnosis, and as their treatment differs very little from the one to be described in this 
paper, I did not deem it of sufficient importance to speak of them in a special way 
here. As each joint presents some anatomical features of its own, which naturally 
influence our views in regard to diagnosis and treatment, it may be best to treat of each 
one separately. It was my intention to speak of all the joints of the upper and lower 
extremities, but as this would exceed the allotted space, I have only chosen the hip, 
knee and ankle joints. 200 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
COXITIS, OR TUBERCULOSIS OF THE HIP JOINT. 
It is of some practical value to divide this affection into three stages. We notice 
first a certain fixity of the joint, and in the erect position of the patient the suspected 
limb has a tendency to slight abduction and flexion at the knee and hip joint, but the 
feet stand parallel with each other. The gluteal region becomes flattened and the 
gluteo-femoral crease is lower and not as deep as on the healthy side. We should not 
forget to test the rigidity or mobility of the joint, at least of some muscles, i. e., the 
psoas magnus, iliacus internus or the adductors. For this purpose the patient should 
be placed on the table and laid flat upon his back, care being taken that the whole spine is 
brought upon the plane, which can be done by lifting both thighs in placing your arm 
under them. To make sure that the pelvis and trunk are at right angles with each other, 
we may draw a line from the centre of the sternum over the umbilicus to the centre of 
the pubis, this is then crossed at a right angle by a line drawn from one anterior superior 
spinous process of the ilium to the one on the other side. In health the limb can be 
brought down so that the popliteal region will touch the plane without lifting the 
spinous process or upsetting the relation of the lines. We are also able to flex the 
limb to such an extent as to touch the chest with the knee without raising the pelvis; 
any impediment in this direction should, therefore, excite some suspicion in our mind. 
In disease we find adduction also very much limited, so that the patient is not able to 
cross the affected limb over the sound one without moving the pelvis. There is a little 
more scope in abduction if the limb is slightly flexed and rotated outward. Pain is 
occasionally felt at the outside of the ilium, sometimes at a spot in front, or the inner 
aspect of the thigh, a little below the apex of Scarpa's triangle. Offener, however, 
we have a pain near the inner condyle of the knee, or over the whole joint. Various 
explanations as to the cause of this pain have been furnished, of which only the one 
ascribing it to irritation of a small branch of the obturator nerve in the vicinity of the 
ligamentum teres, can give us some sound anatomical reasons. A few years ago 
an explanation was offered by Fick, which, if for no other purpose, deserves notice, at 
least for its ingenuity and the originality of his observations. He made the deduc- 
tion that the pain exists in the hip joint, but was erroneously projected to the knee. 
In asking a number of persons, who had no knowledge of anatomy, as to the joint 
that was mainly used in walking, he was almost invariably referred to the knee joint. 
In this way, he thinks, some ground is furnished for locating the pain in this joint. 
We should not forget, however, that this pain of the knee may also be felt in other 
affections besides that of the hip joint, as i. e., caries of the lumbar vertebra, inflam- 
mation of the sacro-iliac joint, abscess within the pelvis or Scarpa's triangle. It, there- 
fore, has value only in combination with other symptoms. The severe pain, which will 
startle the patient from his sleep, is undoubtedly due to the sudden contraction of the 
muscles surrounding the joint, pressing the articular surfaces together. 
Second Stage.-At this time we have apparent lengthening of the limb, the foot is 
everted in the erect position, the knee is bent and held a little in front of the sound 
leg. We find the lumbar side curved toward the affected side; the pelvis is also lowered 
on the same side, and this is what simulates the apparent lengthening. If you tell the 
patient to keep the knees straight and the feet together, he will either bend the knee, 
or get on the toes of the sound limb, throwing back the diseased side of the pelvis and 
protruding the buttock. Abduction, flexion and rotation outward of the limb, which 
are generally a well-marked sign of the second stage, are at times also found in inflam- 
matory processes outside the joint, i. e., in front of the joint, in swelling of the glands 
or some other periarticular abscess, also abscesses in the region of the psoas or iliac 
muscles. But we generally have no great difficulty in making a correct diagnosis 
between these conditions and coxitis, except in cases of psoas or iliac abscess. Abduc- 
tion and rotation outward in these cases, it is true, do not reach a very high degree, but SECTION VII ANATOMY. 
201 
we also meet cases of coxitis where these abnormal positions are not very pronounced. 
We may, therefore, be somewhat in doubt at the beginning, especially as long as we 
have no other signs of vertebral affection. We know of only one means under such 
circumstances which will assist ns in excluding coxitis. In psoitis an insurmountable 
resistance is only felt in the attempt at straightening the limb, and the movement of the 
corresponding extremity is only limited in the abnormal position. If you bend the 
limb further you will find flexion, and within this position of stronger flexion nearly 
always rotation and lateral movement comparatively free. This examination should, 
of course, be made gently. Pain is often felt on pressure in front or behind the head 
of the femur or upon the trochanter. We should also mark the swelling, especially at 
the front part of the joint, neck of the femur, or at the trochanter. Tumefaction below 
the great trochanter, to the outside, is not well defined ; as its consistency is not differ- 
ent from the rest of the limb, it appears as a simple increase in size. It indicates 
extensive disease of the neck near the epiphysis. The iliac fossa should also enter into 
our field of examination. It is best to place patient on his back, or slightly turn him 
to the sound side, with the knees drawn up and the shoulders supported by a pillow. 
Standing on the affected side, place your flat hand and fingers inside the iliac spines; 
press the bowels gently over toward the middle line ; after your hand has pushed on 
deep enough toward the sacrum its palm should be turned outward, and you will get 
an opportunity to examine the iliac fossa and brim of the pelvis. Examination through 
the rectum will often detect swelling where the acetabulum is affected. Wasting of 
the muscles is also well marked, the gluteal muscles are flabby and the fold of the 
nates is found obliterated. 
The Third Stage is the one of adduction or shortening; it is also combined with 
rotation inward and flexion. Swelling (para-articular) is considerable, especially at the 
contour of the joint as far as the trochanter, so that its point is not distinctly felt. We 
find the trochanter, in osteomyelitis or circumscribed necrosis, at times enlarged. If 
suppuration perforates the iliac bursa, we will have fluctuating swelling at the anterior 
surface. Not unfrequently we may find perforation above the trochanter minor, at the 
lower edge of the obturator externus, and matter will sink along the adductor muscles. 
Fistulæ below the trochanteric region will indicate an osteal process in the trochanter 
or femoral neck. Perforation may in rare cases occur posteriorly upon the edge of the 
acetabulum. We there detect a hardness and thickened condition of the ilium, 
evidence of inflammatory irritation of the periosteum produced by disease of the 
acetabulum. Of a very grave nature are abscesses caused by perforation of the aceta- 
bulum into the pelvis. They may burrow into the small pelvis toward the perineum 
or posterior part of the thigh down to the knee, at times toward the rectum. Abscesses 
of the rectum may also have their origin from the lower posterior part of the aceta- 
bulum. It is quite difficult to recognize an osteal focus before it breaks through into 
the joint. A very grateful task it generally is to remove a depot from the head or neck 
of the femur which will perforate near the great trochanter. We there find an abscess 
or only a soft spot, or a groove upon the bone; in such a case it is well to follow up the 
tract with chisel or scoop. Occasionally we may succeed in tracing a focus to the 
acetabulum and in removing it from there. As an example, circumscribed abscesses 
may present at the posterior rim of the acetabulum, or a focus in the region of the 
inferior spinous process may produce an abscess at the outside of the thigh, below Pou- 
part's ligament, with slight coxitic symptoms. Although such centres are not of 
frequent occurrence, they have repeatedly been removed and the integrity of the joint 
saved. At such a stage we may have spontaneous luxation of the joint, mostly pro- 
duced by the filling up of the acetabulum with granulations, and by destruction of the 
ligamentum teres. Where this real luxation exists, we may suspect an osteal process of 
the acetabulum. Nélaton's line, which is a line drawn from the anterior superior iliac 202 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
spine to the most prominent part of the tuber ischii, will enable us to estimate the 
amount of dislocation. In the normal position the trochanter j ust touches this line, 
whereas in dislocation it will either be found above or below it. Bryant's method of 
examination, which consists in drawing lines horizontally outward from the iliac spines, 
and from which you then may measure the vertical distances to the trochanters on 
both sides, may also be employed. The femoral head may be partly or totally absorbed; 
the acetabulum also enlarged by absorption, so that the trochanter travels upward; in 
this way we may also have the appearance of dislocation. A very instructive case, 
reported by Volkmann some years ago, should find mention in this connection, 
because of its difficult diagnosis. In this case the femur had been affected from the 
neck down to the knee, and it was bent near the hip in the shape of an ?, so that the 
ligamentum teres was about two and a third inches below the summit of the tro- 
chanter. The limb was considerably shortened, adducted and rotated inward. The 
joint, under anæsthesia, was slightly movable, with no crepitation, and post-mortem 
examination found it intact No doubt the femur was in a softened condition at the 
time when the osteomyelitis had reached its acutest stage, from which resulted its 
twisted shape. If diagnosis had been possible in time, amputation probably might 
have saved this patient. 
Treatment.-The first thing besides rest is certainly correction of any abnormal 
position, and in this regard the anatomical points mentioned above should be our 
special guide. Plaster-of-Paris bandage or extension with weight and pulley are at 
first our best measures. After a while Taylor's or Thomas' splint, also Hutchinson's 
plan (high-soled shoe on the sound limb with a pair of crutches) may be used to great 
advantage. In a few of my cases they have given quite satisfactory results, and other 
surgeons seem to be equally well pleased. With Hutchinson's method, however, I 
have found it of advantage to use extension at night, to prevent any return of muscular 
contraction. Small abscesses may, in the milder forms of coxitis, be treated expectantly ; 
if they, however, get larger, their opening should be advised. An undoubted case of 
pelvic abscess will necessitate resection to give free exit to the matter, and besides that 
an incision near the anterior superior spinous process should be added, to clean out the 
cavity. Multiple abscesses, with fluctuation in front and behind the joint, demand 
resection, as well as fistulæ, which have no tendency to heal after the abscess has been 
opened. The experience of some surgeons leads to the opinion that in about half the 
cases the acetabulum is the starting point of tuberculosis. Abscess or fistulæ of the 
trochanter should, as already mentioned, be laid open and cleaned out with chisel or 
spoon; some surgeons praise thermo-cautery very highly. This treatment is also 
applicable in case of abscess or fistulæ at the edge of the acetabulum. Some localized 
focus may be found at the upper part of the acetabulum near the anterior inferior 
spine; it may reveal itself as a cheesy tumor or abscess below Poupart's ligament, a 
little to the outside. Operations of a similar kind have been performed in this locality 
and a cure accomplished without interfering with the integrity of the joint. These 
localized processes are, however, not so frequently found alone, since in most cases they 
are running along with a deeper destruction of the joint, so that resection of the femur 
will have to be resorted to. A probable diagnosis of this condition is gained by the 
pain resulting from movement of the joint, or a slight push or blow upon the 
straightened extremity, especially where symptoms of coxitis have existed before. 
Spontaneous luxation leaves very little doubt of osteal coxitis, principally of the cotyloid 
region. In the majority of cases we have the iliac form of luxation, or then the head 
is found in front of the acetabulum; even if in these instances no abscess exist, resection 
will generally be called for. We not unfrequently see neglected cases with severe con- 
tracture; as long as they are without abscess or fistula an attempt should be made to 
reduce it, either with weight or under anæsthetics. Should these means not succeed SECTION VII ANATOMY. 
203 
and unmistakable signs of destruction of the joint exist, resection with the chisel 
should be given preference to sub-trochanteric osteotomy. It need not be stated that 
resection is more urgent where fistulæ and abscesses accompany the former condition. 
Langenbeck's incision seems to answer best in most of the cases. This is made in a 
line from the superior anterior spine to the middle of the trochanter, in one stroke down 
to the bone. In this way the capsule is opened and we get directly down to the head 
and neck of the femur. After having nipped the cotyloid ligament (limbus cartilagi- 
nous), divide the muscles in front of the trochanter with the knife, which is rendered 
easier by pushing the index finger under them and rotating the thigh outward. For 
the muscles behind the trochanter, repeat the same act with rotation inward. After 
some traction and slight adduction of the leg, cut the ligamentum teres and then remove 
the head and neck below the trochanter. Sayre's method has also a number of advo- 
cates. He enters the knife about midway between the anterior superior spinous process- 
and the point of the great trochanter right down to the bone. Keeping it there firmly, 
he draws it in a curved line to the top of the trochanter between its centre and posterior 
border, thence forward and inward. Ollier makes a somewhat similar incision; not 
curved, however, but forming an obtuse angle, which begins four finger-breadths below 
the crest of the ilium, and the same distance behind the anterior superior spinous pro- 
cess, running down to the summit of the trochanter and from there directly down tö 
the shaft. Neuber makes a curved incision down to the bone, forming a semicircle 
around the great trochanter. The summit of the trochanter is sawed off obliquely. 
This, together with the flap, is separated from the femoral neck and the edge of the 
acetabulum and turned upward. The projecting edge of the acetabulum is then chiseled 
off, the neck luxated and removed with the saw. After this the femur is placed firmly 
into the acetabulum, the trochanter fixed with nails to its former point of attachment, 
and the upper part of the wound is united with sutures, leaving the lower part open, 
which affords natural drainage. The advantage claimed for this operation seems to be 
that the diseased parts can be readily inspected and removed with ease. So far not 
much is known about the functional result. A method described by Koenig a few years 
ago, and tried in a number of cases, is gaining very much favor with some surgeons. 
Koenig, after having made an incision similar to Langenbeck's, does not separate the 
muscles from the trochanter with the knife, but he breaks off with the chisel the anterior 
and also the posterior part of the trochanter, leaving these parts and also the muscles 
loosely in contact with the shaft. This procedure will leave a small zone of the tro- 
chanter, which is now obliquely chiseled off. This gives better access to the neck and 
the joint, and we can! now get in with a fine saw and separate the neck. Some difficulty 
may be found in removing the head. This can, however, be facilitated by a scoop- 
shaped elevator designed by one of Koenig's assistants. Should we suspect mis- 
chief in the acetabulum, it will be well to remove a piece of its posterior aspect, so 
that we can fully oversee the ground and remove whatever is diseased. After the 
affected bony parts have been removed, the diseased synovialis should share the same 
fate. A pair of strong scissors, of some length, will be very convenient in removing 
most of its parts, except, perhaps, a pocket near the small trochanter, which will yield 
to the sharp spoon. Roser's incision at the anterior sidd of the joint begins close to the 
outside of the crural nerve and divides the rectus femoris, sartorius, tensor fascia lata, 
etc. Luecke and Schede have modified this by making a vertical instead of transverse 
incision outside the crural nerve, beginning a little below and to the inner side of the 
anterior superior spine of the ilium and running directly downward. Volkmann con- 
siders it a practical way for enlarging fistulæ situated in front of the joint, for the pur- 
pose of scooping out the joint with the sharp spoon, or for the extraction of the sepa- 
rated head of the femur, etc. For the purpose of resection it seems to be a less expe- 
dient method. 204 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
KNEE JOINT. 
According to some authors the synovialis of this joint seems to be offener affected 
than the bony structures. In some rare cases we have what is now called "hydrops 
tuberculosis," which seems to have almost its exclusive seat at the knee joint. Ana- 
tomically, there is no diagnostic difference between this form and a serous synovitis. 
The natural depressions at the sides of the patella and its ligament are filled in by the 
exudation in a similar manner as in the latter instance. The swelling will reach about 
three fingers wide above the patella, and even the bursa supra-genualis, situated under 
the rectus femoris, becomes filled up. The patella will float as upon a water bed, and 
on pressure will dip upon the femoral condyles. If there is only a small quantity of 
fluid present we may compress the joint from above, so as to get the fluid under the 
patella ; on pressure, then, we get the same sign of ballottement. In many cases we have 
the granulating form of synovitis without suppuration as long as the knee is protected 
from severe injury. This granulation is more pronounced at the folds of the capsule, 
near its insertion to the sides of the condyles and patella. Fluctuation is seldom 
present, and if so, very slight in comparison to the swelling. The contour of the 
patella, as well as of the condyles, becomes obliterated; the anterior aspect of the joint 
is globular. The swelling is somewhat characteristic, at least it distinguishes itself 
from the one caused by serous exudation into the joint. In the latter form the syno- 
vial sac is more distended near the upper recessus, whereas in the granulating synovitis 
the swelling is more in the region of the condyles, at the joint line on both sides of the 
ligamentum patellae. There the granulations, as they increase, cause the sub-synovial 
fat to bulge outward, and, as the swelling gradually lessens toward the upper and lower 
region of the joint, the knee assumes a spindle shape. Abscesses are at times localized 
near the upper recessus, and, when found at the anterior margin of the tibia or at the 
lateral surfaces of the condyles, they point to an osteal focus. Contractures are found 
not only in a position remaining within physiological limits, but also in the most abnor- 
mal attitude, which only destruction of the joint would admit. Complete luxations 
are very seldom found, more often, however, sub-luxations. Genu valgum is the prin- 
cipal deformity, probably owing to constant pressure of the bony parts upon each other, 
caused by muscular contractions. If inflammatory signs have appeared before, and the 
knee is left in a flexed position, it is fair to assume some destruction near the external 
condyle. Genu varum is very seldom seen, and in case it should occur it may be the 
result of an osteal affection of the inner condyle. Genu recurvatum may follow an 
awkward attempt to straighten the diseased joint. Sub-luxation of the tibia backward 
may take place where the ligaments or articular surfaces, or both together, have suf- 
fered some change or disintegration. If a case has not been observed from the begin- 
ning, it will be very difficult to say whether we have an osteal or synovial affection 
before us. A focus under the joint surface of the tibia is not easy of recognition. A 
focus at the condyles or the anterior surface of the tibia, however, may at times admit 
of an accurate diagnosis if pain and a doughy swelling at a definite spot of the bone 
have been felt before symptoms of synovitis have set in. It is somewhat peculiar that 
ostitis and periostitis of the lower end of the femur occur with such great regularity at 
the posterior surface between the long flexors of the leg. As to the tibia, a focus is fre- 
quently found to burrow into the joint at the anterior portion of the meniscs and the 
anterior border of the insertion of the capsule. 
Treatment.-Immobilization and rest is here, as well as in all other joints, the first 
indication. Plaster-of-Paris bandage serves, in cases where contractures are absent, or 
present only in a slight degree, its best purpose. Extension may be employed for a 
short time where contractures require it ; it will change the points of contact and 
thereby relieve the ulcerated portions of the joint from pressure. Hueter ascribed to it 
also an antiphlogistic effect, as the tension of the skin and muscles produces a slight SECTION VII ANATOMY. 
205 
compression with some increase of intra-articular pressure. Some authors recommend 
Thomas' knee splint and crutches in patients old enough to use them. In this appli- 
ance the weight is transmitted through the tuber ischii and the foot does not reach the 
ground. Where the disease is active, it might be best not to correct the deformity from 
the first, but simply mould the bandage to the present position; the muscular spasms 
will gradually subside and the limb admit of more and more extension. Should the 
knee be fixed in a position of flexion with slight displacement backward, extension will 
be the best method to reduce it. It should be used in the longitudinal axis, but may 
also be aided by a pulley in a perpendicular line to lift up the displaced head of the 
tibia. Forcible redressment is only admissible in cases with severe pain or spastic mus- 
cular contractions. Cicatrices in the popliteal region with extreme emaciation of the 
leg may lead us to think that the popliteal artery is embedded in the cicatricial tissue; 
they should, therefore, serve as a warning that no great force be used. In such cases 
appliances for extension are preferred by some. Where the displacement backward and 
outward is considerable, it will be difficult to correct it, on account of the rigidity of the 
ligamentous structures at the back of the joint, even after the hamstring muscles have 
been divided. The knife in such cases will have to be resorted to. These measures 
may, in quite a number of cases, be sufficient to effect a cure. But in spite of all our 
endeavors, we will find cases which need some more radical mode of procedure. Typical 
resections in children are generally always followed by bad results, as shortening, and 
contractures will occur in spite of plaster-of-Paris bandage or other splints. The con- 
tractures seem to be due to the peculiar mode of growth, since more bone is deposited 
in the front portion of the epiphysis than in the popliteal region. In view of this fact 
it was, therefore, no surprise to see it condemned by a number of surgeons, and it was 
merely a logical consequence that some would contrive measures to get at the seat of 
affection without mutilating the joint to any high degree. We may in this connection 
state with some satisfaction that, in regard to this joint, they have during the last few 
years accomplished surprising results. The antiseptic period had also in this field of 
surgery its influence full of blessing. Some authors, as for instance Ollier, speak very 
highly of the effects of actual cautery, others again of injection of carbolic acid. I 
am, however, inclined to think that the results recently obtained by partial resections 
will encourage most all surgeons to imitate this plan of treatment. In children with open 
circumscribed abscesses we may make an attempt to remove the granulations with the 
sharp spoon. But in cases where the fistulse have no tendency to close in a short time, 
where suppuration will spread or where soft tuberculosis rapidly produces a lax or 
dangling joint, we should not hesitate to open it by a large incision and remove the 
diseased synovial sac and osteal foci. In adult patients we should resort even with less 
reserve to such measures and remove grave fungi with soft consistency thoroughly, at an 
early time. Volkmann has given this operation the name of arthrectomy, whereas he 
calls the simple incision into joint arthrotomy. Arthrectomy again is divided by him, 
according to the amount and anatomical character of the structures removed, into- 
1. Partial and total synovial arthrectomy. 
2. Partial and total osteal arthrectomy. 
3. Osteal and synovial arthrectomy. 
To judge by the results so far reported, arthrectomy seems to supersede typical 
resection in a great majority of cases, and in not a few instances almost an ideal result 
has been obtained. As the synovial form of tuberculosis primarily predominates in 
adults, the total extirpation of the capsule seems to meet all the indications. And 
again in children who are more predisposed to the osteal form, the primary foci are so 
small that they can be removed without any further destruction of the joint surface. 
In the graver cases it may be well to follow Volkmann's advice to prepare them for 
such an operation. Contractures should be removed either by extension or manual 206 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
redressment and the limb kept in a fixed bandage. A large abscess should be opened 
and scooped out, afterward closed again and well drained ; where septic symptoms are 
present, disinfection should by no means be neglected. We should then wait for the 
proper time for arthrectomy, or else the fungous proliferations in the wound, fistulæ or 
abscesses will repeat themselves. As to the mode of performing this operation, every 
surgeon seems to have his own favorite plan, and too great importance should not be 
attached to this, as long as the object of removing all the diseased portions of the joint 
is fully attained. 
Volkmann prefers a transverse cut into the joint; this at once enables him to make 
a digital examination and to decide whether total extirpation of the capsule, or simple 
drainage, or scooping out of the affected parts will bring about the wished for result. 
Should you have decided upon removal of the capsule, you enlarge the incision and 
divide the patella transversely with the saw. Should the fungous masses reach up to 
the bursa extensorum and produce thickening of its walls, it might be of advantage to 
make a flap with its apex reaching above the bursa and its basis a little below the joint 
line. Esmarch's bandage is used only in exceptional cases, as the acute angle of flexion, 
and also the hand of the assistant, encircling the thigh firmly above the knee, control 
the bleeding very nicely. With a number of hooks the soft parts, with the separated 
halves of the patella, are pulled widely apart, so that the capsule is bulging outward. 
The entire capsule and also the ligaments are then dissected out from the healthy 
tissue with knife and scissors. The whole bursa extensorum is also extirpated in that 
region, a few small incisions made for drainage openings. The apophysis of the femur 
is cleanly dissected off to the width of three or four fingers, and also the head of the 
tibia freed from any portion of capsule or semilunar cartilage, so that at the end of the 
operation only muscles or healthy tissue are visible. Any focus visible at the epiphysis 
may be scooped out, as it will not interfere with primary union. After all the tissues 
are removed, the limb should be brought into slight flexion with careful coaptation of 
the epiphyses. The patella, if it has been divided, should be united with catgut sutures, 
or the tendon of the quadriceps femoris stitched to the patella, in case a flap operation 
has been selected. Catgut sutures or steel nails are used where any displacement of 
the epiphyses is expected. 
Some others follow Koenig's plan with great satisfaction, which consists in making a 
slightly curved incision at the inner side with its convexity backward. Beginning at 
the tibia near the insertion of the inner margin of the ligamentum patellæ, you follow 
the convex line with your knife, pushing the internal lateral ligament back; after 
having reached the upper part of the joint turn toward the middle line, where you 
readily find the distended synovial sac. This incision is everywhere carried deep into 
the joint, and vertically it also separates the vastus internus muscle along the course 
of its fibres. Another shorter incision at the outside of the joint, in front of the 
external lateral ligament, will assist very much in getting free access to the sac in that 
region. If circumstances should require, you may nip the ligamentum patellæ at the 
inside, and even divide the internal as well as the crucial ligaments. Another very 
ingenious method, which will undoubtedly gain some followers, has been lately 
reported by Israel, having obtained in two cases, so to say, an ideal result. His plan 
consists in making a large flap with its convexity downward; then he saws off the 
tuberosity of the tibia in an oblique direction, so that it remains with the patellar 
ligament attached to the flap. This gives him ample room to remove the entire capsule 
in connection with the crucial ligaments and semilunar cartilage. After having inserted 
the drainage tubes he nails the tuberosity to the tibia. ' Primary union followed in his 
cases and patients were early induced to use passive movement of the joint. Ono 
patient, about eleven years old, can bend the leg at an angle of 100 degrees, has full 
strength in its use, without any shortening and with a natural shape of the joint. SECTION VII-ANATOMY. 
207 
Helferich has in one case also treated the lateral ligaments in a similar manner; they 
were chiseled off from the femoral condyles anteriorly and from below, and posteriorly 
left in contact with the periosteum. Riedinger has a method which is also favorably 
spoken of by some surgeons. He makes a longitudinal incision over the middle of the 
patella, including at the same time the lower portion of the quadriceps and the tendon 
of the patella. After the tissues are divided down to the bone with one stroke, he, in a 
corresponding line, separates the patella into two symmetrical halves with the saw. 
By pulling them apart the joint can be inspected with ease, and the extirpation of the 
capsule and removal of the joint-ends present very little difficulty. Anatomically this 
method certainly presents some advantages, as the coaptation of the parts after the 
operation is simple, and immobilization during the process of repair is also readily 
secured. Moreover, the way the structures are divided, the functional result will not 
be interfered with in case movement of the joint is an object to be obtained. We may, 
in not a few cases, encounter some difficulty in removing the affected synovialis from 
the popliteal space, at least we may experience some uneasy sensation in working in 
such close proximity to the popliteal artery. A few hints thrown out by Zesas in this 
respect may, therefore, serve us in good stead. He advises to carefully remove the 
superficial granulations and then go down directly to the blood vessels and dissect them 
off all along the granulations. In some very grave cases with extensive granulations 
we may be obliged to get at the blood vessels from behind, in a manner similar to their 
ligation. 
Typical resections may be carried out by incisions similar to those referred to when we 
spoke of arthrectomy. The transverse incision with division of the patella is quite in 
favor with some surgeons. Flaps, with their convexity downward upon the tibia, or 
upward above the patella, have also their advocates. My experience would lead me 
to adopt Hahn's method, as in my hands it presented all the advantages pointed out by 
this surgeon. An incision is made at the inner side, starting from a point as far back 
as possible at the line of the joint, cutting the tendon of the quadriceps close to the 
patella and ending at the outside at a corresponding point. The advantages of this 
method seem to be that the wound heals faster, as it nowhere is in immediate contact 
with the bone. It also affords good drainage and free access to all the parts of the joint. 
The patella also is easily kept in its place and hemorrhage is not to be dreaded, as very 
few blood vessels are cut 
ANKLE JOINT. 
In fungous inflammation of the ankle joint, and especially where there is a large 
•quantity of exudation, we at first notice in front a soft swelling of the synovialis along 
the extensor muscles, at the outside between the external malleolus and the extensor 
digitorum, at the inner side between the internal malleolus and the tendon of the 
tibialis anticus. Posteriorly, we notice it on both sides of the tendo-Achillis, and it is 
often well marked here when swelling elsewhere is very slight. It presents a somewhat 
diffuse appearance as it is kept down by the deeper muscles, and we have here an elastic 
touch, while in front distinct signs of fluctuation are exhibited. These different promi- 
nences will serve us to decide whether the exudation is in the tibio-crural joint, or 
simply under the tendons, as in the former case pressure in front will increase tension 
behind. We have still another sign enabling us to determine this question, which is 
also caused by the exudation distending the tibio-fibular joint. By its internal tension 
the fibula is pushed outward and gives the ankle a broader appearance. The astragalus 
can now be easily moved from one side to the other, and in striking it against the 
malleoli we hear a knocking sound, "bruit du choc malléolaire." (Aubry.) 
If swelling is only present at the posterior part of the joint, we may infer trouble in 
the talo-calcaneal joint. But, as a rule, the swelling of the capsule presents rather a 208 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
doughy than fluctuating feeling, and gradually diffuses into the peri-synovial tissue, 
giving the joint a spindle-shaped appearance. In affection of the calcaneo-tarsal joint 
we have swelling on both sides of the calcanéum, behind and below the malleoli, and 
the heel looks very broad. In case Chopart's joint is involved, the principal swelling 
is on both sides of the extensors ; at the inner side about the tuberosity of the scaphoid 
bone, at the outer side over the anterior process of the os calcis. The fungous masses 
will proliferate toward the plantar side and flatten the foot; at the dorsal side they will 
spread under the tendons in front of the talo-crural joint. Somewhat characteristic is 
the form of tuberculosis sequestrum of the tibia in smaller children; there we have 
thickening of the tibia, with fistula and consecutive affection of the joint. A really 
typical affection has its origin in the body and neck of the astragalus. Perforations 
here most frequently appear near the insertion of the synovialis at the talo-crural joint; 
but they may also penetrate through the cartilage of the astragalus into the tibio-tarsal, 
talo-calcaneal or scaphoid joint, singly or together. The bones which communicate 
with the astragalus have also a certain importance in regard to affection of the ankle 
joint. The scaphoid bone seems to form an exception, as it frequently has been extir- 
pated alone and no tendency to involve the neighboring bones was found. The close 
connection of the three joints makes it easy for these pathological processes to travel 
from one joint into the other. We see this especially in tuberculosis of the ankle joint, 
which easily spreads into the talo-calcaneal joint, and vice versa. Less often it happens 
that an osteal focus of the astragalus simultaneously involves the upper and lower joint. 
Should the tibio-tarsal joint be affected at the same time with the talo-navicular, we 
may, as a rule, assume that the primary tuberculosis has its seat in the astragalus. 
Abscesses are rather frequent, and they develop at the anterior surface of the joint and 
spread along the extensor muscles of the leg. In other cases they may burrow under 
the tendo-Achillis or the flexors behind the malleoli, especially behind the inner one. A 
large abscess at the anterior surface of the foot, breaking open in the region of the neck of 
the astragalus, almost invariably points to an osteal focus of the astragalus. The same 
is true with abscesses over the malleoli; they generally indicate a process located there. 
We might think this recognition of the exact seat and extent of the mischief of very 
slight practical importance; in fact, in the earlier stages of the disease the treatment is 
very little affected by it. But where operative interference comes into consideration we 
feel its necessity very keenly. It is then important to know whether the tibia, astraga- 
lus or the tarsal bones, or the synovialis are involved. In most cases we will be enabled 
to establish, even before fistulæ exist, whether certain bones are affected or not, as the 
diseased tarsal bones are generally sensitive to indirect pressure. If you wish to know 
whether one of the cuneiform or scaphoid bones are affected, you steady the ankle joint 
with one hand, and with the other you exercise an equable pressure in the direction of 
the longitudinal axis of the foot successively upon each head of the first three meta- 
tarsal bones. If you suspect the cuboid bone, practice a similar test upon the two outer 
metatarsal bones while you steady the os calcis. In a similar manner you may recog- 
nize affection of the astragalus by pressure upon the plantar surface of the calcanéum, 
steadying, at the same time, the leg. Somewhat after this method you may discover 
the seat of primary affection of the synovialis in the different joints of the foot by test- 
ing their function separately. You must not forget that flexion of the foot takes place 
in the tibio-tarsal or ankle joint; pronation and supination mainly takes place between 
the astragalus on one side and the calcanéum and scaphoid bone on the other. Affec- 
tion of the meso-tarsal or Chopart's joint may be detected by strong flexion of the foot 
in this joint. Passive movements in synovitis are generally very painful, and an exten- 
sive destruction of the ligaments is revealed by abnormal lateral mobility of the joint; 
in exceptional cases also by crepitation. Of course this method of examination will SECTION- VII ANATOMY. 
209 
only be of value with patients who give expression to pain in a reliable way ; children 
generally baffle our efforts very much in this respect. Should swelling exist and no pain 
be elicited in this manner, we may suspect periostitis. 
Treatment.-With children a conservative treatment is generally indicated. But 
where extensive suppuration exists, and where unmistakable signs of an osteal process 
of the tibia, astragalus or malleolus, are manifest, operative interference can be recom- 
mended equally well ; it will at any event shorten the whole process. As to grown 
persons there is, in severe cases, less agreement among surgeons in regard to treatment 
in this locality than in any other joint. Some advise evidement of the fistulæ, and, in 
case nothing is accomplished by it, immediate resort to amputation ; others again 
recommend amputation from the start. A number of others, again, have their own 
special method of typical resection, by which they gain access to the affected portions 
and remove them with the sharp spoon, saw or chisel. Hueter recommended a trans- 
verse cut at the anterior aspect of the joint, right through all the tendons and nerves, 
but so far, and probably with good reason, his method has found no imitators. Busch 
tried to get at the parts from below by sawing through the calcanéum from the plantar 
side, and Vogt would immediately begin with extirpation of the astragalus to get a full 
view and access to the rest of the portions necessitating removal. These methods may 
answer in a few cases, but there is no reason to think that they ever will be generally 
adopted. If possible, we should avoid total extirpation of the astragalus, at least, it 
should never be done for the simple purpose of getting better access to the parts. Aside 
from the shortening of the foot, it is not always easy to adjust a proper shoe, as the heel 
becomes very short. We should therefore only restrict it to cases where the bone itself 
is affected, or the surrounding joints, i. e., the talo-navicular and the talo-calcaneal 
joint. The observation, that in the majority of cases osteal processes start from the 
anterior region of the tibia and astragalus, induced Koenig to make the incision more 
in front. He makes two lateral incisions in front of both malleoli, which really furnish 
all the room necessary to inspect the inside of the joint. The inner incision begins 
upon the tibia, about 1 to 1J inches above the joint surface, between the inner side of 
the extensors and interior margin of the tibia, opening the joint and taking its course 
downward. It is extended over the body and neck of the astragalus and ends at the 
inner side of the foot, near the prominence of the scaphoid bone. This incision does not 
injure any important structures, and admits of a very good inspection to nearly all the 
parts of the joint. But a fuller view is gained by a second incision running along the 
anterior margin of the fibula and ending at the height of the talo-navicular joint. If we 
have a tuberculosis of the synovialis, it will bulge forward and can be removed with 
some ease. By elevating the soft parts you can now examine the anterior and a great 
part of the lateral aspect of the astragalus. By making traction upon the foot you can 
oversee the largest part of the joint surface, and are already enabled to remove some 
osteal foci as well as the diseased synovialis. Should the astragalus be affected, the 
question will confront us whether to remove only a part or the entire bone. A focus 
of the body of the astragalus near the confines of its neck undoubtedly necessitates 
total extirpation, as it otherwise might break through into the surrounding joints. 
With the incisions already indicated, we have no great difficulty in accomplishing 
this, and also in removing the posterior portion of the capsule. Any diseased portion 
of the tibia may then be removed by means of the spoon or chisel. But should total 
resection be decided upon, the incisions mentioned above will be very convenient. 
Koenig, in order to give lateral support to the joint, removes the outer shells of the 
malleoli with the chisel, leaving them simply in contact with the periosteum above 
and with the ligaments below. With a broad chisel he removes whatever is affected 
from the tibia, astragalus, and eventually some parts of the calcanéum. I have prac- 
ticed this method in two cases, and am somewhat surprised that it is not more generally 
Vol. 111-14 210 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
adopted by the profession, as the claims made for it by Koenig have been fully sub- 
stantiated in my experience. I did, however, not think it essential to chisel off a shell 
of bone from the malleoli, but simply preserved the periosteum. In one case I removed 
about one inch of the astragalus, one-half inch of the tibia and left the fibula intact; 
the result has been very satisfactory, and the shape of the foot suffered very little. 
Some other methods have of late been published by Zesas and Kocher, which in their 
hands furnished very nice results. The method published by Zesas was first suggested 
by Girard and tried in several cases. The foot rests upon the inner malleolus; an inci- 
sion of about two inches begins in front, above the line of the ankle joint, at the point 
of connection between the tibia and fibula, and runs obliquely down to the point of the 
external malleolus. Keeping the foot at right angles, a horizontal incision, beginning 
right at the external margin of the tendo-Achillis and passing closely to the point of 
the malleolus externus, then ending immediately before the tendon of the peroneus 
tertius, will connect with the first incision. The peroneal tendons are then exposed 
and each one transfixed by a thread in two different places, and thereupon separated 
with the knife between the points of transfixion. After the soft parts are dissected off, 
you can readily see the astragalus and the inner surface of the joint. The capsule of 
the joint is split in its full length, the ligaments are separated at their insertion, and, 
while the foot is kept in supination, the astragalus is extirpated with ease ; after 
this the foot is luxated inward. The cavity of the joint is now fully accessible, and 
any suspicious portion can be removed. The claims for this method are, that it affords 
a better view and access to all the parts than any other method so far known. Quite 
similar to this is Kocher's method; it, in fact, seems to differ only in the external inci- 
sion. Keeping the foot at right angles, he begins at the tendo-Achillis and makes a 
slightly curved incision over the point of the external malleolus, ending at the exten- 
sors. He also divides the peronei tendons, and afterward unites them again. Reverdin 
also has operated in a similar manner, but, besides, he divided the tendo-Achillis, and 
did not unite the peroneal tendons. In cases where the astragalus and calcanéum, and 
even the rest of the tarsal bones are affected, and where partial resection might not 
promise a satisfactory result, we may resort to an operative method known by the name 
" Wladimiroff, " Miculicz's osteoplastic resection. This method seems to have given 
great satisfaction in about thirteen cases. Kümmel has in one case even removed parts 
of the tibia and fibula, all the tarsal and part of the bases of the metatarsal bones, with 
very good functional results. Miculicz begins the incision a little in front of the tu- 
bercle of the scaphoid bone, and carries it across the plantar surface to a point behind 
the base of the fifth metatarsal bone. Schattauer made the cut about one-fourth to 
three-fourths of an inch anterior to this, running his incision over the cuneiform and 
cuboid bones. Then from these points incisions are made on the tibial and fibular side, 
upward and backward to the malleoli, and these again are united by a horizontal inci- 
sion, dividing the tendo-Achillis. Fenger has modified this method somewhat in order to 
preserve some branches of the posterior tibial artery, as the fear of gangrene of the foot 
is not altogether unfounded, seeing a case reported by Sordina. He does not carry his 
incision entirely across the sole of the foot, but begins about three-fourths of an inch 
outside the tibial surface of the os cal cis, below the sustentaculum tali and to a point 
one inch back of the sustentaculum ; then it is continued upward along the tibial border 
of the tendo-Achillis to the posterior side of the ankle joint. It is a little more difficult 
in this way to get at the ankle and Chopart's joint than by Miculicz's method. But this 
difficulty can be overcome to some extent by separating the soft parts subperiosteal!y 
from the calcanéum and astragalus, and by raising the fibular incision more upward 
toward the dorsum of the foot, so it will terminate about one-fourth of an inch in front 
of the external malleolus. It is best to begin the disarticulation of the ankle joint first, 
as this gives more room for the separation of the dorsal flap, with the extensor tendons SECTION VII ANATOMY. 
211 
and anterior tibial artery, from the neck of the astragalus. Chopart's joint is also more 
readily disarticulated in this manner than from below. Separation of the dorsal flap 
from the astragalus should be the next step, and this should be done sub-periosteally; 
any injury to the anterior tibial artery is thereby excluded. The preservation of the 
extensors secures also more active mobility of the toes, rendering thereby the gait more 
elastic. After this the ligaments of the calcaneo-cuboid and talo-seaphoid joint are cut 
from above, and the heel is removed. The malleoli, the articular surfaces of the tibia, 
cuboid and scaphoid bones are then taken off with a saw, and if we find any further 
affection of the bony parts we may use the sharp scoop. Should the tuberculosis extend 
along the sheaths of the tendons, we may remove it with the spoon or with scissors and 
forceps. 
FUNDAMENTAL ANATOMICO-MECHANICAL CONSIDERATIONS 
UNDERLYING THE SUCCESSFUL TREATMENT OF 
DEFORMITIES, DISEASES AND WEAKNESSES 
OF THE SPINE. 
CONSIDERATIONS ANATOMICO-MECANIQUES FUNDAMENTALES BASES DU 
TRAITEMENT AUREUX DES DIFFORMITES, MALADIES ET 
FAIBLESSES DE L'EPINE DU DOS. 
FUNDAMENTALE ANATOMISCH-MECHANISCHE ERWÄGUNGEN, DIE DER ERFOLGREICHEN 
BEHANDLUNG VON DEFORMITÄTEN, KRANKHEITEN UND SCHWÄCHEN DES 
RÜCKGRATS ZU GRUNDE LIEGEN. 
BY MILTON JOSIAH ROBERTS, M. D., 
Professor of Orthopedic Surgery and Mechanical Therapeutics in the New York Post-Graduate Medical 
School and Hospital ; Visiting Orthopedic Surgeon to the New York City Hospitals on 
Randall's Island ; Consulting Orthopedic Surgeon to the Woman's 
Hospital,Brooklyn, etc. 
The present paper will be eminently of a practical nature. No measure is herein 
advocated which has not been thoroughly tested and shown to be of practical value. 
Method.-Believing that specialization is the surest road to success, no matter what 
branch of knowledge it is sought to advance, I have for several years devoted a large 
part of my time to the study and treatment of spinal diseases and deformities. It will, 
therefore, be understood that whatever I have accomplished in the way of increasing 
our therapeutic resources for the cure or amelioration of spinal affections, has not 
been the result of so-called "happy thoughts," but, on the contrary, has been the out- 
come of persistent and laborious endeavor in this special direction, extending over a 
period of several years. 
Aim and Motive.-I have aimed atthe acquisition of that kind of knowledge which is 
available for the cure of spinal disease, the relief of human suffering and the preven- 
tion of unsightly deformity. I have endeavored all along to maintain that frame of 
mind so essential to the avoidance of self-deception, viz., that of being absolutely 
indifferent as to which one of two or more ideas are true; my only concern being to 
ultimately arrive at accurate and trustworthy conclusions based upon facts which all 
trained observers can verify for themselves. 
The Elaboration of Means to an End.-In the practical execution of the mechanico- 
therapeutic ideas arrived at I have spared no expense, time or labor necessary to pro- 
duce the most effective, comfortable and elegant apparatus. (In adopting this course 212 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I have received much encouragement from the afflicted, for in my professional capacity 
the one question which I have been most frequently and earnestly besought to answer 
by anxious parents bringing children for treatment of spinal disease or deformity is, 
What is the best that can be done in the way of relief and cure of my child ? What is 
the most serviceable, comfortable and least conspicuous form of support for him to 
wear? The prime question has not been, as so many physicians seem to think, " How 
much will treatment cost, and what is the cheapest apparatus that can be used ? ") 
Though I have received much encouragement from this source, it is scarcely pos- 
sible for any one to adequately appreciate the ground gone over, who is not practically 
familiar with the difficulties of procuring competent workmen to carry out novel 
mechanical ideas, who is a stranger to the frequent encounter of what at first appear to 
be insurmountable obstacles, and who has never shouldered the burden of the 
enormous number of perplexing details which continually present themselves while 
conducting to a successful issue a series of mechanical experiments. 
Result.-The invention of the spinal corset herein described was made over four 
years ago. Desiring above all things to be absolutely accurate in my statements regard- 
ing it, the corset has thus far been used without being brought to the attention of the 
medical profession. Since its invention I have been engaged in elaborating it, and in 
making a most thorough and extensive test of its practical value in the treatment of 
all forms of spinal affections. 
The uniformity of success which has attended the use of the apparatus herein de- 
scribed in arresting the progress of that terrible malady-spinal caries (Pott's disease) 
-and in preventing the great suffering as well as the development of that hideous de- 
formity which often results from the ravages of this disease ; its wonderful adaptability 
to the treatment of all forms of lateral curvature and weaknesses of the spine, and 
finally, the universal expression of satisfaction on the part of patients wearing it as to 
its comfort, inconspicuousness, and elegance, all combine to encourage me in now 
bringing it to the notice of the profession. This I do with the fullest confidence that 
those whose minds are unbiased and who will give it a thorough practical test in the 
light of therapy and hygiene will be as enthusiastic in declaring its superiority over 
all other forms of portable supports as are the members of the limited circle of physi- 
cians and patients who now know its worth. 
Distinctive Features.-The distinctive features of my corset are, that it is woven out 
of wire in the form of thread, that the weaving is done over an exact * form or cast of 
the body, and that the meshes, while affording the most perfect ventilation to the body, 
are formed in such a manner as to combine permanency of contour with elasticity of 
support and accuracy of fit. 
Personal Qualifications and Management.-The fullest success obtainable in the treat- 
ment of spinal affections implies a high degree of manipulative dexterity on the part 
of the surgeon. He must also possess a sufficient knowledge of mechanics to readily 
overcome the numerous little obstacles that present themselves in the course of treat- 
ment, which are dependent, for the most part, on the peculiarities of the bodily contour 
and physical condition of individual patients, and, therefore, cannot be satisfactorily 
considered in detail in books or articles on treatment. When anything goes wrong 
with a support which a patient is wearing, the physician in charge of the case should 
immediately endeavor to overcome the difficulty complained of. He should neither 
ignore its importance nor postpone giving attention to it. It is requisite also that the 
physician should be sufficiently familiar with human nature and the art of giving 
* Sometimes the form is modeled for therapeutic or æsthetic purposes prior to the weaving 
of the corset. In this way a corrective action may be exerted by the corset, or the bust may 
be given any desired form. SECTION VII ANATOMY. 
213 
directions, to secure the hearty cooperation of those interested in the carrying out of 
any plan of treatment laid down for individual patients. 
Technology.-Success in the scientific treatment of spinal diseases, deformities and 
weaknesses implies a knowledge of, and personal familiarity with, a very considerable 
number of technical details. These aré, for the most part, matters of general applica- 
bility, and, therefore, will be considered first. 
JWdamentaZ Ideas Regarding the Support of the Body Proper for the Cure of Disease, 
the Relief of Suffering or the Arrest of Deformity.*-If mechanical support is to be util- 
ized as a therapeutic agent, a definite idea should be entertained by the physician as to 
the modus operandi of the production of its beneficial effects. Otherwise, he who uses 
such means may some day wake up to find that he has been the credulous supporter of 
authority or the blind follower of the teachings of tradition, rather than an intelligent 
institutor of remedial measures the rationale of which he thoroughly comprehends. 
The Normal Spinal Column.-Viewing the normal spinal column, stripped of its 
appendages, we see that it presents a graceful curvilinear outline, that the vertebral 
bodies, with their respective processes and articular facets, alternately rest upon and 
are supported by intervertebral substances. 
Spinal Caries or Pott's Disease.-When caries of the spine has progressed to the stage 
of deformity, the anatomical relationship of the different parts of the vertebral column 
to each other becomes changed. A good idea of the disastrous nature and extent of the 
changes which take place when the disease is not properly treated from the first, can be 
gained by a description of the vertebral column of a child, aged four years, who was 
brought to me for treatment. The bodies of the tenth, eleventh and twelfth dorsal 
vertebrae were the seat of disease. The necrosed remnants of the bodies of the eleventh 
and twelfth dorsal vertebræ lay loosely in a capacious abscess sac anterior to the spinal 
cord. There was marked thickening of the periosteum anteriorly, together with the 
usual inflammatory fusion of the periosteum and cord membranes, forming the posterior 
wall of the abscess cavity. 
These, then, are the terrible ravages of disease which the surgeon is obliged to face, 
and which he seeks, through the agency of mechanical and other remedial measures, to 
aid nature in repairing. Owing to the inaccessibleness of the diseased areas of bone, 
they being buried deeply beneath the soft parts, it would, at first sight, seem as if the 
surgeon were utterly powerless to aid nature in such a manner as to bring about a cure. 
But let us see if we cannot elaborate a rational basis for mechanical support in diseases 
of the spine. 
In ostitis, or caries of the vertebral bodies, the establishment and consummation, of 
reparative processes depend upon the material lessening and final arrest of irritation at 
the seat of the disease. Now, it is perfectly feasible, in my judgment, to more or less 
effectually interrupt or prevent the transmission of all mechanical irritation to the seat 
of disease. The sources of such irritation are :- 
1. That which is caused by undue pressure at the inflammatory focus, from super- 
imposed bodily weight. 
2. That which results from jars or vibratory impulses due to the impact of the feet 
against the ground in walking, and which are imparted to and conducted up along the 
bony framework to the seat of disease, f 
See leading article on this subject, by author, in the New York Medical Record for July 
16th, 1887. 
j- See paper, by author, entitled, " The Fundamental Principles of Mechanico-Therapy in Hip 
Disease, based on a consideration of Clinical, Pathological and Physico-Physiological Data, with 
a description of New Forms of Elastic Tension Hip Splints." Read before the Medical Society 
of the State of New York, February 6th, 1884. The New York Medical Journal, March 15th, 214 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
3. Jars which result from riding in vehicles of any kind, and which are transmitted 
along the bony framework to the seat of disease. 
4. Direct blows or concussion resulting from falls. 
The relief of irritation from the first-named cause, viz. : superimposed weight, 
involves the use of an apparatus which will either transfer the weight of the parts of 
the body above the seat of disease to healthy parts below, or to some source of support 
other than the body of the patient. The relief of irritation from the second and third 
named sources, resulting in jars or vibratory impulses, involves, in addition to the 
thorough vertical sustentation of the patient, the use of an apparatus which will, at the 
same time, deflect or interfere with the transmission of jars or vibratory impulses 
along the bony framework to the seat of disease. This can be accomplished only by 
the use of an elastic or resilient apparatus. To guard against irritation from the last- 
named sources necessitates the use of an apparatus which is, in itself, a coat of mail, and 
is, at the same time, a resilient support. 
But, how is relief from irritation to aid repair ? The answer is this : In all inflam- 
matory lesions of bone we have the formation of new or embryonic cells. If the irri- 
tation at the seat of disease be excessive, these cells will break down and form waste 
products. If, however, the irritation, be not too great, they become developed into 
healthy bone tissue.* 
Thus, it will be seen that for the cure of caries or Pott's disease of the spine, we have 
a clear indication for the relief of mechanical irritation by means of mechanical appli- 
ances, and just in proportion to the thoroughness with which we are practically able 
to carry out this indication will reparative processes be established. 
Furthermore, experience has taught us that, for the relief of suffering, the complete 
and permanent removal of undue bodily weight above the seat of disease will be found 
all that is necessary to be done in order to overcome the pain resulting from pressure 
upon sensory nerves. Finally, for the prevention of deformity in Pott's disease, we 
have learned that no success will attend treatment unless the vertebral bodies are kept 
from falling together by the removal of superimposed bodily weight. 
Again, when there is no longer any inflammation, when the morbid process has 
been transformed into physiological action, or the vertebrae more or less thoroughly 
anchylosed, there may yet remain the indication for support. This is always true in 
those cases where the disease has progressed so far as to seriously deform the spine, and 
thus by interfering with its normal linear continuity, impair its supporting power. 
Lateral Curvature.-In lateral curvature the overtaxing of the spine by superim- 
posed bodily weight is a potent factor in the production of the deformity and the conse- 
quent pressure upon nerves. In support of this statement, it is only necessary to recall 
the familiar experiment of making linear traction upon the spine for the temporary 
reduction or obliteration of deformity, and in aggravated cases, for the relief of pain, 
and in this way to relieve the spine of its undue burden. The use of any mechanical 
appliance in which it is sought to overcome the spinal deformity by means of force 
applied through levers, will result in disappointment. 
Linear traction on the spine is the most efficacious method known of reducing all 
forms of lateral curvature. Such traction can only be applied with full efficiency 
through gymnastic exercises. The tendency of all supports, if worn constantly, is to 
lessen the power of the spinal muscles, and especially is this the case in true rotatory 
May 3d, and May 24th, 1884. The Proceedings of the Medical Society of the State of New York, 
1885. 
Vide " Manual Pathological Histology," by Cornil <fc Ranvier, translated by A. M. Hart, 
Vol. I, p. 116. "Whatever maybe the origin of the embryonic tissue, it has a tendency to 
reproduce the tissue of the region in which it is situated." London, 1882. SECTION VII-ANATOMY. 
215 
lateral curvature. In lateral curvature there is no new formation of bone taking place 
which is to ultimately act as a prop to strengthen the spine, as in the case of Pott's 
disease. It thus follows that spinal supports must be used with the greatest caution 
in this class of cases. Otherwise, through the weakening effect which they have upon 
the muscles, and by the neglect of gymnastic exercises, the patient will soon be 
rendered more helpless, when the support is temporarily removed, than at the inception 
of treatment, before any support was applied. 
Then again, as in Pott's disease, so in examples of true rotatory lateral curvature, 
when the deformity has become so marked that all hope of diminishing it to any con- 
siderable extent must be given up, there yet remains the indication for lessening the 
burden of the spine by providing a suitable support ; for while the weight of the body 
remains about the same, the normal spinal curves have been so seriously distorted that 
the column can no longer perform the function of supporting the body, and the result 
is great discomfort to the unfortunate victim. 
In all these cases the patient will always be made more comfortable by the wearing 
of a suitable spinal support. These patients should, however, never be led into the 
belief that they will, after a more or less prolonged course of treatment, be able to go 
about unsupported with as much comfort as while wearing a suitable support. 
Traumatic Spinal Curvature.-There is a form of lateral curvature which occurs 
most frequently in male adults, and is directly traceable to injury of some of the soft 
parts outlying the spinal column proper. Cure is, as a rule, rapidly brought about in 
all such cases by wearing an efficient and properly adjusted support for a short time, 
thereby restoring the body to its normal position and relieving the injured tissues of 
undue irritation during the period of repair. 
Spina Bifida.-In examples of spina bifida which do not prove fatal early in 
life, artificial spinal support may be demanded, or at least found of great practical 
utility. 
Spinal Weakness.-In simple weakness of the spine, unaccompanied by deformity, 
the patient continually assumes faulty attitudes, both while standing and sitting, 
thereby cramping the chest and abdominal organs and giving rise to more or less dis- 
comfort. All such patients are greatly benefited by using a stay which precludes the 
possibility of their assuming faulty attitudes. At the same time it is of the greatest 
importance to supplement such treatment by suitable gymnastic exercises and attention 
to the general physical condition of the patient. 
These, then, are the considerations which lead us to make use of mechanical sup- 
ports in the treatment of spinal affections. The treatment, therefore, resolves itself 
into two questions: first, how and where to get hold of the body in order to support it 
in such a manner as to relieve irritation ; and secondly, the determination of the best 
means or therapeutic agents to employ in order to effect this desirable end. 
How and Where to Get Hold of the Body.-In considering how and where to get hold 
of the body in order to support it, the problem should be viewed from a thoroughly 
mechanical standpoint. We have the skeleton and overlying soft parts to deal with. 
Now, it is the prime function of bone to support weight. To transfer weight from 
healthy parts above to healthy parts below, in order to relieve an intermediate diseased or 
weakened segment of the spine from mechanical irritation, it is obviously necessary to 
get hold of some part of the skeleton above and below the diseased or weakened zone, 
and introduce some form of artificial prop to take off the burden from the weakened 
spin**. The maximum efficiency can only be obtained by so fastening this prop to the 
body that the same relative position between it and the body will be maintained at 
all times. A clear idea of this extremely important part of our subject may be gained 
from a consideration of the normal relationship of the different parts of the body. 
When the cervical region of the spine is affected, the globular form of the skull, 216 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
together with the lower jaw and the shoulder girdle can be relied upon as points against 
which pressure may be exerted to relieve the affected region of the neck. 
When the dorsal part of the column is affected, we again have the head and chin for 
the points against which upward pressure is exerted, through the agency of some form 
of head-rest, and the pelvic girdle, upon which to rest our support. It will thus be 
seen that we are here wrorking at a far greater disadvantage than when dealing with 
the disease in the cervical region, for we have the enormous weight of the head, 
shoulders, upper extremities and that part of the body above the diseased vertebrae, 
which must be transferred to parts below in order to relieve the irritation. 
When the lumbar region is affected, we rest our support upon the pelvic girdle 
and make upward pressure against the bulge of the thorax. I have elsewhere* stated 
that "it is a pertinent fact, and one that should never be lost sight of by those 
who are brought into the responsible position of making a prognosis in any given 
case of spinal caries, regarding the prevention or arrest of the development of 
deformity, that the results of treatment in the vast majority of cases tally exactly with 
the above ideas regarding mechanical support of the spine. That is to say, the best 
results are obtained when the cervical and lumbar regions are affected; the 
most disastrous when the middle dorsal region is the seat of disease. Formerly, 
it was supposed that in the mid-dorsal region the best results could be obtained 
by treatment. Regarding the diseased and deformed spine as a broken shaft which 
could be drawn into position by means of a lever, theory suggested the idea that, w ith 
a fulcrum in the middle of the back and power applied to the body above and below, 
deformity could be prevented, or overcome, by drawing the body backward above 
and below against the lever, where it could be secured. But it must be remembered 
that the spinal column cannot be likened unto a shaft broken at one point-it has 
many segments-and that to execute the above idea in the same manner that we 
would reduce deformity when a long bone is fractured in its middle, is out of the 
question." 
Before leaving this part of our subject, I wish to state that when dealing with 
patients requiring support, in whom the disease has already advanced so far as to give 
rise to serious distortion of the bony framework, the question of selecting sites for 
getting hold of the body not infrequently becomes a difficult problem to practically 
solve. All such cases must be considered as individual problems with reference to 
deciding where and how to attach support to the body. 
Sometimes, especially when the disease is in the dorsal region of the spine, it is a 
mechanical impossibility to get hold of the body with any portable support in such a 
manner as to effectually relieve the irritation. Enough support may be rendered, 
however, to add greatly to the comfort of the patient. Under such circumstances, if 
the disease be active, we should not permit ourselves or our patient to rest contented 
with even the best of portable supports. Certain adjuvants should be made use of, to 
which the superimposed bodily weight is to be transferred. 
We are now prepared to consider what therapeutic agents should be employed to 
relieve a diseased or weakened spine of irritation and of its undue burden. Without 
stopping to criticise any of the existing forms of apparatus, I will proceed at once to 
describe what, in my judgment, after a four years' practical test in a large number of 
spinal cases, representing various phases of disease, curvature and weakness, excels all 
other spinal supports which I have met with during eleven years' close study of this 
subject, in its efficiency, comfortableness, inconspicuousness and elegance. 
*" Fundamental Ideas Regarding the Support of the Body Proper for the Cure of Disease, 
the Relief of Suffering or the Arrest of Deformity," New York Medical Record, July 16th, 
1887. SECTION VII ANATOMY. 
217 
Moulds or Impressions of the Body.*-The object of making moulds or taking 
impressions of the body, in connection with the plan of treatment which I now adopt 
in spinal affections, is to secure a form over which the support to be worn by the patient 
is constructed. In dealing practically with patients sufficiently good results can be 
obtained by making moulds over closely fitting knit shirts, after the fashion of applying 
a plaster jacket, the operation being, in fact, conducted in the same manner and in 
accordance with the usual directions for applying a plaster jacket, except that the 
layers of plaster bandage should be carried as far up behind and in front as possible, 
and the lower margin of the mould extended to the pubis in front and the coccyx 
behind. As soon as the plaster sets a longitudinal division of the mould and shirt is 
made in front. It is then removed by gaping the cut edges apart, after which they 
are approximated and secured in position by a roller bandage. The mould is now 
placed on supports over a stove or in the hot-air chamber of a furnace, until thoroughly 
dried. The cast made from such a mould will exhibit all the anatomical points which 
are so essential to the construction of an accurate and easily fitting corset. To over- 
come the objectionable feature of this method of taking a mould, which involves at the 
time of its removal the leaving of the patient's body entirely nude, I have had a 
special skin-fitting garment constructed. This garment or shirt is furnished with head 
and arm holes at the top. At the bottom there are holes for the lower extremities, the 
space between these latter openings being closed. The garment is drawn on by first 
passing the feet through the neck holes, and afterward through the respective openings at 
the lower end of the shirt. As the garment is drawn up over the body the hands are 
passed through the arm holes and the ribbon is tightly drawn about the neck. These 
shirts are made very thin, and, as I have said, are skin fitting. Over such a 
garment applied by the patient's attendant, an ordinary skin-fitting knit shirt is 
drawn, such as is now widely used, over which to apply a plaster jacket. In making a 
mould of the body, after the fashion of applying the jacket, as can readily be under- 
stood, the plaster adheres only to the outside shirt. It is, therefore, only necessary, 
in removing the mould, to cut through this and remove both the mould and the entire 
shirt together, leaving the body of the patient entirely covered by the garment first 
applied. By adopting this plan, the most sensitive lady is not subjected to undue 
embarrassment. 
The Attitude of the Patient while Moulding the Body.-The most convenient attitude 
for the operator to place his patient in while moulding the body is that secured by sus- 
pension. For this purpose I use a modified form of apparatus that enables me to know 
at all times the amount of traction force used on the head and arms. 
In suspending a patient with a view of getting a mould from which to make a cast 
over which a wire corset is to be woven, it is important that the patient should not be 
placed in an attitude which, when the corset is applied to him, he will be unable to 
maintain. To take a mould with the body in such a position would frustrate our thera- 
peutic endeavors, as it would be impossible for the patient to wear with comfort any 
form of portable apparatus that necessitates the maintenance of an unnatural attitude. 
The form of suspension styled self-suspension should never be made use of while 
moulding the body. 
Casts.-Having secured a mould of the body, the next step is to make a cast. This 
is done by making a mortar of plaster-of-Paris and water, and filling up entirely or 
lining the mould with a thick layer of this mortar, which soon sets. The mould is then 
cut down, spread apart and removed from the cast in the same manner that it was 
removed from the body. 
* See article by author, entitled, " Moulds, Casts and the Modeling of Casts for Therapeutic 
Purposes." Neio York Medical Monthly, 1887. 218 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Modeling of Casts for Therapeutic and Other Purposes.-It will be remembered that 
the corset which we are to use is to be constructed directly over the cast of the body of 
our patient. There results from this plan of construction far greater nicety of adapta- 
tion to the contour of the body, or the ends of remedial endeavors, than can be obtained 
in any other way. 
If we desire to exert remedial pressure upon any part of the body for the purpose of 
overcoming deformity or preventing its increase, much can be done to effect this end by 
modeling the cast of the body of the deformed individual prior to making a corset over 
it for him to wear. This will be readily understood by a description of the casts of a 
patient sent to me by Dr. George C. F. Williams, of Cheshire, Conn., who had lateral 
curvature of the spine. The projecting shoulder on the convex side of the superior 
curve was cut down, and the corresponding concavity built up. The undue projection 
on the convex side of the inferior curve was also cut down, and its corresponding 
depression filled up. The distorted lateral outlines of the waist were made to more 
nearly correspond to the normal. Changes analogous to those just described were 
also made in the cast anteriorly. Now, when the corset has been woven over the 
corrected cast and accurately adapted to the contour of its surface, it will retain its 
form when removed from the cast. It can be readily understood, therefore, that 
when it is applied to the distorted body of a patient, a corrective force will be con- 
stantly exerted by it that will tend to push the body into the improved form of the 
corset. All unnatural depressions having been filled up, abundant space will be left for 
the development of the corresponding parts of the body. All the unnatural promi- 
nences of the cast having been cut down, a corresponding degree of corrective force will 
be exerted on unduly prominent parts of the body. The corset is thus made to fulfill 
•'the double function of an automatic remedial agent and beautifier of external figure 
tontours. 
Again, casts of patients suffering from lordosis and round shoulders can be corrected 
so that when the spinal corset made for them is applied to the person, it will exert 
remedial pressure. To understand how this is done I will describe a cast of the body 
of a young lady patient sent to me by Prof. Seneca D. Powell, of New York. The 
cast was divided through at the waist. The upper part of the cast was then tilted 
forward until the lordosis had been corrected, and it was held in this position by a 
plug placed between the upper and lower parts posteriorly. The dimensions [of the 
wedge-shaped piece which it was necessary to remove from the upper part of the cast in 
order to correct the round shoulders, could now be very accurately estimated. Having 
marked upon the cast the dimensions of this wedge, the base of which pointed posteriorly, 
it was removed from the cast by means of a saw and used to fill up the gap made in the 
correction of the lordosis. Having removed the wedge-shaped piece, as already des- 
cribed, from the upper part of the cast, the surfaces were now placed in apposition and 
there resulted the correction of the cast for the round shoulder deformity. A corset 
made over such a corrected cast will, when applied to the patient, exert remedial pressure. 
There are many other ways in which casts may be modeled for therapeutic and 
other purposes, which will suggest themselves to those engaged in the treatment of this 
interesting class of cases. In modeling casts for females it is desirable oftentimes, for 
the comfort of the patient, but frequently for appearance sake, to make the breasts 
more or less prominent, according to circumstances. In this way the asymmetrical 
development of the mammæ in lateral curvature can be concealed from the eye, for a 
corset made over the corrected model will hold the clothing out equally on both sides. 
Material out of which the Corset is Constructed.-It is made directly out of wire in 
the form of thread. In this respect it differs from all other attempts to construct cor- 
sets out of wire. The desirability of constructing an open mesh corset has been recog- 
nized in various parts of the globe for a number of years, as shown by the efforts of SECTION VII- ANATOMY. 
219 
various inventors. All these efforts, however, so far as I am aware, have had for their 
object the adaptation of wire gauze in sheet form to the contour of the body. All such 
garments are very clumsy in appearance and unsatisfactory in use. The application of 
wire in the form of a thread to curvilinear contours, for therapeutic purposes, is, I 
believe, original with myself. The wire used in the construction of these corsets may 
be heavy or light, fine or coarse, soft or hard, according as it is necessary to meet the 
requirements for support, resiliency, weaving, twisting, etc. It may be made out of 
any desired metal or alloy of metal. For some time I have been constructing all my 
corsets out of the incorrodible alloy, phosphor-bronze. This makes a remarkably tough 
wire and, when woven up into form, a durable corset. The wire may be plated either 
before or after it has been worked up into corset form. This gives a brilliant finish to 
the completed garment. Again, the wire may be bound with silk, cotton or other 
textile filaments of any desired color or shade of color, after the manner of insulating 
wire for electrical purposes. Or again, the corset, after it is woven up into form, may 
be covered inside and out with a loosely woven or knitted textile fabric. By using 
properly selected materials, it is possible to vary the strength of the corset as required 
for individual cases. That the therapeutic indications can be met with a corset of the 
construction herein described, in the persons of heavy individuals suffering from Pott's 
disease and imperatively demanding efficient support, I have demonstrated over and 
over again. 
The Pattern of the Corset.-The pattern of the corset may vary in shape according 
to the requirements of the individual for whom it is especially constructed, or accord- 
ing to the therapeutic indications which it is intended to fulfill. Remedial stays for 
the treatment of Pott's disease may be constructed in three pieces. When using the 
corset for Pott's disease I prefer, however, to construct it in a single piece, with a 
quadrangular stay in the back, to which the other stays are riveted. By so constructing 
the corset any desired amount of strength can be secured. When plated, the corset is 
retained in position on the body by suitable lacings and clasps. Thus arranged, it is 
easily applied and removed. When a head-rest is required in conjunction with support 
for the body, as in treating caries of the cervical vertebræ, and usually of the dorsal 
vertebrae, the corset may be made in one piece and the thoracic shafts of the head- 
rest incorporated in the meshes of the corset during the process of weaving. 
Again, the corset may be made with one or morè openings or fenestra in its walls, in 
order to render feasible the dressing of wounds or sinuses while the corset is in position 
on the body of the patient. If used for ordinary wear or for the support of weak 
spines, or the cultivation and perfection of the human figure, it may consist of two 
lateral halves joined in the back by lacings and clasped in front. Finally, the pattern 
of the corset may be otherwise modified to meet the exigencies of individual cases. 
Weaving of the Corset into Form out of Wire.-As I have already stated, whatever 
the pattern of the corset may be, its distinctive feature is that it is directly constructed 
or woven out of wire in the form of thread, over a model of the body. Far greater 
nicety of adaptation to the contour of the body, or the ends of remedial endeavors, 
results from this plan of construction than can be obtained by working into form sheets 
of wire gauze. By weaving a corset of the pattern of twisted mesh, it will be found 
that when it is applied to the body and properly adjusted, during the respiratory 
efforts, the meshes themselves anatomically expand and contract with the expansion 
and contraction of the thorax. This feature of the corset, which can be secured by no 
other method of construction, is peculiar to my invention. 
The Application of the Corset to the Person of the Patient.-Having in hand a corset 
woven directly over a cast of the body of his patient, the surgeon, on the occasion of 
first applying it, should see to it that his patient is suspended with a skin-fitting shirt, 220 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
as when taking a plaster mould of the body. In this position he can apply the corset 
and adjust it more satisfactorily than in almost any other attitude.* When the corset 
is first applied the elastic lacings should be loose enough to permit of easily clasping it 
about the body of the patient. After fastening the clasps in front the lacings on either 
side and at the back should be drawn up so as to bring the corset closely in contact with 
the body all around over its entire surface. When this has been done the patient can 
be lowered from the suspension apparatus, and if a head-rest is attached, the head gear 
adjusted. Not infrequently, in adjusting corsets which have head-rests attached, it is 
necessary, as will be understood, to curve the cephalic shaft or alter the inclination of 
the short piece which connects it with the triangular shafts which are incorporated in 
the corset, so that the pivot holding the crossbar to which the head straps are attached 
is over the centre of the head. Should the corset cause any discomfort whatever, it 
should be removed at once and the part where the discomfort is experienced gently 
pounded out from the inside with some rounded wooden instrument, or, when applied 
to the patient, pressure can be relieved at any point by inserting a button hook through 
the meshes and making outward traction on the wire. Usually, the slightest alteration 
in the plane of the meshes will be sufficient to relieve any discomfort. If properly 
adjusted, on the occasion of first applying the corset, it ought to require no breaking in, 
but be comfortable from the first. 
There is one point to which particular attention should be paid. It is the adjust- 
ment of the strength of the elastic used as a lacing to the strength of the respiratory 
effort. When the corset is applied and laced up, as I have directed, the patient should 
be able to overcome the elasticity of the lacing so as to take a full, deep inspiration, 
without undue effort. Upon expiring, the elasticity of the lacings should cause the 
corset to automatically follow the receding chest walls, so that at no time during the 
respiratory effort do the chest walls leave the corset, as is the case with the plaster 
jacket, felt jacket and all other rigid enveloping spinal supports. This is the test 
which must be applied to each individual case. If it is found that the patient is unable 
to overcome the elasticity of these lacings, so as to take a full breath, it will be neces- 
sary to use lighter ones. If, during the process of expiration, it is observed that the 
lacings do not automatically keep the corset in contact with the receding chest walls, 
then one of two things is true : the corset has not been laced up properly, or the 
lacings are too wbak and should be replaced by stronger ones. The lacings can be 
secured in almost any dry goods store. If, however, those of the exact size desired 
are not in stock, I would advise taking two or three or more threads of small size, and 
using them as a single lacing. 
When the corset has been applied as directed and laced up, it is no longer necessary 
to readjust the lacings with each successive application of the corset. They will 
require readjustment only when the strain upon them has been continued for a suffi- 
cientlength of time to deprive them of a certain amount of the elasticity. A sufficient 
supply of lacings should be always kept on hand, so that when occasion presents the 
old ones can be replaced by new ones. 
Improving the Appearance of the Hopelessly Deformed.-It cannot be gainsayed that 
there is a very considerable number of patients who apply for treatment whose deformity 
cannot be overcome or even ameliorated to any considerable extent. The indications in 
all these cases are two. First, to relieve the sufferings of the patient by rendering him effi- 
cient support with a comfortable and movable apparatus. Second, to give him, when 
dressed in ordinary attire, as symmetrical a form as possible, in order that he may not 
®If, however, this is impracticable, the patient should be placed in a horizontal position and 
the corset applied and laced up while he is in that position. SECTION VII ANATOMY. 
221 
attract undue attention by the conspicuousness of his bodily deformity. To this latter 
end it is customary to apply pads of varying thicknesses and sizes over the abnormally 
depressed parts of the body, either on the inside or outside of the spinal jacket, in order 
to give the appearance of a symmetrical form when the patient is clothed. These pads 
are not only hot and uncomfortable, but they also absorb the perspiration of the body, 
and soon become filthy. There is an additional objection, viz : that such pads are con- 
tinually changing their form. To overcome these serious objections I resort to the 
following method in constructing one of my wire corsets : An exact cast of the body 
is made. Over this cast a skin-fitting knit shirt is drawn. A mortar of plaster-of-Paris 
and water is now used to fill up the undue depressions of the body, so as to make the 
cast appear as symmetrical as possible. After having done this, the shirt is cut down 
in front and removed, together with the newly constructed pad of plaster. We are 
now ready for the weaving of the corset, which is proceeded with over the original cast 
after the manner already described in detail. Before removing the corset from the cast 
or mould over which it has been woven, the plaster pad or pads modeled on the outside 
of the shirt, and which give the appearance of greater symmetry to the form, are now 
placed in their respective positions over the wire corset. With these pads in place, 
strands of wire are intertwisted with the meshes of the corset at the upper margins of 
the body. The dependent portions of said strands are subsequently intertwisted and 
woven into a mesh covering the pad and corresponding to its contour. The pad is then 
removed, and the margins of the newly woven piece are made fast to the original 
corset. There results, as can be readily understood, a space between the original 
corset which exactly fits the contour of the body and that part of the garment which 
corresponds to its external contour, and which restores the symmetry of the body when 
the corset is applied to the person and the patient is attired in ordinary clothing. 
In this manner, the hot, uncomfortable pads which are commonly used under the 
clothing to restore the symmetry of deformed bodies are done away with, and we have 
a cool and hygienic garment instead thereof. 
Special Provisions for Exerting Additional Remedial Pressure through the Agency of the 
Wire Corset.-Under the head, modeling casts for therapeutic purposes, I have called 
attention to the fact that corsets woven over corrected models of the body of deformed 
patients exert remedial pressure when applied. There are, however, a considerable 
number of examples of spinal asymmetry in which it is desirable to exert upon unduly 
prominent parts of the body the maximum degree of corrective pressure which can be 
borne without causing the patient unnecessary inconvenience and discomfort, and at 
the same time, without necessitating the weaving of conspicuous apparatus. For this 
class of cases I have devised a useful adjuvant to the already described plan of exerting 
remedial pressure. It consists in the peculiar weaving of the corset, and in the attach- 
ment to it and conjoined use of elastic lacings placed on the outside of the corset over 
the site of the abnormal prominence. The weaving of the corset is so executed as to 
permit, when completed, of the crowding together of its meshes from side to side. 
Being in possession of a properly woven corset, the meshes of which may be crowded 
together to any desirable extent over the unduly prominent parts of the body, narrow 
strips of strong cloth or leather, provided with eyelets, are sewed or otherwise fastened 
to the corset stays on either side of the abnormal prominence. The elastic lacing is 
now introduced through the eyelets and stretched across that part of the corset which 
is over the unduly prominent part of the body. By tightening the lacing the meshes 
of the corset are crowded together and the degree of pressure thus regulated. Now, 
when the corset is placed in position on the body, it will be necessary to expand the 
meshes under the elastic lacing in order to get the corset into proper position about 
the body. Once secured in position on the body, a gentle elastic force will be con- 
stantly exerted against the abnormal prominences. 222 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Adjuvants.-Under the heading "How and where to get hold of the Body," I 
called attention to the fact that when disease of the spine was located in the dorsal 
region, it is impossible to furnish the desired amount of support without resorting to 
some adjuvants to which the weight of the body above the seat of disease may be 
transferred. Of several adjuvants which I have invented for this purpose I wish 
to mention one, the suspension tricycle. It is used as follows : To the wire corset 
shoulder straps are sewed on either side, and upon these shoulder straps small rings 
are placed. To these rings are attached elastic straps connected with the cross- 
bar of the tricycle. The crossbar is suspended by means of a cord which passes 
through the pulley in the tricycle over the head, midway between the two upright 
shafts. From thence it passes over another pulley down to a cleat riveted to one of 
the lateral shafts of the tricycle. By means of this arrangement any desired amount 
of upward traction can be exerted. When the patient is in the tricycle the front 
part of the shoulders is brought up against the lateral shafts of the apparatus, and in 
this way it is pushed forward at the same time, being guided by a lever. 
Binding of the Corset.-The stays and edges of the corset may be covered with strips 
of cotton, silk, velvet or any other fabric. I have recently invented a method of 
covering the stays and the edges of the corset with unabsorbing and incorrodible mate- 
rial, such as hard rubber, celluloid, etc. 
Therapeutic Advantages.-The therapeutic advantages of this corset are, that it 
affords more efficient and constant support than any other form of apparatus ; that it is 
resilient and therefore not irksome to the wearer ; that it is extremely cleanly, not 
absorbing the perspiration ; that it affords perfect ventilation to the body ; that it per- 
mits of easy and unrestricted expiratory movements ; that it is durable, elegant, and 
thoroughly adapted to the varying contours of the body and exigencies of individual 
examples of diseases, deformities, and weaknesses of the spine. It possesses, in addition, 
the superior qualities of extreme lightness, compared with many of the corsets or 
spinal supports now in use. Furthermore, the discharges from the body when brought 
in contact with it, do not weaken it or render it foul by their absorption, as is the case 
with the plaster-of-Paris jackets, felt jacket and supports made of felt or other similar 
materials. It does not absorb and become fouled by the perspiration. 
I have now fully described my invention and indicated in general terms its uses. 
Though this is the first occasion of formally bringing it to the notice of the members 
of the medical profession, I commend it in no uncertain language. My reasons for 
doing this are good. During a period of nearly four years I have been engaged in 
practically testing its value. To this end I have applied it to a large number of 
patients whose cases represent all forms of spinal affections in which mechanical sup- 
port can be advantageously used. The results which I have obtained in the treatment 
of this class of cases during this period are far better than I have ever before known to 
be generally obtained or have myself been able to obtain while using other forms of 
spinal support. Complaints of undue pressure at certain points, so commonly met 
with in using the plaster jacket, felt jacket, and other forms of spinal supports, have, 
in my experience with the wire corset, been almost unknown. I have found that it 
possesses a wider range of applicability as a therapeutic agent in spinal affections than 
any other support which I am acquainted with. In short, extended experience, close 
observation, earnest study and the subjective testimony of patients who have worn 
many other forms of spinal supports, force upon me the conviction that, for efficiency, 
cleanliness, comfortableness, inconspicuousness, and elegance, the wire corset has no 
equal. SECTION VIT ANATOMY. 
223 
DISCUSSION. 
Dr. W. J. Herdman, of Ann Arbor, Mich.-I have been much impressed with 
the value of Dr. Roberts' suggestions, and wish that his paper could have been read 
before the entire Congress, instead of one Section only. The importance of the sub- 
ject, the careful and painstaking manner in which he has presented it, and the 
admirable illustrations with which it has been attended, have made it fully worthy 
of such distinction. Cases of spinal curvature are not of interest solely to the 
specialist. So numerous are they in all classes of society and everywhere that the 
general practitioner must, of necessity, have more or less to do with them, and so 
important is it that the nature of the disease should be recognized early and the 
proper treatment applied, that an intelligent exposition of the causes of the distor- 
tion and of the principles underlying its treatment cannot be too widely disseminated. 
The primary reason why greater success has not attended the treatment of curvatures 
of the spine is because of woeful ignorance, on the part of many who undertake its 
cure, of the mechanism of the parts involved. All will concede the first essential to 
a proper understanding of spinal curvature is a thorough knowledge of the anatomy 
and physiology of the trunk of the body-a knowledge of the structure and working 
of the machine. Who would not think it foolhardy to place a man in charge of the 
locomotive of a passenger train who was ignorant of the arrangement and purpose 
of its varied parts ? But how much more complicated and intricate, by comparison, 
is this part of the mechanism of the human body, with its bones, ligaments, carti- 
lages and muscles, making not only one but many joints capable of a great variety 
of movements? The shoulder, elbow or hip joint is a simple structure to compre- 
hend as compared with the spinal column, and there are few, if any, who have made 
a mastery of it. But a knowledge of the normal must be the starting point for a 
proper understanding of the abnormal, and the orthopædic surgeon, above all others, 
if he would be successful, must heed this fact. 
The second essential in the successful treatment of cases of spinal curvature is 
ingenuity on the part of the surgeon in devising means for correcting the disordered 
action. No two cases are alike. Each has its peculiarities, and no fixed form of 
apparatus can be made to meet the requirements of successive cases. It is the mind 
and dexterity of the surgeon that controls the forces and works the cure, while the 
material he- employs is of minor importance, provided it may be made to fulfill the 
conditions in a satisfactory manner. 
But in the selection of a material for a spinal support it is essential that one be 
chosen which, while it meets every requirement for the successful treatment of the 
case, will at the same time be always ready at hand and within the means of all. 
Plaster-of-Paris has, through its intelligent use by Dr. Sayre and others, proved a 
most valuable agent, solely for these reasons. By means of it the surgeon's idea of 
treatment can be materialized by his own hand, and the substance he employs for 
the purpose is so cheap that it is within the reach of all who are in need of it. No 
material will be able to replace plaster-of-Paris as an agent in the treatment of 
spinal curvatures that cannot compete with it successfully in these two particulars, 
i.e., cheapness and adaptability. It would seem that in the wire gauze or netting 
employed so successfully by Dr. Roberts we have a material that bids fair to replace 
plaster-of-Paris, since, aside from being an agent equally efficient in meeting the 
required conditions of support, it is, or ought to be, cheap ; and certainly it is 
lighter, much more elegant and cleanly. 
We are all indebted to Dr. Roberts for calling our attention to this material, and 
his admirable illustration of its adaptability to the requirements of all forms of 224 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
spinal curvatures. But those who are engaged in the treatment of cases of spinal 
disease must not overlook the fact that no form of spinal brace will of itself return 
a distorted spine to normal shape and action. With it, properly applied, much may 
be done to arrest the deformity, and by it something may be gained in the way of 
restoring weakened and diseased portions of the spinal mechanism ; but at the best 
it is a temporizing measure, employed to gain time and arrest further progress of 
the deformity, while attention to the general bodily condition, massage, electricity 
and properly devised gymnastic exercises, all have their part to play in effecting a 
cure or establishing permanent improvement. 
PROPER METHODS IN THE TEACHING OF ANATOMY. 
METHODS PROPRES À L'ENSEIGNEMENT DE L'ANATOMIE. 
DIE RICHTIGEN METHODEN FÜR DEN ANATOMISCHEN UNTERRICHT. 
BY A. H. P. LEVE, M.D., 
Of Philadelphia, Pa. 
The object of this paper is to point out briefly the defects of the present plan of 
anatomical instruction, and to show that, in fact, it is not a plan, for it lacks method. 
There seems to be no objective point except that of cramming facts into unwilling 
heads, with the trite information that it is most likely to be of subsequent use. 
The defects of the present method, or lack of method, may be summarized as fol- 
lows :- 
1. The instruction is special, thorough and complete only as regards certain organs 
or parts of the body. 
2. It is too general as regards other organs or parts of the body. 
3. It is neither the one nor the other as regards still other organs or parts of the 
body. 
4. It is the custom to generally overlook those relations of organs to one another 
which, if properly taught, would be very useful to remember. 
5. There is a general failure to prepare the student's mind with a proper incentive 
to acquire anatomical knowledge before it is imparted. 
6. Too little is said of the philosophy or principles of anatomy, which, if properly 
taught, would make remembrance easier. 
7. The failure to always clearly show the relations of anatomy to the other branches 
of medicine. 
8. Incompetent teachers, or such who, though competent, are indifferent or have not 
sufficient time to do their duty. 
The remedy for this state of affairs may be tersely summarized as follows :- 
1. Teach the special anatomy of every organ or part of the body distinct from all 
others, and do it thoroughly and completely. 
2. Give also a general idea or outline of each organ or part of the body. 
3. Never fail in any instance to do this in the case of every organ or part of the body 
so far as our knowledge will admit. 225 
SECTION VII ANATOMY. 
225 
4. Invariably show the true and exact relations of the parts to each other. 
5. Always try to create in the student's mind a desire for the knowledge to be 
acquired by showing its necessity. 
6. Show in a natural way, without too much mnemonics, how many anatomical 
principles and associations there are which, if remembered, will do alike for many or 
all parts of the body. 
7. Give thorough instruction as to the relations of anatomical study to the other 
branches of medicine. 
8. Obtain the services of thoroughly competent teachers, and only such as can attend 
to their whole duty. 
My purpose now is to separately consider these summarized headings in outline so as 
to more clearly bring out their meaning. 
DEFECTS OF THE PRESENT METHOD. 
1. The instruction is special, thorough and complete only as regards certain organs or 
parts of the body. 
The heart, blood and lymph vessels, stomach, gut, bladder, seminal vesicles, Fal- 
lopian tubes, uterus, vagina, gall bladder and ducts generally are all hollow, contractile 
organs, having essentially the same structure, and yet are pointed out to the student 
individually as separate and distinct organs, and as though to have studied one was not, 
in a way, to have studied all. Here the individualization of parts of the body is 
extreme and leads to wrong impressions, which too often are never removed. In the 
study of one or a few of these organs, an effort is made at generalization by a passing 
remark, for instance, to the effect that they all have muscular coats composed of longi- 
tudinal and transverse fibres, and that the longitudinal fibres are external to the trans- 
verse. Yet just here there is a failure to impress the fact that this is a general rule that 
affects the arrangement of muscle bundles throughout the body-transverse fibres 
internal to those that are longitudinal. The anatomy of the nervous system, as gener- 
ally taught, is behind the times. While considerable is said about the stomach, gut 
and liver, the spleen and pancreas are passed over in a few words. 
2. It is too general as regards other organs or parts of the body. 
Thus, muscles are apparently described with considerable minuteness and their 
actions taken up in the same way, whereas, many of their important anatomical fea- 
tures are overlooked and an analytical study of their actions avoided. Let me instance 
the deltoid. It is said to abduct the arm. Some books give it credit for doing more. 
No book, however, credits it, so far as I am aware, with all its actions, and those are 
abduction, adduction, anteduction, retroduction, in-rotation and out-rotation. That it 
is of great importance to implant this accurate knowledge, no one who has kept abreast 
of modern research can deny. Great attention is given to the formation of the axillary 
plexus, but comparatively little is said of the exact muscular and cutaneous distribu- 
tion of its branches. In the medicine of the present day, when we often have to 
locate pathological processes through our knowledge of the significance of anæsthetic 
and hyperæsthetic areas, of motor joints, and our knowledge of the nerve supply of 
muscles, it is of extreme importance that every one be taught accuracy in anatomy. 
This shows the necessity for accurate anatomical knowledge for the physician. So, also, 
is it necessary to know exactly the various collateral channels of circulation and the 
exact attachment, action and location of muscles. 
3. It is neither the one nor the other as regards still other organs or parts of the body. 
For instance, we fail miserably in reaching even the usual standard of either spe- 
cific or general instruction in teaching the anatomy of the lymphatic apparatus, the 
sympathetic nervous system and the venous system. Especially is this true as regards 
their connections with each other. The failure in this instance is more with teachers 
Vol. Ill-15 226 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
than with books. The confusing nomenclature helps to increase the obscurity of what 
little is taught in this direction. 
4. It is the custom to generally overlook those relations of organs to one another which, if 
properly taught, would be very useful to remember. 
Let me call attention to how few appreciate the small interval between the liver, 
stomach and spleen on the one hand, and the right lung, heart and left lung, respec- 
tively, on the other hand. How many realize the relative proportions of the oesophagus 
and trachea, or the relations of the inferior vena cava to the liver, diaphragm and right 
auricle ? Again, how many can tell with reasonable accuracy the distance between the 
anterior and posterior lacerated foramina of the cranial base, or between the supra- 
orbital and mental foramina ? How does a man turn his body and head half way 
round ? What muscles do this ? Is this often taught ? Witness the making of a post- 
mortem examination by what is usually considered a well-informed medical man, and 
see his utter helplessness. See where he gropes for the kidneys or spleen, and note 
with what perseverance he searches for a pancreas where it never was intended to be. 
How many men have grasped the bodies of the lumbar vertebras, ready to cry "Eureka!" 
in the fond belief that they had discovered an abdominal scirrhus ! The fault here lies 
at the door of the teachers of anatomy. 
5. There is a general failure to prepare the student's mind with a proper incentive to 
acquire anatomical knowledge before it is imparted. 
This is a great and, I believe, universally prevalent defect. Occasionally, especially 
with reference to some parts of the body, it is done, but, as a rule, it is either wholly 
neglected or but feebly attempted. It is not sufficient to state that such and such 
knowledge is imperatively necessary to the making of an ideal physician or suigeon, 
but every statement should be backed by at least one good example. This failure to 
show a reason for the attainment of difficult facts seems to be one of the most deplor- 
able and most damaging of the present defects in anatomical teaching. Its disadvan- 
tages cannot be over-estimated. Anatomy is usually a dry branch of medicine, whereas 
it should be the most interesting. Let students see why they should learn these facts. 
Beautify anatomy in their eyes by showing its usefulness and application. Give the 
students pegs of demand upon which to hang anatomical facts. The present prevailing 
method is to thrust at learners innumerable isolated or partly connected facts, with the 
repeated advice that it is knowledge that will prove of much future use ; and as they 
advance in their studies, it is the rule not to show them how their knowledge, not only 
of anatomy, but other branches as well, helps them in the acquirement and retention 
of additional information. 
6. Too little is said of the philosophy or principles of anatomy, which, if properly taught, 
would make remembrance easier. 
For example, not enough attention is paid to the common structure of mucous mem- 
branes and their annexa-glands. How many students understand that glands are 
indented and modified mucous membranes ? In the enumeration of the parts of the 
body developed from the blastodermic layers, no special effort is made to inculcate the 
principle of the development in such a way as to make it easier to understand and 
remember. The rule too often is for teachers, on the day before the lecture, to memorize 
what structures are developed from the various blastodermic layers, and then give it to 
their hearers like a parrot, and feel relieved when they have successfully passed the 
ordeal. Then, again, much more should be said than is usually done about the general 
plan of our bodies and their parts, and they should constantly be compared, both as 
regards structure and function. It is of vast importance to know the physiological 
relations of one part of the body or organ to another, and yet this is most imperfectly 
taught. The fascination of anatomy to those who feel its attraction is in the wonder- 
ful mechanism it brings to view, and the incentive it offers for the satisfactory exercise SECTION VII ANATOMY. 
227 
of the reasoning faculties. To bring about a reasoning habit is, therefore, one of the 
many ends to be attained in the dissecting room, in addition to the common one of 
imparting dry anatomical facts. 
7. The failure to always clearly show the relations of anatomy to the other branches of 
medicine. 
Let me instance the relations of the lungs to the heart in heart disease, or of the 
liver to the heart under the same conditions. Again, of the alimentary tract and portal 
system to the liver. Also, the necessity of remembering nerve distribution and motor 
points by giving examples of imaginary or actual cases. Students are permitted to get 
and retain the idea that thorough anatomical knowledge is only necessary to the sur- 
geon, and only slightly so, and then only in special regions, for the physician; whereas 
the fact is that this knowledge is equally necessary to both, and can never be either too 
minute, accurate or extensive. It must be remembered that these defects are lasting. 
If not eradicated during college life, they become permanent fixtures of one's profes- 
sional character. No one can gainsay me when I afiirm that the mass of practitioners 
fail utterly to comprehend the true relations of different parts of the body, or of the 
body itself as a whole, and this fault is principally due to a cause summed up in the 
few words-incompetent or careless instructors ; at all events, defective instruction. 
8. Incompetent teachers, or such who, though competent, are indifferent or have not suffi- 
cient time to do their duty. 
Of those who are indifferent or who have not sufficient time to do their duty, it may 
be said that they should resign and give place to men equally as competent and more 
willing to do their full duty. Of the incompetent, it may be said that they should 
never be appointed. College faculties commit a great wrong by appointing men to 
teach this important branch who themselves confess that the only object in taking the 
position is to make capital and to compel themselves to learn anatomy to the extent 
which seems to them desirable or necessary. This is an imposition upon the students, 
who confidently place themselves in the care of a trusted institution for the purpose of 
acquiring a medical education at a par with the medicine of the times. 
THE REMEDY. 
This is simple enough, and consists in overcoming the defects just indicated. For 
this purpose, it is not only necessary that teachers of anatomy be good practical and 
thinking anatomists and students, but that they be philosophical as well as practical 
physicians in every sense of the word. At no time in a medical education is instruction 
so potent for future usefulness, or its neglect so certain of ultimate failure, as the work 
done in the dissecting room and the quality of the anatomical lectures before the class. 
1. Teach the special anatomy of every organ or part of the body distinct from all others, 
and do it thoroughly and completely. 
While in following this plan the student may not recall all that is told him, he has 
the benefit of thorough instruction, and enough will remain to leave a clear outline 
around which future studies will cause to crystallize those additional facts which at 
first failed to secure a hold. Thoroughness and repetition are of prime importance in 
teaching this difficult branch. Innumerable facts are not memorized with ease and 
never to any decided advantage unless their relations to each other are mastered in the 
smallest detail. The instruction covering any part, therefore, should be specific, 
detailed and thorough. 
2. Give also a general idea or outline of each organ or part of the body. 
This is necessary, as it emphasizes the most important facts to be remembered, and 
thus insures the attainment of the main object of the preceding paragraph. Of mucous 
membranes, for instance, it might be said that they all are composed of thin layers, 
i. e., a superficial one of cells, a middle one or basement membrane, and a deep one or 228 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
submucosa. In the liver, the five fissures, five lobes, five ligaments and five vessels 
could be briefly summarized. In the thigh, a single mention of its form could be fol- 
lowed by the statement that it is composed of a bone, muscles, vessels, nerves, loose 
connective tissue, fat, fascia and skin. The bone is the femur ; the muscles being the 
four leg extensors, four adductors, two flexors of the thigh, a superficial group of three, 
three extensors of the thigh, six out-rotators, and four flexors of the leg ; the fascia 
lata and its intermuscular septa; the anterior and posterior sets of vessels ; the anterior 
and posterior nerves ; the loose connective tissue and fat variously predominating in 
different portions of the thigh, notably in the groin and upon the inner side ; and lastly, 
the skin over all. 
3. Never fail in any instance to do this in the case of every organ or part of the body, so far 
as our knowledge will admit. 
By adhering to this rule it is much easier to show the relations of different parts of the 
body to each other, and so make the whole mechanism more easily comprehensible. It also 
lessens the chance of students receiving false impressions of the relative importance of 
parts of the body. It is natural to suppose that those organs that are most thoroughly 
explained are the most important, whereas this rule by no means always follows. 
Because it is more difficult to teach the anatomy of certain organs or regions is no reason 
why the task should be shirked. A true and competent teacher would be all the more 
anxious to devise means for its simplification, so as to bring it before students in a 
manner to make it easy of comprehension and remembrance. 
4. Invariably show the true and exact relations of the parts to each other. 
This facilitates still more the comprehension of the whole mechanism. For instance, 
how many students ever have it impressed upon their minds that the upper fibres of 
the pectoralis major and the anterior fibres of the deltoid act alike ? How often is a 
student made to realize the difference in the action of the anterior, middle and posterior 
fibres of the deltoid ? Again, the same may be asked of the upper and lower fibres of the 
pectoralis major or trapezius. Note the great similarity of action between the posterior 
fibres of the sterno-cleido-mastoid and the anterior fibres of the trapezius, and their being 
both supplied by the one nerve. Are students ever permitted to realize that the deltoid 
is a downward continuation of the trapezius, and that both muscles may be viewed as one 
large, triangular, fleshy mass, having its base of origin from the posterior median line of 
the body from the occipital protuberance to the last thoracic vertebra, whence its fibres 
converge over the shoulder, forming its cap, to be inserted into the middle of the outer 
side of the humerus ? In its course over the shoulder, it has the bony interruption of 
the shoulder girdle. Anatomy taught in this way has its fascination. Many and many 
a dull man have I seen develope a lively interest in the work of the dissecting room after 
pointing out facts of this kind and affording an opportunity for the exercise of reason. 
We are too apt to teach that the action of muscle is to produce that effect which equal 
contraction of all its fibres necessarily yields, but this is fallacious. Parts of muscles 
may and do contract independently. Contiguous borders of muscles contract while the 
remaining portions are passive. This is not generally taught, but should be. These 
four illustrations suffice to show my meaning, and similar ones may be had from all 
parts of the body. 
5. Always try to create in the student's mind a desire for the knowledge to be acquired 
by showing its necessity. 
This can be done by supposing fictitious cases or citing actual ones, preferably such 
as have been seen by the students themselves. Suppose a fracture of the humerus, 
with a large effusion of callus, and consequent compression of the musculo-spiral nerve, 
and the incidental wrist-drop and radial anaesthesia. Suppose muscular atrophies and 
disease of motor or sensory nerves. Suppose disease of the cerebro-spinal axis. Give 
symptoms and exercise the student's mind in locating the lesion, or suggest a lesion SECTION VII ANATOMY. 
229 
and let the symptoms be worked out by the dissector. Suppose, again, an oral hemor- 
rhage, and then let the student say, if possible, whence the blood came. Show then 
the different places from which it may have come. They can be taught how a nasal 
hemorrhage may give rise to bloody vomit, and will be only too glad to master the 
anatomy of the nose, and learn how to plug it in case of nose-bleed. In this way 
they will be anxious to learn, will do it readily, and will retain it better than in the 
usual way. They can be told that a bronchial hemorrhage does not necessarily 
imply phthisis, and then they will be only too eager to learn how this can be a symptom 
of heart disease. These examples, I hope, are enough to clearly convey my meaning. 
6. Show in a natural way, without too much mnemonics, how many anatomical princi- 
ples and associations there are which, if remembered, will do alike for many or all parts of 
the body. 
Thus, for instance, all organs, whether bones, muscles, or viscera, are composed essen- 
tially of a supporting framework of connective tissue containing essential cells, nutrient 
vessels, coordinating nerves, and sometimes efferent ducts. Again, to quote from a 
former paper of mine,* " It is an invariable rule for muscles to act on every joint they pass 
over." " It is evident, also, that the action of a muscle on a joint depends upon its rela- 
tions to that joint." Now, inasmuch as moving a joint will often change the relative 
positions of it and its motive muscle, it follows that the actions of muscles may 
change during contraction, or act either with increased or diminished effect. These 
will suffice as examples of principles. I will instance associations, as follows : Each 
bicipital ridge has attached to it a muscle; to the inner, or posterior, the teres major and 
to the outer, or anterior, the pectoralis major, i. e., a " major " to each ridge, the ante- 
rior ridge having inserted into it the anterior or pectoral " major " muscles, while the 
posterior ridge gives attachment to the posterior or round major muscle. The associa- 
tion is a simple one. Again, take the scapula; it is three cornered, has three borders 
and three great fossa. (Supra-spinous, infra-spinous and subscapular.) Attached to 
it are three muscles arising from these fossæ and bearing corresponding names. (Supra- 
spinatus, infra-spinatus and subscapularis.) The anterior border gives attachment to a 
group of three muscles (teres major, teres minor and triceps). The posterior border 
affords insertion to another group of three (rhomboideus major, rhomboideus minor and 
levator anguli scapulæ). The coracoid process gives origin to three muscles (short head 
of biceps, coraco-brachialis and pectoralis minor). Then there remain three unclassi- 
fied muscles (longhead of biceps, omo-hyoid and serratus magnus). There still remains 
a pair of processes (coracoid and the acromio-spine) and a pair of muscles (deltoid and 
trapezius). Another association is noticed in this way : Going from below upward 
are both the anterior and posterior scapular border; the first muscle is a " major " and 
the second a ' ' minor, ' ' being the teres muscles in front and the rhomboids behind. 
Associations of this kind are not too artificial, aid remembrance, and are possible in 
all parts of the body. 
7. Give thorough instruction as to the relations of anatomical study to the other branches 
of medicine. 
Take the liver, for example. Show its structure, and let the student realize that the 
blood of the whole alimentary tract, from the cardiac orifice of the stomach to the 
anus, inclusive of that from the spleen and pancreas, must pass to the heart through 
the capillaries of the liver. Show clearly that in doing so it must pass through the 
central vein of the lobules. Show also that every lobule is surrounded by connective 
tissue. Explain that if this tissue is inflamed, it proliferates, increases and eventually 
contracts, and that in doing so it compresses, squeezes, the lobule and its central vein, 
* The paper is entitled " Additional Factors Concerned in Fractures of the Humerus in the 
Vicinity of the Elbow Joint," and appeared in the Annals for Anatomy and Surgery, July, 1881. 230 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and so obstructs the flow of blood through the liver to the heart. Tell them that this 
compression or constriction may become so excessive as to lead to marked damming 
back of blood in the veins of the alimentary tract and cause turgescence, elongation and 
convolution of the veins ; haemorrhoids ; gastro-intestinal hemorrhage ; alternating 
constipation and diarrhoea ; anasarca ; inevitable failure of the digestive power ; loss 
of appetite ; falling strength ; and ultimate death. Thus, the study of anatomy would 
become objective and interesting throughout. 
8. Obtain the services of thoroughly competent teachers, and only such as can attend to 
their whole duty. 
The too prevalent custom in this country is to appoint dissecting-room teachers 
from among those who admittedly only desire to learn a little anatomy themselves, and 
who want to use the demonstratorship as a stepping stone to what, in their eyes, is a 
better position. The dissecting room is the place where can be laid to best advantage 
the foundation of the medical education of every student. It is, therefore, of the 
utmost importance that demonstrators be thoroughly competent. The importance of 
the position in this country is far below what it is said and appears to be in Europe. Our 
practical anatomy is too often in the hands of incompetents, who are appointed to their 
positions through injudicious and vicious influence, at the cost of such as have the 
requisite ability and would give sufficient time to the scientific advancement of this 
branch, besides teaching it in a manner making it a pleasant, in fact a fascinating, 
study. It is an outrage upon the students who confidently pay their money, as well 
as upon the public at large who will have to employ them when they graduate, to 
entrust the very fundamental work of their medical education with those who have 
hardly begun to realize the scope and depth of medical science. Time and again have 
I seen demonstrators compelled to ' ' read up ' ' for special demonstrations, or even to 
correctly answer an ordinary question, for instance, as to the attachment of a muscle 
or the branches of a blood vessel. That the existence of facts like these is a disgrace, 
no one can deny. That every such appointment is a fraud upon the student and com- 
munity, all must admit. That it lowers the grade of institutions that tolerate it, 
is inevitable. That it keeps ambitious, competent and able talent in the back- 
ground, and thus retards the advancement of anatomical science, goes without saying. 
Weed out the incompetents ; appoint the able, willing and ambitious ; remove these 
when their ardor cools or when their attention is diverted by other interests, or make it 
to their advantage to devote themselves exclusively to the work for which they have 
proven their fitness. Good teachers are worth having at even considerable expense, 
and not over-plentiful at any time Never appoint an incompetent to teach anatomy, 
or for that matter any branch, but train or grow the teacher. Prove fitness before 
appointment, and then let the position be first held for a definite period on trial. 
The excuse that there are not enough in our ranks of those who like or are well 
versed in anatomy is fallacious, for there are many. SECTION VIII-PHYSIOLOGY. 
OFFICERS. 
President: JOHN H. CALLENDER, M. D., Nashville, Tenn. 
VICE-PRESIDENTS. 
J. Rose Bradford, m.d., London, England. 
Richard Caton, m. d., Liverpool, England. 
Daniel Clark, m. d., Toronto, Canada. 
Austin Flint, m. d., New York, N. Y. 
Wm. Dobinson Halliburton, m. d., London, 
C. H. Hughes, m. d., St. Louis, Mo. 
Wm. Abram Love, m.d., Atlanta, Ga. 
John Alex. McWilliam, m. d., Aberdeen, Scot- 
land. 
H. P. Stearns, m. d., Hartford, Conn. 
England. 
SECRETARIES. 
Randolph Barksdale, m. d., Petersburg, Va. 
R. W. Bishop, m. d., Chicago, Ill. 
Edouard Fournlé, m. d., Paris, France. 
Bernard Frankel, m. d., Berlin, Germany. 
COUNCIL. 
O. Everts, m. d., Cincinnati, Ohio. 
W. Hutson Ford, m.d., St. Louis, Mo. 
J. Henry Jackson, m. d., Barré, Vt. 
C. H. A. Kleinschmidt, m.d.,Washington, D.C. 
T. S. Latimer, m. d., Baltimore, Md. 
Thomas O. Summers, m. d., Jacksonville, Fia. 
A. Wetmore, m.d., Waterloo, Ill. 
J. H. Wythe, m. d., Oakland, Cal. 
231 232 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met in the Physiological Lecture Room of Columbian University, 
on Monday, September 5th, 1887, at 3 P. M., and was called to order by its Presi- 
dent, Dr. J. II. Callender, of Nashville, Tenn., who delivered the 
INTRODUCTORY ADDRESS. 
Gentlemen :-In formally inaugurating the proceedings of the Physiological Sec- 
tion of the Ninth International Medical Congress, it affords me great pleasure, in 
the name of the workers in that field of medical science in this country, to tender an 
earnest and cordial greeting to those present who have come from other countries to 
contribute to the information expected to be imparted in those proceedings, and to 
afford interest to its discussions, and to participate in this great convention of medical 
men representing many peoples and all departments of our extensive science. This 
salutation is as comprehensive in its scope as the area from which you have journeyed, 
and as sincere in its expression as the spirit which has moved you to come. I hope 
that the exercises through which this Section may pass will in some measure repay 
you for the journey, and form an agreeable and profitable memory to you in the 
history of this Congress and the recollection of your visit to the Capital city of the 
United States of America. We are assembled not only as devotees of science, hoping 
to derive mutual benefit from the interchange of opinions on themes of professional 
interest, and from new researches into the mines of scientific store to be unfolded, 
but we are here as fellow-men, bonded in the sympathy of common labors and pur- 
suits, and entertaining for each other sentiments of esteem flowing from the elevated 
calling of which we are members. I earnestly trust the former expectation may be 
amply realized, and that the estimation in which we hold each other may be enhanced 
by the personal contact and intellectual and social enjoyment which will be felt in the 
sessions of this Section and of the Congress ; and that the occasion may be instru- 
mental in forming valued friendships between those heretofore known only by name 
and character, and of strengthening the ties of those heretofore formed. In such 
assemblages, the scientific object is hardly more important than the amenities and 
humanities with which it may be mingled, and it cannot but be, that all of us- 
whether foreign or native here-shall come to know, in this current week, that the 
"bright consummate flower" of these can be cultivated to the highest perfection 
in this representative city of enlightened, prosperous and hospitable America. 
Since the Presidency of this Section was assigned to me by those in charge of the 
organization of this Congress, it may not be out of taste for me to say, that in under- 
taking its duties, a more than usual pressure of multifarious official duties has 
oppressed me with more than a usual sense of my unworthiness of the distinction it 
confers and the responsibility it imposes, and that I have been painfully distrustful 
that its work, under the imperfect management it has received, would fall short of SECTION VIII-PHYSIOLOGY. 
233 
the just expectations of those who might attend its sessions; and at times have felt I 
should have obeyed the first impulse and declined the duty, knowing it could have 
been more capably performed by many of my brethren more justly entitled to the 
honor of the position. Under this feeling, I have only been sustained by the gener- 
ous aid offered in the task of organization, and by the knowledge that in the discharge 
of my functions now, I shall have the cooperation of the accomplished men who 
form the roster of Vice-Presidents and Council. Until almost the latest moment 
before leaving home, other engagements have so taxed my time, that it seemed the 
only contribution possible to the meetings of the Section I could make, and perhaps 
the best to be made, would be the performance of the routine duties of the chair and 
a respectful listening. A proper sense, however, of the trust and dignity of the 
position, has impelled me to prepare an introductory address, in some degree appro- 
priate to this opening Session, the brevity of which, at least, will perhaps be appre- 
ciated, and a pardon for these personal allusions, I hope, may be, at the same time, 
granted. 
This Congress has met to consider the present state of the science of medicine- 
to promote its advancement as a pure science and its perfection as a practical art- 
and to consult of its interests as one of the highest professions which can enlist the 
thought and energies of men. Its general meetings will, in some respects, doubtless, 
pass under review many of the features of these important subjects, in which all of 
its members are immediately and deeply concerned. Those of us, however, who 
compose the body of this Section, and are entrusted with the conduct of its exercises, 
in the subjects to be discussed here, are more directly concerned with medicine in its 
strictly scientific relations. Medicine, to speak accurately, is a mixed science and art 
for the cure and relief of all physical disorders and infirmities. As a science, it is an 
aggregation of different species of knowledge, or separate sciences, and that of physi- 
ology, or the conditions and laws of life and organization in a state of health, and of 
the iunctions of tissues and organs, is one of the cardinal and indispensable compo- 
nents of medical science. Until by the accumulated labors of many generations of 
observers, there was a systematic body of knowledge, more or less exact, of the func- 
tions of organized bodies, medicine was nothing more than an unqualified empirical 
art, and could not be otherwise. Indeed, while it is true that a knowledge of ana- 
tomical and histological structure is necessary to a knowledge of the functions of organs 
and tissues, the latter is even more necessary as an equipment for the scientific phy- 
sician, and only as physiological science has developed, has medicine positively 
emerged from the mists of blind experiment, and become securely established on a 
scientific foundation. The great events in physiological discovery have specially 
marked great epochs of advancement in scientific theories and modes of cure. It may 
be claimed, then, that in the group of natural sciences from which the profession of 
medicine receives its most reliable strength as a scientific practical agency, physiology 
is outranked by none, and that in the great muster of sciences which this Congress 
parades to-day, it must be conceded to march with the vanguard. 
Many intelligent unprofessional persons who may observe the proceedings of a 
Congress like this are moved to inquire why medicine, which the general mind is 
accustomed to regard as a unit, should be so subdivided into departments or sections; 
and there be conservative critics in the profession, who question the wisdom of what 
they fear may lead to conflicting division of studies and an injurious diffusion of ener- 
gies. The trend toward specialism is indeed strong and increasing, but notwith- 
standing the liability to become excessive, and the danger that physicians in pursuit 
of special lines of work, may become shallow in the fundamental principles of the 234 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
science afe a whole, and consequently narrow in views, there are yet cogent reasons 
impelling this movement. It is not in the scope of an address of this character to 
set these forth, and this digression may end with the remark, that the body of 
knowledge under the term medicine is becoming so copious and complex, that it 
requires diversity of cultivation that it may be fully mastered-no one mind, however 
endowed, being equal to the task. In whatever degree such criticism may be appli- 
cable to some features of the organization of this and previous similar Congresses, the 
relationship of physiology to every possible refinement of practical medicine is so 
intrinsic and essential, its students and cultivators, are, by necessity, recognized as 
forming one of the grand divisions of the comprehensive science, and are properly 
assembled in a Section, from whose exercises and discussions all others may possibly 
derive facts and suggestions of great value. 
Our science-biology and physiology-for generically and strictly they are one- 
resting on histology and organic chemistry, under the exquisite modern methods of 
research constantly being rendered more accurate and subtle, can now legitimately 
claim to be a true science, answering the Ciceronian definition-"cognitio certa ex 
principiis certis deducta"-a body of approved facts, rather than a system of imper- 
fect theories and ingenious doctrines, with here and there only an indisputable fact. 
Mainly it is above such obscuring fogs, resting in the sunlight. The great mass of 
its data is sound, proven and germinal in its character, fertilizing every department 
of medical science and producing a fruitage so wholesome and perfect, that the genu- 
ineness of the seed-the truth of the facts-is therein fully vindicated. We have 
advanced to that point when we no longer speculate, or vainly search for the principle 
of life, but are wisely content and more profitably employed in investigating the con- 
ditions and phenomena of living beings. The results of this philosophical mode of 
prosecuting the study of physiological truth, has afforded scientific basis for patho- 
logical deduction and therapeutic agency. As we have been enabled to know the 
true molecular and atomic structure of tissues and their functions and normal pro- 
cesses, so we have been enabled to perceive with greater clearness their disturbances 
which constitute disease, and so also are we enabled to measure with greater science 
and skill the qualities and force of remedial resources for their rectification and 
relief. 
In any reference to physiology and its inexpressible importance as the basis of a 
true science of medicine, it would seem impossible, as indeed it would be ungrateful, 
if not almost irreverent, not to date its own true scientific origin and development in 
the discovery and verification of the circulation of the blood by the immortal Harvey. 
That became a bright light and landmark, and indeed a condition precedent to much 
we have learned, with slow and patient labor, in the two and a half centuries since, a 
very great deal of wdiich is directly traceable to and immediately dependent on that 
cardinal fact. It is to physiology, in some sense, what the law of gravitation is to 
physics. None perhaps will question that the supreme and commanding fact in the 
physiology of this century, and of to-day, in its potential consequences on the progress 
of medical science, is the function of the cell in all forms of life, vegetable and animal. 
The full history of its promulgation and demonstration and the attempt to award the 
honor therefor, is not pertinent in this cursory allusion. Like many other of the 
greatest of the achievements made in natural science, the horizon was gradually 
illuminated from it long before the intervening peaks which obstructed its brilliant 
and vivifying rays were surmounted. The genius of Bichat, at the opening of the 
present century, first caught a clear glimpse of the field wherein lay this invaluable 
gem of scientific truth. His great work on "General Anatomy" and Treatise on SECTION VIII PHYSIOLOGY. 
235 
Membranes, ' ' philosophically evolved under laborious investigation of facts, while it 
cut him down in the morning of life, marked one of the most signal advancements in 
human knowledge of which the century has since been so prolific. The microscope, 
first under the eye of Schleiden in plants, and soon after that of Schwann in animals, 
and since by a host of observers, followed the magical scalpel of Bichat, and now 
reads the marvelous susceptibilities and metabolic characteristics of cells as the alpha- 
bet and cypher to nearly all the phenomena of vital activities of which we are 
cognizant. 
Though with the rise of what may be called modern physiology, in the sixteenth 
century, the fantastic dreams of the ancient alchemists conceived, in the crude, early 
days of chemistry, that there was resident somewhere in the human organism a subtle 
essence, or force of life, for which their mystic art could find an elixir rendering it per- 
petual, were effectually dissipated, still, eminent scientific minds, who led the thought 
of their time at successive periods until a comparatively recent one, continued to hold 
the theory that, in some form, animal bodies contained a sort of regnant archeus 
president over the mechanism of life. The demonstration of the cell and its func- 
tions has scientifically exploded the idea which underlaid alchemic absurdity, and 
equally disproved the more enlightened type of error. It has wrought a thorough 
revolution in our conceptions of life. Instead of being regarded as an entity whose 
sum was liable to constant waste, which, if unarrested, would result in final expendi- 
ture or death, or a conservative principle stored up in some great organ or apparatus 
of organs, the degeneration and decay of either of which must be stopped in order 
to combat disease or to preserve life, we now know that this degenerative alteration 
-this incessant decay-is life itself, and that the perversion of the order and charac- 
ter of these perpetual changes is disease, and that their total and universal arrest is 
death. We know that the sum of the life of an organism is the myriad lives of the 
minute cells of which its tissues are composed, and that the changes in these cells 
are metamorphoses of their structure in which they are constantly dying and being 
reproduced. Such and so great has been the transformation in biological science by 
the discovery of this notable fact and its laws. 
How important and profound have been the results of its application to medicine. 
The existence of the normal physiological cell and its properties opened the vista of 
a new pathology, and dispelled every cloud and fleecy rack of the obscurity of the 
animistic, humoral and visceral theories. The cellular pathology, which is so clearly 
unfolding and elucidating many of the problems of disease, was a scientific induction 
from the physiological theory, and the accumulating array of facts in each is 
corroborative of the truth of both, and that the cell doctrine is a certain and 
enduring addition to the body of our knowledge of the laws of living bodies in 
health and disease. 
Not alone in the sphere of pathology proper have the principles of this doctrine 
touched in its effects on practical medicine. Within the last decade or two, the para- 
sitic or germ theory as to the causation of diseased states and conditions, though 
long before speculated upon in the manner of hypothesis or conjecture only, has 
fixed the attention of investigators, and the discovery of these microscopic vegetable 
and animal bodies in living organisms and the unquestionably important relation 
they bear to the generation, or development by presence, of cell disturbances specific 
in their character, is a scientific fact yearly coming to have fewer gainsayers or 
doubters. Whatever of solid and permanent acquisition in the field of the aetiology 
and prophylaxis of disease that may accrue to science from the labors of Haller and 
Koch and Obermeyer and Pasteur, the initial point of their profoundly interesting 236 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
inquiries must be conceded to be found in the new laws of biology and organic 
chemistry established in physiological investigations. 
In the realm of hygiene and remedial medicaments, the newly-developed physio- 
logical data traceable to cell metamorphosis and modifications are making a profound 
impression. The efficacy of external antiseptic agencies, which, under Lister and 
his associates, has so strengthened the hand of the surgeon, is in great part due to 
laws whose clues were found first in the physiological laboratory, and whatever 
now of promise may yet be accomplished in antiseptic measures applied to the blood 
must acknowledge the same guiding finger in its scientific results. And, again, within 
the last half-century a considerable amount of accurate and positive knowledge of 
the rationale of the action of a large number of the articles of the materia medica- 
vegetable and mineral-have been only elucidated and verified by experimental physi- 
ology. 
But this discursive reference to the fundamental importance of this branch of 
science to the great organic body of medical science this Congress has assembled to 
represent, is unnecessarily extended in the enlightened presence before me. The 
utterance of the claim preferred will doubtless, in the main, be sustained by all, if 
not entirely for the reasons advanced in so desultory a manner. It has been the object 
merely to emphasize the truth, that as the science and art of healing in all its 
branches progresses, it becomes more obvious that its true philosophical line of advance- 
ment lies primarily, and in no degree subordinate to any other, in the field of work 
occupied by this Section. 
If the attempt were made to further fortify this title to a first position among the 
cultivators of medicine, by citing the eminent names in physiology which have illus- 
trated the annals of that science, it would require me to recite, in great part, its his- 
tory. From the ' ' De partibus animalium ' ' of the great naturalist and philosopher, 
Aristotle, whose pregnant writings on whatever subject his extraordinary mental 
endowments were employed incited among the ancients, and indeed all coming after 
him, the thirst for knowledge, down to the learned men who, during the sessions of 
this body, are to continue inquiries into the same subject, our special science displays 
a galaxy of ability and achievement unsurpassed in any other sphere of intellectual 
effort by the human race. Their names are as familiar to you as household words, 
and this allusion to them passes the long line in procession before the mind. They 
represent all past and present nations, tongues and literatures, as this body repre- 
sents in its composition those living, and their united contributions are before us, for 
taking an account at this day of what we know of life and its phenomena, and for 
measuring as best we may what we do not know, and, in this finite state, may never 
know of those stupendous problems. 
The programme of subjects for consideration and discussion at the several sessions 
of this Section, as submitted through me to the Council and approved by that body, 
will be found of great interest, not only in the fact that each one is of leading import- 
ance, but that an entertaining variety is offered. It would be violative of propriety 
and good taste to remark at length upon any of these in anticipation of the discussion 
they will elicit. It may not be improper, however, to briefly allude to each, or to 
those which may be naturally grouped. 
We shall have before us the blood in some of its most interesting com- 
ponents and characteristics-the function of the red corpuscle and of its coagulat- 
ing element, and the relation of that physiological process to a peculiar post-mortem 
condition. SECTION VIII-PHYSIOLOGY. 
237 
The problem of nutrition and its forces acting under mediate and collateral condi- 
tions will be presented, and the trophic influence of the nervous system will be con- 
sidered in further elucidation of a process which, in some degree, may be held to be 
the leading object of all other functions of the organism. 
The first of the secretions of the alimentary tract in observation of its properties 
and uses-local and general-as seen in some of the lower order of animals, will 
be offered ; and as more or less cognate to processes thereby commenced, the 
ultimate evolution through further chemico-physiological changes of alcohol in 
the organism. 
A paper on the physiology of elemental fibres, and one analyzing the soundness 
of certain prevalent doctrines touching the inter-relation of nerve and muscle fibres, 
will form an interesting topic in the exercises. 
The par vagum, with its extensively ramified anatomy and its multifold and pro- 
foundly important physiological connections and sympathies, will claim that share of 
your attention the discussion of its different functions demands. 
We shall have the electrical force, whose phenomena in relation to living bodies 
are yet so recondite, but which, even in their imperfect development, intimate such 
wonderful possibilities, brought to view in a paper on their presence in cerebral gray 
matter, and one also in its action on the heart. 
Two papers touching the highest function predicable of organic matter-its 
psychical expression-will complete the catalogue of subjects. One will interrogate 
the basal ganglia, and the other the hemispherical ganglia in this supreme relation 
of matter to mind. Both, it may be assumed, will apply the physiological method 
of inquiry to the modes by which mental phenomena are produced, and in this view 
we shall be brought to contemplate the cell energies of the cerebrum and its connec- 
tions as the seat and source of intellection, volition, emotion, and self-consciousness, 
and be made to appreciate Goethe's sublime thought, that man is so fashioned and 
endowed as to be the medium of the first and only dialogue that nature has ever 
held with God. 
It will be noted that the physiology of the nervous system in some of its divisions 
and functions, and electro-physiology, so closely connected, as it probably is, with 
nerve functions, will occupy a large portion of the attention of the Section. This 
may be fortuitous only, or it may be due to the fact that recent physiological inquiry 
has been, in a great degree, so directed, and that in a body of representative physi- 
ologists at the present time it should legitimately offer itself for full consideration. 
Whatever may be the cause or causes, it may be safely asserted, that within the pro- 
fessional memory of all who hear me neuropathic disorders have increased in number 
and variety. Whether this be attributable-to borrow a military term-to the rapid 
mobilization of human energies which have ensued from the activities in all the con- 
cerns of life, set in motion by Puck's girdle of communication around and in every 
direction over the realm of civilization, with the speed of locomotion which supple- 
ments it and stirs every fibre to its utmost tension, will only be mooted as I pass to 
a conclusion. Certain it is that "the wear and tear" of what Prof. Huxley, in his 
fine army figure of the human organism, calls the ' ' headquarters and field telegraph, ' ' 
has been great within that time, and its results have taxed the diagnostic skill and 
therapeutic resources of practical medicine. Neurological investigation has moved 
with the consequent requirements for more accurate and scientific insight into the 
wondrous relations and sympathies of that most intricate and delicate apparatus, 
and the localization and explication of its functions is, at this time, equipping the 
surgeon and physician with most valuable suggestions of treatment and remedy. 238 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
But, gentlemen, I am transgressing the limit promised you. Repeating the gen- 
eral welcome extended, and presuming to express the sense of pleasure which inspires 
us all, I now declare this Section of the Ninth International Congress opened for 
business. 
Dr. Daniel Clark, of Toronto, Canada, read a paper entitled- 
THE BASAL GANGLIA OF THE BRAIN AS PSYCHIC CENTRES 
LES GRANDS GANGLIONS CEREBRAUX COMME CENTRES PSYCHIQUES. 
DIE GROSSEN GEHIRNGANGLIEN ALS PSYCHISCHE CENTRA 
The following points are to be discussed :- 
1. The radical difference found in the circulation of the blood, both as to mode of 
distribution and quantity, suggests the reasonable inference of greater functional activity 
existing in the centre than in the circumference of the brain. 
2. The want of uniformity in psychical and functional results when definite and 
similar portions of the cortical substance are stimulated, impaired or destroyed ; hence 
exists no positive proof that this is the seat of so-called true motor centres. 
3. It would be consistent with pathological and experimental facts to consider that 
these motor and psychical centres are located in the base and central ganglia, yet in 
sympathetic relations with, being influenced by, but not absolutely controlled by, the 
cortical substance. 
4. The localization of function in the brain surface ignores the fact that there is a 
want of distinctive physiological features in the several convolutions. 
In taking up the first of these statements, let us remember it is an axiom that the 
more life action in any part, the more is blood supply needed. In studying the brain 
circulation, we find that the centre and base are much more plentifully supplied with 
blood than are the cerebrum and cerebellum. This is a striking fact, when we remem- 
ber that all the parts constitute one organ, with multifarious functions and offices. Let 
us remember how direct and ample is the blood supply to the base and central ganglia 
in comparison with the cortical supply. This is especially true of the quantity which 
is furnished to each corpus striatum and thalamus opticus. The cortical substance is 
nourished in a round-about way through the pia mater, but the central system is 
reached directly through the large vessels springing from the circle of Willis and the 
cerebral arteries shooting upward and inward from this polygon of vessels. These fur- 
nish a perfect and copious fountain of blood supply near at hand. These two sources of 
supply are not only distinct as between each of these groups, but also unconnected, to 
a great extent, with one another. The anastomoses between these two sets of vessels is 
very slight indeed. The streamlet in each can be dried up or seriously interrupted in 
many ways without disturbing the neighboring vessels to any appreciable extent. This 
accounts for so many circumscribed lesions in the cortical parts, and for the little effect 
their proximity produces on the adjacent tissues and circulation. I am inclined to think 
that, on account of this localization of circulation, and consequently, a tendency to 
restricted areas of disease, a good many fallacies of reasoning have obtained currency 
in respect to cortical centres of function. Heubner cites a large number of pathological 
cases which prove conclusively that obliteration of any one of the large vessels of the SECTION VIII-PHYSIOLOGY. 
239 
cortical system or any of its branches has, during life, given no pronounced abnormal 
symptom to indicate depreciation of function. (Charcot.) 
Let us now turn to the arterial circulation in the gray central ganglia. It needs only 
a moment's reflection on our knowledge of Anatomy, to remember that the basal ganglia 
are largely supplied with blood from the Sylvian artery, as well as from the nutrient 
vessels which spring in large numbers directly from the great central reservoir, and from 
the basilar at its bifurcation. The sum total of the calibre of those vessels which go to 
the basal organs, shows a much greater capacity for blood supply per inch square, by 
double the quantity, than does any other part of the brain. Such being the case, we 
know this augmented blood supply, being normal, means proportionally increased func- 
tional activity. Hence it follows, as a matter of fact, that any abnormal increase or 
decrease of blood circulation which will disturb the natural equilibrium always brings 
about more or less physical and mental perturbation. In this respect congestion, equally 
with anæmia, is followed by analogous results ; that is, more or less suspended sensi- 
bility, impaired voluntary action, and conscious deficiency in mental activity. It is my 
impression that, because of this inequality in these vital centres, do we find the import- 
ant pathological fact that, in hemiplegia from cortical disease it is "limited, transient, 
and variable " (Charcot), but in paralysis of the body from disease of the centre or base 
organs of the brain it is permanent, general and uniform. It is a pathological fact 
that, general or partial paralysis is produced by any part of the brain becoming affected 
with inflammation, embolus, tumor, or exostosis. So distinct and important is the cir- 
culation in these small brains at the base, that when the partial or complete obliteration 
of the middle cerebral takes place all the ganglionic centres become immediately seri- 
ously affected, and cerebral hemiplegia, accompanied by hemianæsthesia, is the result. 
This fact alone shows the greater importance these ganglia hold as functional centres, in 
comparison to the cortex, or even the entire hemispheres. Professor M. Schiff, of 
Florence, has caught the same idea, when he says, in his monograph on " Motor Cen- 
tres,''that "human and comparative pathology have stated, with certainty, that the 
motor centres do not extend above the base of the brain." 
A sharp controversy is being carried on and antagonistic opinions have been uttered 
by the leaders of thought in our profession on the functions of the convolutions of the 
brain. These have been mapped out by imaginative surveyors with the accuracy of 
the streets of a city, and each district has been declared to be a specialized centre of 
functional energy. Although no dividing lines exist in the substance of the brain, yet 
the comparatively slender divisions of the sulci are made to do duty as boundaries of 
organs in which great differences of operation are said to exist. These observers seem 
to forget that in mammalia next higher in order to man these outlines are very feeble, 
yet these animals have many physical functions of a higher capacity than have the 
genus homo. 
All anatomists know that although the outward depressions on the brain of man 
maintain a certain degree of uniformity in direction and outline, yet the differences 
in detail are considerable. These fissures do not make distinct and complete division of 
the surface. The even continuity of the surface of each convolution by an isthmus (so 
to speak) at the extremities and sides of each, indicate no striking dividing lines, but 
rather the contrary. The dips in the gray matter underlying these fissures and in 
proximity to the white substance show that a certain degree of uniformity in quantity 
of gray matter exists throughout the periphery of the brain. It is true that differences 
in cell formation are seen in the various layers of the cortical substance, but these cellu- 
lar distinctions are found only in each layer lying parallel to the surface. There is no 
physiological distinction found in one convolution distinct from another. The uni- 
formity of cell structure in the several layers of the cortical substance is continuous, 
and nowhere bounded by the surface fissures and convolutions. In other words, all 240 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the convolutions are similar in structure. Were sections of any parts of the cerebrum 
cut out from without toward the centre and submitted to the closest analysis no micro- 
scopist could tell, from the construction of such sections, where each topically belonged. 
The same is true of the structure of the cerebellum. 
The various shaped cells are uniform in texture, in whatever layer they may be 
found, and there is no convincing evidence to show that large and small, round and 
ovoid, angular and caudated, deep and superficial, transparent and opaque, are not 
members of the same family in different stages of development. 
It is also to be remembered that there is no direct nervous communication with the 
body from the cerebrum and cerebellum except through the basal ganglia, notwith- 
standing statements to the contrary. Whatever injury disease or traumatic lesion may 
inflict on these upper nerve masses with comparative impunity, so important are the 
centre and base ganglia that similar abnormal conditions cannot be found in these with- 
out dangerous results. 
These are, in my opinion, the true motor and psychic centres of the system. Physi- 
ology teaches this, and there is no necessity to go beyond them to prove a localization 
theory. The distinctness and variety seen in the base ganglia, with well-defined boun- 
daries, and the want of uniformity in structure, point strongly to specific functions. The 
juxtaposition of the medulla oblongata, the spinal cord, the nerve ramifications not only 
to the organs of special sense but also to the locomotive and organic systems, point out 
these districts as being peculiar and focal centres. If this theory be correct it can explain 
all the phenomena manifested through experimentation and pathological conditions, 
without resorting to the chart based on such shifting, incomplete and varied bounda- 
ries as the sulci of the convolutions afford. 
Let us consider this point in another aspect. Fritsch, Hitzig and other experimen- 
ters, agree that in no appreciable degree do mechanical or chemical agents excite motion 
in the cerebral substance. Excitation by galvanism is said to be very feeble and very 
limited in either cerebrum or cerebellum, and this want of response is seen throughout. 
It is evident that by this powerful agent no functional centre could be found. Herr- 
mann shows that even after the gray matter is destroyed by chemical cauteries, a very 
feeble current of galvanism applied to the abraded surface produced only a slight move- 
ment. He significantly adds, that in cutting away slices of the brain the effect was 
more decided in proportion as the central regions were approached. (Richet.) In other 
words, the foci of nerve energy seemed to be in the ganglia at the base of the brain, 
and that the destruction of the cerebral substance did not produce that disturbance of 
the system commensurate with the loss of such tissue, once supposed to be so necessary 
to the continuance of physical function and mental action. 
Richet says, in speaking of the localization theory as propounded by Ferrier and 
his ardent followers, that "absolute inflexible localization of the motor zones is impos- 
sible. There are zones which encroach upon each other, but none of these zones have 
limits of determined vigorous constancy. The best proof of this is the difference exist- 
ing among authors. ' ' If this statement means anything, it is that although paralysis 
and abnormal functions, in many instances, follow the destruction of certain cortical 
parts, from experiment or as the result of disease, and although a certain degree of uni- 
formity in physical results may follow, yet it is equally true that these same areas 
may be destroyed without any such manifestations following. Their own experiments 
are taken as proof of this statement. These circumscribed areas cannot, therefore, by 
any show of reasoning, be the organs which are the centres of distinct functional activ- 
ity. These upper nerve masses doubtless are the centres of general power and activity, 
but the functions for coordination and mental scope must be sought for elsewhere. 
The unsatisfactory nature of their own theories seems to have received the attention 
of these able and earnest workers. Richet, in speaking of cerebral excitation by means SECTION VIII PHYSIOLOGY. 
241 
of electricity, is forced to say, in explanation of certain phenomena, " Known facts 
demonstrate that excitation of the convolutions which surround the sigmoid gyrus act 
with extreme energy upon the ganglionic centres of the brain (opto-stnated). It is 
possible that such excitation culminated in the cerebral centres, and that these centres 
thus surcharged discharge to the muscles. ' ' Charcot says, in speaking of the lenticular 
nucleus of the corpus striatum : ' ' These gray nuclei are possibly so many centres 
endowed with distinct properties and functions." Dr. Symond, in the Gulstonian lec- 
tures, says : ' ' Pain does not seem to be in the nervous matter, whether vesicular or 
tubular, of the cerebral hemispheres, or of the cerebellum. No evidence of feeling has 
been obtained by vivisectors till they approached the sensory ganglia, the thalami optici 
and corpora quadrigemina. But these are the centres of sensation to all parts of the 
body as well as to the head." 
Maudsley says, in his " Pathology of Insanity," "The disturbance of the cortical 
cells is, in reality, secondary ; it is a reflex functional result of the primary morbid action 
that is going on in the neighborhood." And again: " Portions of the hemispheres may 
be cut away without the patient feeling it, though he is fully conscious. ' ' Quotations to 
the same effect might be made from the works and monographs of writers of note in 
many lands, to show that the cortical localization theory is still sub judice, even among 
its advocates. 
This theory of basal influence was advanced by me in this city before " The Asso- 
ciation of Medical Superintendents," at the meeting of 1878. I spoke then in the 
following terms: " Large portions of the cerebrum and cerebellum may be taken away 
from the living body without immediate danger of death; but the organs in the base 
of the brain, from which spring the numerous nerves so essential to life, cannot be 
touched, in vivisection or by disease, with impunity. From this central region nerve 
influence radiates to every part of the body, making its connections with the 
depositories of nerve power in the spinal cord and with the ganglia of the 
sympathetic system." {Vide "The Animated Molecule," page 38.) The writer 
advocated the same views in a paper read at Ottawa, before The Dominion of 
Canada Medical Association, in the following words: The functional area is really 
circumscribed to the most vital parts of the brain. It is then evident why traumatic 
injury and pathological processes in the cortex are not always followed by aberrations 
of function and mental unsoundness. The surfaces and upper portions of these nerve 
masses are adjuncts to vital organs in the centre and base of the brain. The former 
give power, but do not impart special function; they are auxiliaries but not necessities 
to the ganglionic centres; they bestow and intensify energy, but do not direct; they 
are-as it were-additional cells to the battery, but not its controlling power. It is a 
matter of experiment and pathological history that such a large area as the Rolandic 
zone can be physiologically destroyed, and yet leave the intellect unimpaired. A con- 
siderable portion of the frontal or even of the occipital lobes can be removed without 
any apparent alteration of the physical or intellectual powers. The corresponding lobes 
of either the frontal, occipital or parietal regions have been destroyed without affecting 
the conscious being or those functions said to have their seat of power in these 
parts. It is certain, then, that the hemispheres and the cerebellum are not the sole 
habitations of mind or of specialized physical operations. The reciprocity between 
mind and body is strikingly seen in amnesic aphasia. My experience teaches there can 
be no aphasia without more or less impairment of the memory, j udgment and voli- 
tion. Yet the functional and mental disorder can exist either without or with injury 
to the third frontal convolution. There is no basis for believing that this part is 
functionally energized to perform certain special operations, as an organ. It is the fact 
that we can have aphasia, paralysis of the legs, arm and face, with these so-called centres 
of nerve force unimpaired, or if impaired, without these results. 
Vol. Ill-16 242 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
We know that aphasic conditions can exist with the centre of disease in the island 
of Reil or in the paracentral lobe. I remember a case of amnesic aphasia in which 
the post-mortem revealed softening of the upper limb of the first frontal, and no 
disease in any other part of the brain, as far as the microscope could reveal. In a 
monograph of mine, styled " Brain Lesions and Functional Results, " published in 1880, 
I have given a large number of cases recorded in medical literature, especially in war 
records, to prove this point beyond all controversy. 
I took a brain and passed wires through it in all the directions described in medical 
literature within my reach, in cases where there was brain injury and no functional or 
psychical perturbation after the shock of injury had passed away. I found a large 
number of such cases recorded in Mathews' and McLeod's " Surgical History of the 
Crimean War," in Chenn's " Surgical History of the Same War in the French Army," 
and in that admirable compilation, which has no equal, "The Medical and Surgical 
History of the War of the Rebellion." The result of my experiment was that the 
brain substance had been injured in every conceivable direction and in every half-inch 
square of the hemispheres, yet with no results at all commensurate with the lesions 
inflicted. If these parts are motor centres, then have we the miraculous phenomena 
of organic operations without organs; of varied and distinct functions without motive 
power; of uniform results without efficient causes. Were we to consider the brain a dual 
organ, the difficulty would remain, because there is any number of cases on record 
where corresponding sides have been simultaneously injured. In all the dual organs 
of the body we find sudden injury to one is always followed by imperfect and dimin- 
ished work in its fellow until time is given to allow provision to be made for the 
extra labor imposed. 
When we find no impairment in function consequent on injury to even one so-called 
motor centre, we are led by uniform analogy to doubt a doctrine so anomalous and con- 
tradictory, notwithstanding the great names which cluster round its acceptance. It is 
better to receive with caution a theory, now so popular, but which is accepted from 
experiments in isolated and exceptional cases. It is evident to me that more recent 
investigations establish my contention as being most consistent with physiological and 
pathological facts. 
It seems to be overlooked, however, that in changed conditions nature, with won- 
derful aptitude, accommodates itself to new situations. In its vicarious provisions, in 
the inroads of tumore, in the cutting off of blood or nerve supply, and in the gradual 
breaking down of tissue, we always find heroic efforts put forth to repair the mischief, 
and often successfully. These gradual invasions and the physical results which flow 
therefrom may be altogether different in intensity and manifestation to the sudden 
shock of electricity, or of the traumatic injury made by cautery or scalpel. It is very 
fallacious to reason in every case from the insidious results of disease to those of violent 
experiment. 
DISCUSSION. 
Dr. Ralph Stockman, of Edinburgh :-The subject of localization of cerebral 
function is one about which there may be admittedly much difference of opinion. If 
I understand Dr. Clark aright, he maintains that volitional impulses of all kinds take 
their rise in the basal ganglia, and that there is no special localization of function in 
the cortex of the brain. Holding these views, may I ask him how he explains the 
well-known facts regarding Broca's convolution, and how, after this centre has been 
destroyed, it is the same convolution on the other side which assumes its functions. 
The most recent experiments on the subject-those of Drs. Horsley and Beevor- 
seem to show that localization of function in the cortex is carried to a very high 
degree. In addition, we have the results of grosser experiments on frogs and warm- SECTION VIII PHYSIOLOGY. 
243 
blooded animals. In the former, when the cerebral lobes are removed, spontaneous 
movements cease, and the animal only reacts when external stimuli are applied 
to it. 
In some recent experiments with camphor, I have found also that removal of the 
cortex in rabbits prevents the supervention of the characteristic epileptic convulsions 
caused by large doses of that drug. This points to the fact that these convulsions 
have their origin in the cortex, and that the cortex is, therefore, a motor centre. 
From Ferrier's experiments we conclude, further, that it is divided up into a number 
of motor centres for different muscles. 
A large number of clinical cases have been adduced in support of Dr. Clark's 
views, but these can hardly be accepted in opposition to exact experiment. We do 
not know what exact conditions are actually present in such cases ; and, besides, it is 
notorious that an organ-e.</., the heart-may be seriously diseased and yet perform 
its functions comparatively well. I cannot, therefore, agree with the views which 
have been put forth in Dr. Clark's paper. 
Prof. J. H. Wythe, M.D., of California:-The paper just read has interested 
me greatly. I fully agree with the author that the periphery of the brain and 
cerebral substance are not essential either to motility or intellection. As long ago as 
1853, I made post-mortem examinations of the brains of three children, who (at 
different times) had suddenly died in bed without any appreciable symptoms of dis- 
ease, either mental or physical. Each case revealed extensive brain disease, and in 
one the brain substance was soft as melted butter. There was, evidently, no relation 
between the diseased brain and the mental power. At the last session of the Cali- 
fornia State Medical Society, a skull was exhibited by Dr. Chase, which belonged to 
a man who had been scalped and tomahawked by the Indians, leaving an opening 
three by four inches on the top, from which the brain protruded and gradually rotted 
away for ten years, but during all that time the man was capable of business, and 
was esteemed by his townsmen as a man of shrewdness and ability. I have collected 
about one hundred such instances from medical journals, which show that the popu- 
lar idea of the identity of mind and brain is a fallacy. I would like to ask Dr. Clark, 
however, how he would answer the objection to his view based upon the localization 
of motor centres which has produced such brilliant results in the surgery of the 
brain. I think I can account for it without admitting the cerebral psychology, but 
I should be glad to hear his explanation. 
Dr. W. D. Halliburton, of London, defended the views of cerebral localization 
as taught by Ferrier. He mentioned several experiments which he had seen per- 
formed by Profs. Schafer and Horsley, in which it was demonstrated that excitation 
of certain areas of the cerebral cortex produced a constant effect (movement), and 
removal of the same areas produced loss of that power. Injury to the basal ganglia 
produces widespread effects, probably owing to the injury to the neighboring internal 
capsule, the path by which the cortex is connected to the lower portions of the ner- 
vous system. He held, also, that the recent brilliant achievements in brain surgery 
amply confirmed the experiments made on animals. The cases, also, in which no ill 
result followed extensive injury to the frontal lobes were fully in accord with experi- 
ments on animals, and could not, therefore, be cited as adverse to the localization 
theory. He pointed out that the statement of the reader of the paper, that no dif- 
ference of histological structure can be made out in different convolutions, was erro- 
neous, as it is perfectly easy with the microscope to distinguish a sensory from a 
motor convolution. With regard to aphasia, he pointed out the complex nature of 244 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this affection. True aphasia is always connected with disease of Broca's convolution, 
while all admit that certain forms of amnesia are not. 
Dr. Love, of Atlanta, Ga., said :-Mr. President, I have listened with intense 
interest to the reading of the paper by Dr. Clark. It is a research in an interesting 
field-one in which we all feel deeply interested, and one in which there are very 
many points remaining in deep obscurity. The localization of function centres in 
the brain is still an open question, though it has received the attention of some of 
the best minds in the profession. While physiological experiments, on the one hand, 
would seem to throw much light on the subject now and then, physiological investi- 
gation as quickly knocks all its rays back into utter darkness. But such researches as 
are evidenced in the paper just read give token of a hope that physiological experi- 
mentation and pathological investigation may yet come up hand in hand, in evidence, 
the one for the other, reconcile all these points of difference, and demonstrate that 
truth for which we are all earnestly seeking. 
That Dr. Clark is correct in localizing the more important functions in the basilar 
ganglia to which he alludes-if I understood correctly the reading of his paper-I 
have no doubt, yet, if he is correct, what becomes of the localization theories ? I con- 
fess that I have found it difficult to settle down contented anywhere along the line 
between these two points of contention. Early impressions are not only very lasting 
but very prejudicing, and many, doubtless, find it difficult to drive out of the deep- 
cut grooves in which we have been running for so many years. I remember well my 
earlier impression ; then it was thought that an injury to, or destruction of, the 
brain, however small, was necessarily fatal, but experience in early private practice 
brought me bravely out of that. If it had not, the terrible pass at arms from which 
our countrymen suffered so much, brought under my observation, in field and hospital 
service, abundant evidence of the fallacy of such teaching. I had ample opportunity 
at our central city, where the sick and wounded of 1 1 the Army of Tennessee ' ' (under 
Joseph E. Johnston) gathered. Through orders issued by the post surgeon, all cases 
of wounds of the brain and of serious lesions of the nervous system were sent to our 
hospital and placed under my immediate care. The number of brain wounds and 
lesions, from the very nature of the engagements and defenses of the Confederates, 
was very large. Among the many thus gathered under my care were some of the 
most remarkable brain lesions I have ever known-cases that were both physiological 
and pathological curiosities to me, in the fearfulness of extent of the tissue destroyed 
and the final favorable termination of the cases. These cases brought to my mind- 
as does the paper of Dr. Clark-the researches and conclusions of that brilliant young 
Russian physiologist, Jacubovitch, whose researches were so rare, who rose so high, 
and, like many others who give early token of prospective leadership in the field of 
science, died so young. He contended that in early life the basal ganglia were the 
centre of all physiological action, and that the outside convolutions of white and gray 
matter were made up, in early life, of mere elemental material, to be, during life, 
worked up into fusiform, monopolar, bipolar and multipolar cells-reinforcements, as 
it were, to these great basal centres-that as the one or the other form of these cells 
prevailed in the neuro-histological development of the brain-sensory, fusiform or 
motor, polar-there was prevalence of sensation, or power of motion, in the man or 
animal. His researches were interesting in the extreme, and bid fair to make him a 
leader, iu his day and time, in this department of ours, but he laid aside his lens 
and his labors, and science mourned his early departure to the great beyond. 
In private practice, after the war, a case fell into my care which my experience in 
military practice, alluded to before, enabled me to manage with a success which I SECTION VIII-PHYSIOLOGY. 
245 
could not otherwise have hoped for, as I believe. It was a case in which there was 
seemingly more extensive lesion and more extensive loss of brain tissue than in the 
celebrated case of Bigelow, of Boston, where the patient had a tampon rod, by a 
premature explosion, driven through the face and anterior lobe of the brain, yet 
made good his recovery and lived, as I understand, several years after the accident. 
The case falling under my care was a youth of fourteen years. On his return from 
school, in the afternoon of the day on which it occurred, he got into an altercation 
with a stout negro fellow and was cut in the head with an axe. The blade was 
driven deep into the left anterior lobe of the brain, the cut extending from the left 
supra-orbital ridge, through the frontal into the parietal bone, and deep into the 
brain. The distal corner of the cutting edge of the axe had been, in time, broken 
off and ground down-was thick and blunt-while the sharper edge cut directly 
through both outer and inner plate of the skull. This thick, blunt portion of the 
blade failed to cut through the harder internal plate, but the force detached and 
drove deep down into the brain a piece of this plate, about an inch by an inch and a 
third, irregular in shape. When the blade of the axe was at its greatest depth, the 
heavier pole of the axe deflected to the left, the cut skull acting as a fulcrum ; the 
blade broke up or dished out all that portion of the brain laying to its right in the 
direction of the blow. This carried away most of the left anterior lobe, yet, strange 
as it may seem-in this condition, bleeding and faint-he, with the aid of his school- 
mates, walked to his home, a distance of over two hundred yards. 
When I reached his bedside, which was only a few minutes after he had reached 
his home, he recognized me and extended his hand, but went instantly into convul- 
sions. Chloroform was at once administered to control the convulsions, the case 
examined, the deep piece of bone detected and removed. The greater part of the 
left half of the frontal bone had been broken off, remaining attached to the scalp. 
Bemembering Ollier's experiments for the reproduction of bone by the periosteal 
membrane, that membrane, in the removal of the bone, was left with the scalp, with 
the hope of reproduction. With kindly care and close watching, the patient, under 
cold-water treatment, made good recovery. 
Now to the points of interest here in the discussion of Dr. Clark's paper : This 
patient must have lost between four and five fluid ounces of brain matter ; quite a 
quantity was left on the ground where he received the injury ; it was found on his 
hair and hat, and clothes, to his feet. In removing the bone and broken-up brain 
matter, I filled a two-ounce wine-glass with brain matter-not blood clots-and then, 
in the process of suppurative action which followed, much more necessarily passed 
away in the healing process. 
After his recovery, he resumed school and resumed his study of music and of teleg- 
raphy. After the lapse of a sufficient time, to test the case thoroughly, I inquired 
of his respective teachers- 
1. Whether his mind had been found impaired in any way ? 
2. Whether his memory of the lessons learned before the injury had been found 
good ? 
3. Whether in any one particular branch of study he seemed to evince defective- 
ness or want of ability to grasp the subject? 
4. Whether in his study of music any difference had been noticed as to his 
measurement of time? 
5. Whether in his study of telegraphy (a work in which the perception in time 
must be acute and quick) he had either forgotten the past or evinced deficiency in 
the then prosecution of the study ? 246 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
To all these the most satisfactory answers were given. This youth then is a 
man now ; he and all of his teachers yet live. I have watched the case with intense 
interest. The accident occurred in Febniary, 1868 ; now, September, 1887, nearly 
twenty years, he is (or was not long since) an operator in a very important office of 
the Western Union Telegraph Company. 
Now, in conclusion, Mr. President, I must say that such cases as this and others 
photographed in clear outlines upon my memory-from experience in both private 
and military practice-when brought side by side with the theories and results of 
experimental research by the localizationists, as reported to us, I find myself in a 
condition in which, as I said before, I cannot in content settle down anywhere on the 
line between the two. 
With thanks to you and the Section for the time and your attention, I am done. 
Dr. H. C. Boenning, of Philadelphia, said :-Mr. President, I do not desire to 
protract the session by discussing Dr. Clark's paper, but I desire to call attention to 
the fact that an examination of a hundred brains will show frequent variations in the 
position of the convolutions. I also desire to call attention to the fact that asymmetry 
in the two sides of the same brain occurs sufficiently often. It must be borne in 
mind, also, that the gray matter of the brain is continuous from one convolution to 
another, and if, in rare cases of disease of well-recognized convolutions, certain 
paralyses do not occur, it is not a proof of the absence of cortical centres. One point 
more : Experiments are being constantly performed by disease, and any one with 
sufficient patience and acumen can, in the dead-houses of our hospitals for nervous 
and mental diseases, discover cortical lesions for, if you will, brachial or crural or 
other paralyses. I am strongly in favor of the doctrine of localization. 
Dr. Richard Caton, Professor of Physiology, Victoria University, England, 
read a paper entitled- 
RESEARCHES ON ELECTRICAL PHENOMENA OF CEREBRAL GRAY 
MATTER. 
RECHERCHES SUR LES PHENOMENES ÉLECTRIQUES DE LA SUBSTANCE GRISE 
CÉRÉBRALE. 
UNTERSUCHUNGEN ÜBER ELEKTRISCHE ERSCHEINUNGEN DER GRAUEN HIRNSUB- 
STANZ. 
While the electrical phenomena of peripheral nerves have been fully investigated 
by Prof. Du Bois Reymond, Prof. Donders and others, few researches have been made 
regarding those of the central nervous system. Du Bois Reymond's paper on "The 
Electrical Current of the Frog's Brain," and a brief reference to the subject in a com- 
munication made by Prof. McKendrick and Dr. Dewar to the Edinburgh Royal Society, 
are all I am acquainted with. 
The questions I set myself to solve are the following :- 
1. Does the gray matter of the brain give evidence of electrical currents comparable 
with those of nerve fibre and muscle ? SECTION VIII PHYSIOLOGY. 
247 
2. If such currents exist are they related to tue functions of the brain, and will the 
study of such currents throw any light on those 1 motions ? 
I have, hitherto, experimented on the brains o; .forty-five animals, viz., cats, rabbits 
and monkeys. The instruments used were Sir William Thompson's reflecting galvano- 
meter, with accessory apparatus; Du Bois Reymond's non-polarizahle electrodes, modi- 
fied for the special requirements of the experiments. 
The animal employed was etherized and a portion of the scalp, skull and dura mater 
removed, so as to expose the greater part of one hemisphere. Small, light, non-polar- 
izable electrodes were clamped securely to the skull in such a manner that thin sculptor's 
clay points could be placed on any region of the exposed brain. Light insulated wires 
suspended from a support overhead connected the electrodes with the galvanometer. 
The animal experimented on was tethered loosely to the centre of a table a yard square, 
and allowed to move about, eat and drink at its pleasure. 
The experiment is attended with much difficulty, and is liable to failure from sev- 
eral accidental causes, such as hemorrhage, convulsions, collapse, death from use of 
anæsthetics, as well as non-polarity of electrodes from admixture of the clay with 
blood, serum, etc. 
From one or other of these causes many of my experiments were quite valueless. 
Under favorable circumstances I always obtained evidence of the existence of electrical 
currents of considerable energy-of much greater energy than those of nerve fibre. In 
some cases the currents were so powerful that shunts were needed. 
On applying one electrode to the external surface of the brain, and the other to the 
surface of a vertical section, vigorous currents passed through the galvanometer. The 
external surface was usually positive to the vertical section. If both electrodes were 
placed on the external surface a feebler movement of the galvanometer needle resulted. 
Further fluctuations of the current were observed sometimes, coinciding -with some 
movement of the animal's body or some change in its mental condition. In deep 
anæsthesia, for example, considerable deflection of needle was generally observed, 
lessening gradually as the animal regained consciousness. And when death was caused 
by prolonged anæsthesia, or by that and the opening of a large vessel, considerable 
deflection occurred, and shortly after death the needle fell to zero. 
I obtained more definite results when experimenting on Ferrier's motor and sensory 
areas. 
1. There is a region in the gray matter of the rabbit's brain, stimulation of which 
by the interrupted current causes rotation of the head to the opposite side. In the 
brain of the monkey there is also a corresponding centre. In several instances I found 
that by producing a sound, or by offering food on the one side of the animal experi- 
mented on, I could induce it to turn its head voluntarily to that side; when this move- 
ment was made, electrodes placed on the centre in question of the opposite hemisphere 
showed a fall in the current toward zero, in fact a negative variation; the movement of 
the needle exactly coincided with the movement of the animal's head to the opposite 
side. Probably the explanation is that the brain cells of the region were in a state of 
functional activity connected in some way with the head movement, and that a nega- 
tive variation of the electric current occurred similar to that which is well known to 
occur in a nerve fibre when a reverse impulse traverses it. 
2. It is difficult to induce a rabbit or a monkey to perform any definite voluntary 
act and to repeat the action frequently enough for the basing upon it of a physiological 
inference. The act of mastication is more easily induced than any other. A rabbit 
will frequently eat a piece of fresh lettuce, and a monkey will usually eat a raisin or a 
piece of raw potato as soon as it is offered him. I experimented, therefore, frequently 
on that centre of the brain which when stimulated causes masticatory movements. In 
half the animals used, I found that when the non-polarizable electrodes were placed on 248 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this centre, negative variations occurred invariably when the animal masticated, the 
variations lasting as long as masticatir n and ceasing when mastication ceased. In some 
instances it was evident that the thought or expectation of food caused the movement 
of the needle. If I showed the monkey the raisin but did not give it, a slight negative 
variation in the current occurred. When the electrodes were applied to this region, I 
found that sensory impressions made on the mouth or face caused a similar movement 
of the needle; for example, the introduction of the handle of a scalpel into the mouth, 
pinching of lips or cheeks, or stimulation of skin of face by interrupted currents. It 
seemed from this experiment as though the centres for movement of jaw, for perception 
of sensory impressions from mouth and face, and for ideas of food derived through the 
eye, coincided or were closely adjacent to one another. 
The area associated with these functions appeared to be small. I frequently had to 
search for it for some time. If the electrodes were not upon it but merely near it, no 
relation was observed between mastication and the movements of the galvanometer. 
3. Placing the non-polarizable electrodes on a given motor area, for example, Fer- 
rier's region No. 1, related to the hind limb, I found that if I stimulated the limb with 
an interrupted electric current, negative variations frequently, though not always, 
occurred. Stimulation of other parts of the body had no such effect. This experi- 
ment seemed to indicate that the centres for the production of muscular movement 
and for sensory perception in the skin coincided for the limb in question. 
4. Not unfrequently after continuous exposure of a hemisphere of the brain, spasms 
occurred in one or both limbs on the opposite side. If I placed the non-polarizable 
electrode on the brain area corresponding to the movement, I usually found that a 
strong negative variation coincided with each spasm. This was seen in numerous 
experiments, though not invariably. 
5. I found no part of the brain the electrical currents of which were influenced by 
stimulation by odors or by sound. 
6. I tried the effect of alternate intervals of light and darkness on seven rabbits and 
four monkeys, placing the electrodes on the region (13) stimulation of which causes 
movement of eyes. In three rabbits and two monkeys I found that light caused nega- 
tive variation almost invariably. In those five experiments in which I was successful 
the relation between the intervals of light and darkness and the movements of the galvan- 
ometer needle was quite beyond question. If I partially shaded the animal's eye from 
the light, the effect on the electric current was diminished. The exact way in which the 
light produced its effect is not so easy to determine. It may have excited the visual 
centre especially, or it may have acted as a general excitant to the whole brain, 
or the result may possibly have been due to the heat radiated from the flame 
acting on the electrodes; I think one of the first two theories is more probable 
than the third. 
These are the chief results of my researches. The large number of experiments 
from which I obtained no result at all (more than half the entire number) may be 
explained by the difficulties I have already mentioned. I may add that when swell- 
ing and congestion of the gray matter occurs, it is commonly accompanied by great 
unsteadiness of the electrical current, a condition which renders any observation made 
quite untrustworthy. 
To sum up my results :- 
1. There can be no doubt that the brains examined manifested vigorous electrical 
currents. 
2. These currents were increased during the suspension of functional activity pro- 
duced by anaesthesia, and in that occurring at the time of death. Shortly after death 
they decreased and finally disappeared. 
3. These electrical currents were seen to be influenced coincidently with certain SECTION VIII-PHYSIOLOGY. 
249 
voluntary acts or sensory perceptions, associated with the region of gray matter under 
examination. 
The current was almost invariably diminished when the convolution examined 
was functionally active. In fact, a true negative variation occurred. 
4. The electrical change demonstrated in Ferrier's areas in the gray matter coinci- 
dently with the muscular movement or sensory perception associated by Ferrier with 
such area, is further presumptive proof of localization. 
5. These experiments afford some evidence that the areas of brain related to special 
muscular movements, are also related to sensibility in the adjacent skin. 
Dr. T. O. Summers, of Jacksonville, Florida, presented a paper entitled - 
TROPHIC INFLUENCE OF THE NERVOUS SYSTEM.- V 
L'INFLUENCE TROPHIQUE DU SYSTEME NERVEUX. 
TROPHISCHER EINFLUSS DES NERVENSYSTEMS. 
That there is some subtle force which presides over the distribution of tissue pabu- 
lum and determines its fixation in the cellular elements of the organism, no physiologist 
of the present day will deny. That this force is independent of the chemical affinities 
which arrange the proximate principles of the organism, is also sufficiently apparent 
from pathological observations, a perverted nutrition disturbing these chemical rela- 
tions and disrupting their normal physiological arrangement. 
I shall advance one step further, and declare that, a priori, it is from the nerve sys- 
tem alone that these nutritive elements receive their distributing orders, determining, 
by supreme authority, their ultimate destination in the organism, whether for physio- 
logical or pathological results. To substantiate this I need only refer to the striking 
phenomena of ideo-motor arcs of nervous action, in which that ethereal product of the 
sensorium commune which men call thought, runs like an electric thrill to the remotest 
parts of the organism, solidifying expression in the face, arresting or stimulating 
digestion, quickening or slowing the arterial pulses, and inhibiting every function of 
every organ. The direct influence of the cerebro-spinal system upon the sympathetic 
has been deemed sufficient to explain these phenomena of emotion, but this is not 
sufficient for phenomena of elective assimilation in the nutritive process. We are 
driven to search for some other agency, whose function it is to direct and to determine 
the nutritive elements to their physiological destination and purpose. The idea of 
trophic centres seemed to have been developed originally from the logic of physiological 
necessity, for without this tertium quid in the domain of nerve force there was no ex- 
planation of the manner in which the unconscious activities of the sympathetic executed 
the orderly functions of nutrition. When the chemical acts of digestion are complete, 
when the pabulum is ready for distribution to the various tissues, the organic system 
of nerves can go no further. Presiding over glandular action, it responds to the stimulus 
of blood and sets in motion the great process of secretion and excretion, but it has 
nothing to do with the assimilation of food or the fixation of the pabulum prepared 
for the support of tissues in its proper place. Here comes in that great factor without 
which the problem of nutrition could never be worked out. There must be a portion 
of the general nerve system whose peculiar function it is to feel out after all the prox- 250 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
imate principles of the organism as they sweep by in the current of the blood, just as 
the antennæ of the articulates float out in the water of the sea to find amid the myriads 
of organisms that which is adapted to its own nutrition, and rejecting all others with 
the accuracy of chemical affinities in the laboratory of nature. 
The arrangement of these nerves is very peculiar. As far as I have been able to 
differentiate them, they are small nerve cells of gray matter, lying imbedded in the 
several tissues of the organism. In muscular tissue they appear upon the ends of the 
muscular fibrillæ, and without very close examination would seem to be a prolongation 
of the sarcolemma. These cells are multipolar, and, from the fact that their poles run 
out to the wall of the adjacent blood vessel, I feel assured that they have nothing to do 
with the contractility of the muscle, but only serve to telegraph to it the fact that mus- 
cular pabulum is passing by, and thus set the osmotic relation between the wraste 
materials of the tissue and the nutritive products necessary for its regeneration and 
support. It is in the periosteum, however, that these cellular nervous links are more 
clearly seen, and in all other tissues of the body where I have been unable to demon- 
strate them, I think analogy would justify us in presuming upon their presence. 
If the question should be asked me, What difference in cellular structure deter- 
mined this power of elective assimilation ? I should answer that I can no more explain 
this than the chemist can explain " why sulphuric acid will take baryta from all its 
combinations, or iodine will leave its potassium spouse whenever it meets its mercu- 
rial mistress. ' ' These affinities run through the whole of nature, and determine all its 
ongoings, and I am not surprised that the immortal Darwin should have founded upon 
them the philosophy of universal life. 
Under the anatomical relations which I have described it is easy to explain all 
pathological formations and trace out the process of development in all neoplasm which 
so nearly resemble the tissues in which they are imbedded ; and not only so, but the 
evolutional changes which are continually going on in the variation of species fron 
generation to generation. 
Prof. E. D. Cope, our greatest comparative anatomist, first directed my attention to 
this subject just sixteen years ago, in his remarkable paper upon " growth force," and 
I have gone thus far in my investigations to be well assured that the problem of 
nutritive assimilation is completely solved by the cellular nerve links which bring the 
tissues en rapport with the quality of pabulum necessary for its existence and develop- 
ment, which would, otherwise, pass unrecognized and unappropriated. SECTION VIII-PHYSIOLOGY. 
251 
SECOND DAY. 
The Section met, with the President, Dr. Callender, in the chair. 
W. D. Halliburton, m.d., B. Sc., Assistant Professor of Physiology, Univer- 
sity College, London, England, read a paper on- 
A COMPARISON OF THE COAGULATION OF THE BLOOD WITH 
RIGOR MORTIS. 
UNE COMPARAISON DE LA COAGULATION DU SANG AVEC LA RIGIDITE 
CADAVÉRIQUE. 
EIN VERGLEICH ZWISCHEN BLUTGERINNUNG UND DEM RIGOR MORTIS. 
The coagulation of the blood after it is shed is, in many points, similar to the 
stiffening of the muscles which occurs after death, called rigor mortis. The blood 
plasma is, during life, a liquid; the muscle plasma, i.e., the contents of the sarco- 
lemma is also, during life, a liquid. Both contain various albuminous matters of a 
complex nature. In both, certain of these proteid or albuminous substances undergo 
a change after death ; this change is a solidification ; and the solid substance is called 
the clot; the liquid residue being called the serum. 
In the case of blood, the clot is composed of fibrin (with entangled corpuscles), and 
after coagulation has occurred it floats in blood serum. In the case of muscle plasma, 
the clot is composed of myosin, and the liquid residue is termed the muscle serum. 
The theory now most commonly received as to the cause of the coagulation of the 
blood is Hammarsten's. He regards it as due to the conversion of a previously soluble 
proteid, fibrinogen, into an insoluble one, fibrin. This change is due to a ferment 
action; the ferment (fibrin ferment) being one product of the disintegration of the 
white corpuscles which occurs when the blood is removed from the vessels. The action 
of this ferment can be inhibited by cold, or by the admixture of the blood with certain 
proportions of neutral salts; and thus the coagulation of the blood can be prevented. 
Kühne obtained muscle plasma by squeezing it out from the chopped-up muscles 
of the frog at a low temperature. He found that cold prevents the coagulation of 
muscle plasma, in the same way as it will prevent that of blood plasma. I have been 
able to confirm this statement with regard to warm-blooded animals (rabbits and cats) ; 
and I also found that admixture of the muscle plasma with solutions of neutral salts, 
like sodium chloride, sodium sulphate or magnesium sulphate, prevents its coagulation. 
Dilution of such salted muscle plasma removes the inhibitory influence which the 
strong saline solution has, and brings about the formation of myosin ; coagulation occur- 
ring much more rapidly at the temperature of the body than at lower temperatures. In 
all these points the behavior of muscle plasma is exactly similar to that of blood 
plasma. 
This similarity suggested to me that the cause of the coagulation was the same in 
both cases, viz. : a ferment action ; and I succeeded in obtaining what I propose to call 252 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
myosin-ferment, by the same methods employed by Schmidt in the preparation of 
fibrin ferment. Finely-chopped muscle was subjected to the action of alcohol for some 
months, to coagulate the proteids, and then dried over sulphuric acid. Aqueous extracts 
of this dried muscle had the power of hastening the coagulation of salted muscle 
plasma, and contained the myosin ferment. The ferment is identical with or closely 
connected to a proteid of the class to which Kühne and Chittenden have given the 
name of albumose. Its activity is destroyed at 100° C. It is not identical with fibrin 
ferment, as it does not hasten the coagulation of blood plasma, nor does the fibrin fer- 
ment hasten the coagulation of muscle plasma. The myosin ferment acts upon a pre- 
viously soluble proteid of the globulin class which I have been able to separate, and for 
which I propose the name myosinogen. 
It is thus seen that there are very striking resemblances between the formation of 
fibrin and that of myosin. There are also certain differences, of which the most 
important are the three following:- 
1. Myosin can be easily redissolved by solutions of neutral salts, and this solution 
can be made to undergo re-coagulation by dilution and addition of myosin ferment. 
Fibrin, on the other hand, cannot be made to undergo such a re-coagulation. 
2. The formation of myosin is accompanied by the formation of lactic acid. This 
same acid is formed when the re-coagulation of pure myosin occurs, and its source is 
thus shown to be a proteid one, nota carbo-hydrate, as some have supposed. The for- 
mation of fibrin is not accompanied, so far as we know, by the development of any 
acid. 
3. The conversion of myosinogen into myosin is not accompanied by the formation 
of another globulin, as is the case in the conversion of fibrinogen into fibrin. 
The question of the cause of the disappearance of rigor mortis at a certain time after 
its onset, is a question which I am at present engaged in investigating; the commonly 
accepted theory, that it is due to putrefactive changes, appearing to me to be unsatis- 
factory. So far as my experiments at present show, the passing off of rigor seems to 
be due to a retroversion of myosin into the more soluble substance, myosinogen. The 
agent in this backward change appears to be pepsin, which Brücke showed to be present 
in the tissue, having been absorbed from the alimentary canal. During life it is inactive, 
as the tissues have an alkaline reaction; but after death, when the muscles turn acid, 
it is enabled to act, and at the temperature of the body peptones may be actually 
obtained. After death self digestion does not go so far as this, as the body becomes 
cold; still, I am inclined to believe that it is sufficiently powerful to bring about the 
first stage of digestion, namely, the reconversion of myosin into myosinogen. The 
varying time after death at which rigor passes off may be found to depend on the vary- 
ing amount of pepsin in the tissues, and this again would vary with the condition of 
the alimentary canal at the time of death. SECTION VIII PHYSIOLOGY. 
253 
Dr. J. Alexander McWilliam, Prof, of Physiology in the University of 
Aberdeen, read a paper- 
ON ELECTRICAL STIMULATION OF THE MAMMALIAN HEART. 
DE LTRRITATION ELECTRIQUE DU CŒUR DES MAMMIFÈRES. 
ÜBER ELEKTRISCHE REIZUNG DES SÄUGETHIER-HERZENS. 
The question of the effects of electrical stimuli upon the mammalian heart is one 
of obvious importance, both in its purely physiological and its clinical aspects, 
bearing as it does on the possibility of restoring the cardiac beat after it has been 
arrested by causes of a temporary nature. In the clinical aspect it specially concerns 
the cardiac failure which is so grave a possibility among the results of the action 
of anæsthetic agents. It may, indeed, be alleged that in such instances the cardiac fail- 
ure is frequently due to a general loss of vascular tone, or to a gradual enfeeblement 
and paralysis of the nervous or muscular arrangements of the heart in consequence of 
the prolonged action of the poison upon the cardiac tissues. But, on the other hand, it 
would appear, as Lauder Brunton and others have urged, that in very many instances- 
probably in a large majority of the cases of heart failure during the administration of 
anaesthetics-the cardiac standstill is due to inhibitory impulses transmitted along the 
vagi nerves ; impulses that do not necessarily cause any permanent damage to the 
cardiac tissues, but simply depress or suspend the spontaneous discharge of beats by 
the organ. The possibility of artificially exciting the action of the heart will, in such 
cases at least, appear to be an eminently feasible one. Among the means that have 
been tried to excite the cardiac action, electrical stimuli have been frequently employed, 
and usually without success. The mode of excitation commonly employed has been 
the application of a faradic current to the chest wall over the heart ; at times electro- 
puncture has been used. But Ludwig and Hoffa showed that the application of strong 
constant currents or of faradic currents to the ventricles of the dog's heart immediately 
abolishes the normal beat, and throws the ventricles into a remarkable state of arhyth- 
mic, quivering movement (fibrillar contraction, Herz-delirium, delirium cordis) which 
is entirely insufficient to propel the blood from the ventricular cavities. The heart 
becomes gorged with blood, the blood pressure falls rapidly, and the animal dies as 
rapidly as though the root of the aorta had been ligatured. The essential features of 
this condition appear to occur under faradisation, not only in the heart of the dog, but 
in all mammalian hearts. I have, myself, observed it in the dog, cat, rabbit, rat, 
mouse and hedgehog. I have found it to occur both when the thorax has been 
opened and the heart laid bare, and when the current has been passed through 
the walls of the intact thorax. I have no doubt that it may readily occur in the 
human heart. Hence, it is obvious that the employment of faradic currents as a 
means of faradic excitation is one fraught with the gravest danger. It has, 
indeed, been argued that the currents used to stimulate the heart in man are 
not so strong as those employed by Ludwig and others, and would probably be 
insufficient to produce such a disastrous result. But this argument is one on 
which there is no reliance whatever to be placed, notwithstanding the fact that 
Von Ziemssen and others have described the application of faradic currents to the 
human heart without unfavorable results, for one of the facts with which I have 
been most strongly impressed during my experimental investigation of the subject has 
been the variability of the behavior of the heart in this respect, the extreme readiness 
with which, in certain circumstances, the ventricles pass into the arhythmic, quivering 254 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
condition described. This state of increased sensitiveness to electrical currents appears 
to occur most frequently in abnormal conditions-when the respiration has been inter- 
rupted or when there has been symptoms of incipient cardiac failure from various 
causes (excess of chloroform, etc.). In such cases I have seen again and again an exceed- 
ingly weak faradic current-such as could hardly be felt by the tongue-cause an 
immediate arrest of the ventricular beat, and an immediate supervention of the arhyth- 
mic, fibrillar condition. Von Ziemssen, indeed, tried the effects of faradic currents 
upon the human heart (in a case of " Ectopia Cordis") without obtaining any marked 
results. So also have Herbst and Dixon Mann, experimenting upon the normal chest. 
But the conditions obtaining in these experiments are entirely different from those 
present in the cases where stimulating currents are required clinically. In the former 
the heart was beating normally ; in the latter the cardiac action has been markedly 
impaired or entirely suspended. And it has been seen that in such conditions the 
heart frequently manifests an extraordinary sensitiveness to the influence of faradic 
currents ; a sensitiveness that differs most markedly from the state of comparative 
insusceptibility obtaining in the normal heart. Further, a faradic current too weak to 
provoke fibrillar contraction in the ventricles appears to have no considerable stimu- 
lating influence upon the heart. 
It is certain that some form of stimulation must be sought other than faradic or 
strong constant currents. Such a means of stimulation is available in the form of 
single induction shocks. A single induction shock acts as a powerful excitant of cardiac 
contraction. During cardiac standstill, brought about through the vagus nerves, a 
single induction shock readily excites a single contraction of both auricles and ventri- 
cles. A slow series (say one per second) of induction shocks of moderate strength 
causes a series of complete heart beats at the same rate ; and never in my experience 
have single induction shocks produced the fibrillar condition. Single induction shocks 
are thus readily available for the purpose of exciting cardiac beats. The order of the 
beat (i. e., the succession of auricles and ventricles) varies, however, according to the 
part of the heart most strongly excited by the shock. When a shock is applied to the 
auricles the contraction follows the normal order. But when the shock is applied to 
the ventricles, the ventricular contraction occurs first and then the auricular contrac- 
tion ; in other words, the heart beat occurs in reversed order. And this raised the 
question as to whether such a reversed form of beat would be effective in discharging 
the blood from the heart, especially as in employing induction shocks upon the heart 
in the intact thorax it would necessarily be uncertain what part of the heart would be 
specially acted on by the stimulating shocks. And during my work on the hearts of 
cold-blooded animals, I found in the case of the eel that a series of induction shocks 
applied to the ventricle gave a series of reversed heart beats which were not effective in 
keeping up the circulation of the blood. The auricle became gorged, and the circula- 
tion became palpably obstructed. I have tested this question on the mammalian heart, 
the thorax being opened and artificial respiration kept up by comparing the effects of 
induction shocks applied to the auricles and ventricles respectively during cardiac 
arrest brought about through the vagus nerves. I have found that the state of matters 
is very different from what obtains in the eel. Contraction of the mammalian heart, 
whether resulting from stimulation of the auricles or of the ventricles, whether excited 
in the normal order or in reversed fashion, is effective in causing a discharge of blood 
from the ventricles into the great vessels and a marked improvement in the condition 
of the heart and of the circulation generally. It would appear, then, that during an 
arrest of the heart's action, brought about through the vagus nerves, there is available 
an effective means of excitation by which the activity of the organ may be aroused, 
provided the standstill has not been of so long duration as to cause the death of the 
cardiac tissues. SECTION VIII PHYSIOLOGY. 
255 
In those instances where cardiac failure has occurred, not from inhibitory impulses 
but from a gradual depression and paralysis of the heart by prolonged and excessive 
action of an anaesthetic, it is much more difficult to obtain successful results. But the 
experiments of Böhm show that, in favorable circumstances rhythmic compression of 
the heart in animals, together with artificial respiration, may lead to recovery of the 
heart even after long periods, e. g. 40 minutes, and I have myself witnessed the com- 
plete recovery of the cardiac action in cats after there had been apparent death of the 
organ, in consequence of an excessive administration of chloroform (after section of both 
vagi). Experimenting with the thorax open, I employed rhythmic compression of the 
heart, which is probably the most effective means of restoring the cardiac action in such 
cases. And though such a method available in animals possesses advantages not pos- 
sessed by any method applicable to the human subject, still I have obtained favorable 
results from the use of induction shocks, and it is probable that cardiac recovery even 
in man occurs to a much greater extent than is commonly accepted. 
The mode of excitation by induction shocks appears to be the method plainly indi- 
cated by our physiological knowledge of the subject, based upon facts that appear to be 
applicable not merely to one animal but to the whole mammalian class. 
Induction shocks should be employed in preference to the make and break of a 
primary current, on account of the greater power which the induced current possesses 
of overcoming resistance. The shocks ought to be sent through the heart, one electrode 
being applied over the apex of the heart and the other over the sixth or seventh dorsal 
vertebra, the electrodes to be of large extent. The shocks ought to be about the nor- 
mal rate of the heart's beat. 
Dr. Thomas W. Poole, of Ontario, Canada, read a paper- 
ON THE NECESSITY FOR A MODIFICATION OF CERTAIN 
PHYSIOLOGICAL DOCTRINES REGARDING THE INTER- 
RELATIONS OF NERVE AND MUSCLE. 
SUR LA NÉCESSITÉ D'UNE MODIFICATION DE CERTAINES DOCTRINES PHYSIO- 
LOGIQUES À L'ÉGARD DES RAPPORTS ENTRE NERF ET MUSCLE. 
ÜBER DIE NOTHWENDIGKEIT EINER MODIFIKATION GEWISSER PHYSIOLOGISCHER 
LEHREN HINSICHTLICH DES VERHÄLTNISSES ZWISCHEN NERV UND MUSKEL. 
For some years past I have endeavored to bring to the notice of the profession a view 
of the inter-relations of nerve and muscle-more especially of the vasomotor nerves and 
the arterial muscles-which is entirely at variance with what is taught in our physio- 
logical text-books. 
I should be unable to find any excuse or apology for attempting so bold a task, were 
it not that the proofs which I have to advance are drawn entirely from the authentic 
storehouse of physiological research. While the facts to be here advanced are the 
results of observation by the great Masters in this department of science, I hope to be 
able to show, conclusively, that the inferences or interpretations placed upon these facts 
are, in some instances, erroneous, and ought to be modified or reversed. 
In the examples now to be cited of an erroneous interpretation of authentic experi- 256 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ments, the idea evidently dominating the physiological mind was, that a stimulus from 
nervous energy is necessary to induce muscular contraction. As a corollary to this 
idea, of course, it followed that when the motor nerve supplying a muscle was cut, or 
paralyzed from any cause, the muscle thus deprived of nerve influence was rendered 
incapable of displaying its contractile power. 
That such an idea was apparently justified by the behavior of the voluntary muscles 
is undoubtedly true ; but not so in regard to the non-striated or involuntary muscles of 
organic life, which have been pronounced by physiologists to be paralyzed and powerless, 
at the very moment that the observers saw and recorded the palpable evidences of their 
more or less active contraction. In fact, so far from the current teaching of physiology 
being true, as regards the relations of motor nerves to involuntary muscles, the very 
reverse is true ; the actual fact being that muscles of the involuntary class, as a rule, con- 
tract, not when stimulated by their proper motor nerves, but when these nerves are cut, or are 
paralyzed, or dead. 
The (Esophageal and Gastric Muscles.-To come now to the facts. The statement 
continues to be repeated in each succeeding text-book on physiology, that section of the 
pneumogastric nerves (vagi) is followed by paralysis of the oesophagus and stomach. 
Now, on the theory uppermost in the minds of physiologists-referred to above-the 
oesophagus ought to be paralyzed here, and to be reduced to the condition of a mere 
flaccid tube. But that such is not the case is evident from the fact that after the opera- 
tion, food and drink fed to the animal, " in a few moments are suddenly rejected by a 
peculiar kind of regurgitation." (Dr. Dalton's "Phys.," p. 473.) It needs no argu- 
ment to prove that the sudden rejection of ingesta, in the manner stated, so far from 
being an evidence of paralysis, is really a proof of active contraction in the muscle. 
But it is said that sometimes the ingesta are detained in the oesophagus for a time, 
and, "owing to paralysis of this canal," are not conveyed into the stomach. (16.) 
Dr. W. B. Carpenter, F. K. s., refers to this by stating that "if the pneumogastric be 
divided in the rabbit, on each side, above the oesophageal plexus but below the pharyn- 
geal branches, and the animal be then fed, the food is delayed in the oesophagus, which 
becomes greatly distended." ("Hum. Phys.", 5th Amer. Ed., p. 404.) Now the 
pharyngeal branches supply the upper part, and the oesophageal plexus the lower 
extremity of the muscular tube. Mark what follows on section of the vagi between 
these two ! The upper part of the oesophagus, whose nerves are intact, admits the food 
and drink apparently in a normal manner, while the lower part of the tube, which has 
been deprived of nervous influence, contracts upon itself, and so lessens the calibre of 
the "canal" as to arrest the further passage of the superimposed ingesta, as a conse- 
quence of which the oesophagus "becomes greatly distended." 
Whether the ingesta are thus forcibly detained or " forcibly ejected " would appear 
to depend on the point at which the vagi are cut. But in either case, the result, so far 
from being a proof of paralysis, really bears evidence of activity of the muscle. And this 
is confirmed by the observation of Dr. M. Hall, that ' ' the simple contractility of the 
muscular fibre [of the oesophagus] occasions a distinct peristaltic movement along the 
tube after its nerves have been divided, causing it to discharge its contents when cut 
across." [Italics mine.] (Dr. Carpenter's "Hum. Phys.," 5th Amer. Ed., p. 404.) 
Dr. Burdon Sanderson expresses the idea uppermost in the physiological mind, in 
stating that after section of the vagi " the muscular fibres of the oesophagus are para- 
lyzed, so that regurgitation of food from the stomach is apt to take place." ("Hand- 
book for Phys. Lab.," Amer. Ed., p. 318.) 
Dr. W. B. Carpenter seems to pass over this part of the subject lightly, and it is not 
till treating of the effects of section of the vagi on the gastric secretions that he plainly 
states that, " the first obvious effects of this operation are vomiting (in animals that are 
capable of it), and loathing of food." (p. 423.) He also tells us, in another place, SECTION VIII PHYSIOLOGY. 
257 
that the reopening of the cardiac orifice, on pressure from within, is one of the first of 
that series of reverse actions which constitute vomiting, (p. 404. ) It is evident that 
the " pressure " referred to and the force necessarily required to eject the contents of the 
stomach and oesophagus could not come from "paralyzed" muscles, which the facts 
show to be really undergoing active contraction. 
That nerve force is actually in abeyance in the act of vomiting was fully recognized 
by Dr. Anstie, who places it among the effects of paralysis of the medulla oblongata in 
narcosis. ("Stimulants and Narcotics," p. 168.) While the vomiting of migraine, he 
says, "marks the lowest point of nervous depression." ("Neuralgia," p. 39.) 
Had those eminent physiologists, Drs. Todd and Bowman, doubts of the truth of the 
physiological theory of the day, and a prescience of what the future had in store, when 
they wrote : "The office of the gastric branches of the vagi nerves appears, from Dr. 
Reid's experiments, to be chiefly to control the movements of the muscular coat of the 
stomach." [Italics mine.] ("Phys. Anat.," p. 493.) That is precisely what the 
scope of this paper is designed to show-that in so far as the involuntary muscles, at 
least, are concerned, the function of nerve force is not to stimulate, but to restrain and 
control muscular activity ; which all physiologists regard as an inherent endowment of 
muscular tissue. 
The Bronchial Muscles.-Dr. Burdon Sanderson informs the readers of the " Hand- 
book," that after section of the vagi " the muscular fibres of the bronchial tubes are in 
a similar condition" to those of the oesophagus and stomach, (p. 318.) Then it is 
evident that these muscular bands come under the rule of law laid down above, and 
contract, like other muscles of this class, when deprived of nervous influence. 
The Nasal Muscles.-It is a curious fact, that "owing to the great size of the velum 
pendulum palati, the horse is unable to breathe through the mouth." (Strangeway's 
1 ' Veterinary Anat., " p. 209. ) As a consequence, respiration is carried on in this animal 
exclusively through his nose ; and when both the facial nerves are cut, or paralyzed, 
"the nostrils immediately collapse, and the animal dies by suffocation." (Bernard, 
quoted by Dr. Dalton, "Phys.," p. 458.) 
A result very similar, so far as the closure of the nostrils is concerned, has occurred 
in the human subject, during paralysis of the facial nerve. Thus, Sir Thomas Watson, 
reporting the case of the girl, Jane Smith, says : "When she tried to snuff in air through 
her nose, not being able to keep the right nostril stiff and open, its sides came together, 
and no air passed up that side." (Lectures, Prac. Physic, p. 366.) 
A little reflection will show that this is necessarily due to muscular contraction. The 
effect produced is not to be accounted for by any filling up or stuffing of the nasal passage 
by relaxed or paralyzed muscles, because the muscles are on the exterior of the cartilages, 
and mucous membrane or fibrous tissue does not contract or respond to nerve action. The 
obstruction is caused by the cartilages of the nose coming together, for which the only 
adequate explanation is the action of the constricting muscles, which, as in other 
similar cases, assert their power when nervous restraint is removed. 
Spasm of the Glottis due to Nerve Paralysis.-We now come to a still more striking 
illustration of the truth of the proposition laid down above. The aperture of the 
glottis is closed by one set of muscles and opened or dilated by another. The con- 
stricting muscles are the arytenoidei and crico-arytenoidei laterales, while the dilators 
of the glottis are the crico-arytenoidei postici. 
Dr. Burdon Sanderson states that "the widening of the glottis is a condition of 
general muscular relaxation." He further states that the closing of the glottis is 
equally due to a general contraction of all the muscles; so that the glottis is closed, 
" not because the postici crico-arytenoidei muscles and the other dilating muscles* do 
* There are no " other dilating muscles " than the crico-arytenoidei postici. 
Vol III-17 258 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
not act with the rest, but because they are overpowered by the constricting muscles." 
(Handbook, p. 308.) 
The situation thus depicted becomes quite remarkable and full of interest, when it 
is remembered that the sole motor nervous supply to both these sets of muscles passes 
through the inferior laryugeal (or recurrent) nerve, a branch of the pneumogastric. and 
that when this nerve is cut or paralyzed, the closure of the glottis takes place, as a 
result of spasm of both of the antagonizing muscles, as just stated. 
On page 318 of the Handbook the same eminent physiologist, describing the effects 
of section of the vagi, says: " The glottis is partially closed, just as it is in death." 
How the glottis is closed in death will appear from the fact, vouched for by Dr. Austin 
Flint, in the fifth edition of his "Practice of Medicine," when he says, the operation 
of passing a probang within the larynx "is extremely difficult, if it be practicable, on 
the cadaver." (p. 294.) 
There can be no doubt about the effect of the section referred to being of a paralyz- 
ing character, so far as the nerve is concerned, seeing that the simple section of the 
nerve during life, and the extinction of all nerve force in death, lead to precisely the 
same results as regards the closure of the glottal aperture. Dr. Burdon Sanderson adds 
that, "in animals with divided vagi, life may be prolonged by tracheotomy," showing 
how complete and fatal is the spasm thus produced. Other evidence of similar import 
is not lacking. Thus, Dr. Austin Flint, discussing the ' ' danger of death from suffo- 
cation " in the "obstructed inspiration" occurring in nervous aphonia says: "The 
condition is analogous to that after the physiological experiment of dividing both 
recurrent laryngeal nerves." ("Prac. of Med.," 5th Ed., p. 309.) The same author 
has "reported a case in which the left recurrent nerve being situated between a cal- 
careous deposit and an aneurismal tumor, spasm of the glottis occurred so frequently 
and to such an extent as to prove fatal." (Zö., p. 371.) 
Now, since the recurrent nerve is the only motor nerve supplying these muscles, and 
since section or pressure on a nerve trunk cannot increase nerve activity-the nerve 
trunks being mere carriers and not producers of nerve force-it is evident that no other 
conclusion is possible than that the spasm here referred to is due to the absence of nerve 
force, and not to a stimulus from excited nerve action. And since nerve paralysis is 
thus shown to be directly the cause of spasm of the glottis, it is not necessary to infer 
that whatever is done by reflex action to cause spasm of the glottis must be of a para- 
lyzing character to the nerve also? Thus, what is vaguely called "irritation," by 
which is usually meant an excitation or exaltation of nerve power, and which consists 
really in a perturbation of nerve force, must necessarily be an influence of a paralyzing 
character to the nerves it traverses. Such reflex " irritations " are usually attributed to 
brain lesions, to indigestible food, and other causes of a more or less debilitating char- 
acter which may well arrest, rather than develop, the flow of nervous activity. 
If it be true, that pain is "an expression of impeded and imperfect nerve energy, 
not of heightened nerve function," for which there is high authority (Anstie, "Neu- 
ralgia," pp. 12 and 163), how much more is the perturbation of the nerve molecules, 
which constitutes "irritation," a disturbance of normal activities which is equivalent 
to paralysis. 
Relation of Vasomotor Nerves to the Arterial Muscles.-I propose to show here, on the 
very best physiological authority, that what is known as " paralytic hyperæmia " is- 
contrary to the accepted opinion-venous and not arterial. 
I need not delay to offer proof that the middle muscular coat of the arteries is under 
the control of the vasomotor nerves of the sympathetic, which regulate the calibre of 
these tubes; or that the chief vasomotor centre is in the medulla oblongata, with pro- 
bably lesser centres in the spinal cord. These are among the well-authenticated facts 
of recent physiology. It is in determining the action or play of this mechanism that I SECTION VIII PHYSIOLOGY. 
259 
have the temerity to claim that our physiologists have made an " unscientific use of the 
imagination. " 
The theory of the text-books is, that when the influence of the vasomotor centre is cut 
off from the arterial muscle in any way, hyperæmia of the arteries results. Thus, in 
destruction of the nervous centres by the operation of "pithing"-as a result of sec- 
tion of the spinal cord just below the medulla, and on section of the chief vasomotor 
nerve trunks, in the body or viscera, it is claimed that the corresponding arteries are 
more or less dilated. Dr. Burdon Sanderson contents himself with stating that under 
these circumstances "the arteries are relaxed," and again, that they "become per- 
manently larger. " ("Handbook," pp. 245-256.) Other physiological teachers, such 
as Prof. Kuss, say that here the arteries are "dilated," while Dr. Sidney Ringer, in 
his excellent "Therapeutics," has it that " the arteries remain widely dilated." (5th 
Amer. Ed., p. 312.) We shall presently see how far these statements are justified by 
the facts. 
Section of the Cervical Sympathetic.-To M. Claude Bernard And Dr. Brown-Séquard 
we are largely indebted for what is known on this subject, as observed by them in the 
famous experiment on the cervical sympathetic. Dr. Brown-Sequard enters into the 
details at great length in his " Physiology and Pathology of the Central Nervous Sys- 
tem." Yet, nowhere in this work, in regard to this or any other section of cord or 
nerve, does he once assert that the arteries are dilated. In the pages devoted to 
it he refers to the contemporary experiments on this subject by Waller, Donders and 
his pupils, by Kussmaul and Tenner, Moritz and Schiff, yet he makes no mention of an 
allusion to dilated arteries by any of these eminent observers. This is surely signifi- 
cant. With him it was always "the blood vessels " which are "paralyzed " and "the 
blood vessels " which are " dilated." He says that " the hanging down of an animal, 
by holding it up by its hind legs, in producing a congestion of the brain, produces very 
nearly all the effects of this section." (p. 143.) 
From these considerations it will be evident, first, that it was by no means appa- 
rent-was, indeed, a matter of great difficulty to determine accurately-what particular 
" vessels " were enlarged, hidden as they mostly were beneath the skin and its subja- 
cent tissues. Nay, it is not too much to say, that the statement that it is the arteries 
that are enlarged is purely hypothetical, and not based upon an actual demonstration 
of the facts. Secondly, it will be also evident from the statement just quoted from Dr. 
Brown-Sequard, that venous hyperæmia, the result of the blood being forced out of the 
arteries by their partial contraction, " very nearly accounts for all the effects of this 
section." The truth of this will not only appear from what is to follow now, but from 
the effect of other sections to be noted. 
Notwithstanding an increased afflux of blood, and consequently a relative elevation 
of temperature, with heightened sensibility, " the intimate acts of nutrition appear to 
be modified in nothing. . . . Nor does it appear that this hyperæmia, however intense 
or prolonged it may be, has ever the effect, save under exceptional circumstances, of 
'determining by itself the development of inflammatory action." (M. Charcot, " Leet. 
Nerv. Sys.," pp. 90-91.) This could hardly be the case if the hyperæmia were arterial. 
Among the effects of this section on muscles, as reported by Dr. Brown-Sequard, are 
contraction of the pupil, retraction of the eyeball, partial closing of the eyelids, con- 
traction of "almost all the muscles of the eye," and also of the muscles of the angle 
of the mouth and nose; contraction of the erectile muscles of the ear, and others. Now, 
seeing that it is contraction and not relaxation of all these muscles, which follows sec- 
tion of this nerve, the law of analogy would require that the muscles of the arteries 
supplied by this nerve be contracted also; otherwise the anomaly would exist of the 
same nerve producing contraction in a large number of muscles and relaxation in a 
single instance. Why should the arterial muscle be regarded as an exception among NINTH INTERNATIONAL MEDICAL CONGRESS. 
260 
so many others, especially when all the facts of the case are compatible with arterial 
contraction and venous fullness ? 
As for the second part of the experiment, in which the hyperæmia is dissipated by 
faradisation of the distal end of the cut nerve, that is easily accounted for. The ter- 
minal branches of the cut sympathetic evidently influence the muscles of the head and 
face over a wide area. As is well known, the effect of faradisation is to set up a sue 
cession of rapid contractions and relaxations in muscular tissue. The pressure thus 
brought to bear on the swollen veins would amply suffice to force their contents 
onward, and thus to dissipate the venous congestion. Examples of this very result are 
not lacking. Thus, when Kölliker applied one pole to the umbilical artery and vein 
of a fresh human placenta, there followed contractions by which the veins forced out 
their contents and changed into bloodless strings. (" Meyer's Elec. " Hammond, p. 
88.) 
The following quotations from Rosenthal's " Diseases of the Nervous System," Vol. 
ii, Wood's Library, have a peculiar fitness here: " Kussmaul and Tenner have shown, 
in a series of experiments, by placing a watch-glass in the opening of a trephined 
skull, without allowing the air to enter (Donder's plan) that compression of the carotids 
causes capillary anæmia and venous hyperæmia of the brain and meninges." (p. 64.) 
"In Verneuill's patient, upon whom ligature of the carotid was performed fora 
tumor of the parotid gland, persistent contraction of the pupil developed shortly after- 
ward, with rise of temperature and vascular dilatation upon the temple and gums, and 
abundant perspiration upon the side of the face corresponding to the operation. All 
these symptoms can be produced experimentally upon animals by dividing the cervical 
sympathetic." (p. 26.) 
Here is a remarkable proof that the section referred to causes arterial contraction (and 
not dilatation), seeing that the other effects of the section are equivalent to those pro- 
duced by ligature of the carotid. 
Section of the Splanchnic#.-In a " demonstration of the vasomotor functions of the 
splanchnic nerves," the chief editor of the "Handbook for the Physiological Labor- 
atory" (Amer. Ed., p. 258) informs his readers that these nerves contain vasomotor 
fibres which ' ' are distributed to the arteries of the abdominal viscera. ' ' 
We approach this "demonstration " expecting to find that when these nerves are 
cut the predicted results will follow, in the arteries they supply being more or less 
"relaxed" or "dilated." What isour disappointment to find in all that follows in 
this chapter of the "Handbook" the arteries are never once alluded to! Thus the 
very pith and point of the so-called ' ' demonstration ' ' is entirely ignored ! What occurs 
is thus stated by Dr. Burdon Sanderson : " After section of both nerves the vessels of 
all the abdominal viscera are seen to be dilated." What "vessels " are these ? Not the 
arteries, because Dr. Burdon Sanderson continues: " The portal system is filled with blood; 
the small vessels of the mesentery and those which ramify on the surface of the intestine 
are beautifully injected; the vessels of the kidney are dilated, and the parenchyma is 
hyperæmic; all of which facts indicate, not merely that by the relaxation of the 
abdominal blood vessels a large proportion of the resistance to the heart is annulled, 
but that a quantity of blood is, so to speak, transferred into the portal system, and thereby 
as completely discharged from the systemic circulation as if a great internal hemorrhage had 
taken place." (p. 260.) [Italics mine.] 
It needs no italics to give point and force to this remarkable admission. It is merely 
stating, with a little circumlocution, that the arteries are empty and the veins are full ! 
The "beautiful injected vessels," which the learned editor so much admired, are not 
arteries but veins, the blood in which has become " bright red, like arterial blood," as 
Prof. Kuss explains of venous blood in the mesentery, " because oxygenation has been 
effected simply by exposure to the air." (" Lee. Phys.," p. 326.) SECTION VIII PHYSIOLOGY. 
261 
The contraction and emptiness of the arteries after section of their vasomotor nerves 
is thus proved on the very highest authority. Where now is the justification of the 
assertion that after a section of this kind the arteries are dilated and hyperæmic ? 
Whatever obscurity there might be as to the actual results of section of the cervical 
sympathetic, for obvious reasons, there can be no mistake as to the results here. 
Now the law of uniformity of cause and effect demands that what is true of the 
relative state of the arteries and veins after section of the splanchnics, must be true also 
after section of the cervical sympathetic ; and since the arteries are thus shown to be 
empty and the veins full in the former case, the same condition must be held to prevail 
also in the latter. 
It is worthy of note, in this connection, that both after section of the spinal cord 
and after section of the splanchnics, blood pressure falls, and in both cases may be re- 
stored by faradisation of the divided cord or nerve. It is evident from this that the 
fall of blood pressure (as shown by the kymograph in the carotid) on section of the 
cord is not to be regarded as an indication of arterial relaxation, as appears to have 
been done ; because blood pressure fell also after section of the splanchnics, where we 
know positively that arterial dilatation could not have taken place. 
It may be asked, how could faradisation of the spinal cord or of the nerve restore 
the pressure or tension in the arteries, if the heart and arterial system were already 
empty ? Dr. Burdon Sanderson supplies the answer indirectly, in stating : " It is seen 
that after section of the cord the heart is flaccid and empty, and that its cavities fill 
and its action becomes vigorous when the vascular contraction caused by excitation of 
the peripheral end [of the cut cord] forces the blood forward so as to fill the right 
auricle." (p. 251.) Now the only blood which could be " forced forward so äs to fill 
the right auricle" is venous blood from the distended portal system. Thus it will be 
seen that all the facts fit and, as it were, dovetail into each other, in establishing that 
nervous paralysis and contraction of the arterial muscle go together, the result being 
hyperæmia, not of the arteries but of the veins. 
The explanation just quoted from the Handbook, as to the forcing forward of the 
venous blood as an effect of the faradic current, confirms the explanation made above, 
as to the dissipation of the venous hyperæmia by the same current after section of the 
cervical sympathetic. 
State of the Arteries in Death.-Not only are the arteries invariably as empty as their 
physical structure will permit them to be, when their nerves are cut or paralyzed in 
the living body, but such is also their condition in death of the body, when nerve force 
is extinct. This is a fact too well known to need any special proof. It is a fact, how- 
ever, which ought to be explained by those who hold that in a condition of nerve para- 
lysis the arteries are ' ' dilated ' ' and hyperæmic. 
The Operation of Pithing.-What has just been said of the contracted and empty 
state of the arteries is true also after the operation of "pithing " (in which the medulla 
and spinal cord are destroyed) ; as any one can easily satisfy himself, as I have done, 
by actual experiment. This is inadvertently proved to be the case by Dr. Burdon San- 
derson in his account of an experiment designed to prove the contrary. Two frogs are 
taken. One is " pithed," in the other the nervous centres are uninjured. In both the 
heart is carefully exposed and the single ventricle slit open, so as to show the state of 
the great vessels. The experiment is intended to prove that in the pithed frog the 
arteries are "relaxed" and full of blood. On Dr. Burdon Sanderson's showing, the 
results are these: In the pithed frog, "although the heart is beating with perfect 
regularity and unaltered frequency, it is empty, and in consequence, instead of project- 
ing from the opening in the anterior wall of the chest, it is withdrawn upward and 
backward toward the oesophagus." The heart and its appendages "are alike deprived 
of blood ; " but on opening "the rest of the visceral cavity," " tAe intestinal veins are 262 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
distended." In these, "the whole mass of blood has come forest, out of reach of the 
influence of the heart." (p. 246.) How significant is this ! If the arteries were dilated, 
and consequently full of blood, this blood could not be said to be "out of reach of the 
influence of the heart. " But this is not all. The Handbook continues : " In the frog 
deprived of its central nervous system only a few drops of blood escape-the quantity, 
that is to say, previously contained in the heart and in the beginning of the arterial 
system. In the other, bleeding is not only more abundant but continues for several minutes 
after the section." (pp. 246-296.) [Italics mine.] 
Is it not evident that in the case of the pithed frog the arterial system promptly 
emptied itself into the now " distended veins," and had "only a few drops of blood " 
left to drain away through the open ventricle (the frogs being both suspended) ; while 
in the case of the other frog, whose nervous system was intact, this arterial contraction 
did not take place, and the arteries continued to bleed for several minutes till drained 
of blood. 
The " Handbook for the Physiological Laboratory," from which I have quoted so 
often, occupies to-day a leading place as an exponent of physiological science. The 
reader who studies the details of the experiment just quoted will be surprised to find 
that here again, in an experiment specially designed to prove that "all the arteries 
are relaxed," the condition of the arteries is completely ignored, and never once 
alluded to ! The arteries ought to be "relaxed," "dilated," and even "widely dilated " 
here, on the theory of the text-books, but they are empty and contracted, their final 
act being, as in death from other causes, "to drive their contents into the veins." 
(Kuss, "Phys.," p. 181.) 
An Experiment of Dr. Brown-Sequard.-In this connection I must notice in the 
briefest manner an experiment of Dr. Èrown-Sequard, in which the doctrine here sup- 
ported is confirmed in a remarkable manner. 
In a dog, a section was made of a lateral half of the spinal cord, just below the 
medulla. The result was extreme hyperæmia of the "bloodvessels," to use Brown- 
Sequard's term, of one posterior limb, while the "blood vessels " of the other posterior 
limb displayed a state of spasm and ischaemia quite as extreme. "Very often the 
spasm persists for days," wrote the observer, "and it may be so great that the circula- 
tion is almost entirely suspended," so that "the cutting of the skin hardly gives a drop 
of blood." 
The question at once arose, was the paucity of blood in one limb due to the excess of 
blood circulating in the other, or ■mce wrsa ? Was the spasm on one side, or the dilata- 
tion on the other, the primary or direct effect, through the spinal vasomotor nerves of 
the half section of the cord ? 
Inorder to solve this question, Dr. Brown-Sequard made "direct experiments." 
Among others he ligatured the iliac artery feeding the dilated blood vessels of the 
hyperæmic limb, thus directing "almost the whole of the blood coming from the aorta " 
into the iliac artery of the limb in which the circulation was so much diminished. Not- 
withstanding this, the spasm was but partially overcome ; ' ' the temperature rose but 
little ; " and "it was quite evident the small arteries near the toes did not allow the 
blood to pass freely." 
Here was complete evidence, not only that there was spasm, but also that this spasm 
was arterial. Although the vasomotor mechanism of the spinal cord is as yet only 
very imperfectly understood, there seems no reason to doubt that this active contraction 
of the arterial muscles was here, as elsewhere, due to nervous paralysis, the result of 
the half section of the spinal cord. 
More about the Arterial Muscles.-It will be obvious that the relative state of the 
arteries and veins in the foregoing experiments is incompatible with what M. Charcot 
calls "the paralytic dilatation " of the arteries, as a result of vasomotor nerve section, SECTION VIII-PHYSIOLOGY. 
263 
and could not occur, if after this section the arteries remained ' ' widely dilated, ' ' and 
' ' permanently larger, ' ' as asserted by other authorities already quoted. If this were 
the condition of the arteries, it is evident that they would be wholly incapable of con- 
tracting upon their contained blood, so as to force it forward through the capillaries and 
into the veins; an act depending entirely upon arterial contraction, because the force of 
the heart has already expended itself, and the capillaries have no muscular walls; while, 
that the veins are merely passive, is shown by the fact that they have no vasomotor 
nerves, and their calibre is not, as in the case of the arteries, regulated by nerve 
influence. (Dr. M. Foster's "Phys.,"pp. 263-265.) Thus all the facts show that the 
arteries, so far from being "dilated" and "paralyzed," are undergoing active con- 
traction. 
Some recent authorities appear to suggest the modified idea that the dilation of the 
arteries, instead of being ' ' permanent, ' ' as alleged by some authorities, is a temporary 
effect-"an opening of the floodgates," so to speak, in order to facilitate the transmis- 
sion of blood to the veins. Thus Dr. M. Foster writes : ' ' The section of the splanchnic 
nerves causes the mesenteric and other abdominal arteries to dilate, and these being very 
numerous, a large amount of the peripheral resistance is taken away and the blood 
pressure falls accordingly; a large increase of flow into the portal veins takes place and 
the supply of blood to the face, arms and legs is proportionately diminished." 
("Phys.," 3d Amer. Ed., pp. 220 and 240.) 
It would appear that here, as elsewhere, " the fall of blood pressure" is regarded as 
evidence of ' ' lessened peripheral resistance, ' ' and a proof that the arteries are ' ' dilated, ' ' 
the fallacy of which will presently appear. 
We read again : "When the nervous system is destroyed, dilation of the splanchnic 
vascular area causes all the blood to remain stagnant in the portal vessels; and probably 
these, as well as other veins, are rendered unusually lax, so that the blood is largely 
retained in the venous system, and very little reaches the heart." (ZA, p. 367.) And 
further : ' ' When in the frog the brain and spinal system are destroyed, very little blood 
comes back to the heart, as compared with the normal supply, and the heart in conse- 
quence appears almost bloodless and beats feebly . . . the veins become abnor- 
mally distended, and a large quantity of blood becomes lodged and hidden, as it were, 
in them." (ZZ>., p. 263.) 
Here is the secret, both of the emptying of the arteries and of the fall of blood pres- 
sure. The blood comes to rest in the more capacious venous system (Z6., p. 154), "out 
of reach of the influence of the heart. ' ' Now, seeing that the rapidity of the arterial 
circulation is such that only one-seventh of a second is required for blood to pass from 
the heart to the radial pulse, how long, think you, would be required to empty the 
arterial system of the pithed frog, seeing that at first little blood, and very soon no 
blood, finds its way back through the heart, into the arterial trunks ? Why, the time 
required would be counted by seconds rather than by minutes. There would be no 
time and no necessity for the terminal arteries to dilate ; the emptying of the arteries 
and the fall of blood pressure being amply accounted for by the fact that blood is passing 
out of the arterial system faster than it is being returned to it. 
A precisely similar condition to that just described as resulting from nerve destruc- 
tion, occurs also in the fatal stage of asphyxia. Here, too, the arteries are "contracted " 
and empty, and the large veins are so distended that ' ' if cut into they spirt like arteries. ' ' 
(Dr. Burdon Sanderson, "Handbook, etc.," p. 332.) And here, also, Dr. M. Foster 
tells us there is a fall of blood pressure in the midst of general arterial contraction. 
He says : ' ' On account of the increasing slowness and feebleness of the heart, the blood 
pressure, in spite of the continued arterial contraction, begins to fall ; since less and 
less blood is pumped into the arterial system." (" Phys.," p. 445.) It will be seen that 
the parallel between the two cases is complete, and that the plain facts, as given by the 264 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
highest authorities, do away completely with the assumption that here the fall of 
blood pressure is to be regarded as a proof of arterial relaxation. 
Even in the slower forms of death, when the process of emptying the arteries is more 
gradual, there is still no evidence of, and no necessity for, a dilation of the terminal 
arteries to give exit to the blood; for, granting that contraction of the terminal arteries 
would tend to hinder the outflow of blood, this effect would be counteracted by the 
stronger contraction of the larger arterial trunks above, forcing the blood through and 
out of the numberless terminal branches ending in the capillaries. 
The facts thus far presented refer only to the great vasomotor areas of the cervical 
sympathetic and splanchnics. It seems unnecessary to attempt to discuss the lesser and 
local vascular mechanisms, about which little is known, and that little conies to us 
under the ægis of an erroneous theory. The greater always includes the less. What 
happens when the life of the chief nervous centres is killed, either by sudden and 
intended destruction, or in death from ordinary causes, happens also in a more limited 
area when local or subordinate centres are killed or paralyzed. Since in the former case 
the arteries are found contracted and empty, the same rule must be held to hold good 
iu the case of the individual nerve and artery. 
The Stimulation (?) of Asphyxia.-Is it not a strange proposition to put forward in the 
name of medical science, that an animal dying of asphyxia is actually undergoing a 
high degree of nervous excitation ? Yet such is actually the teaching of the text-books 
in physiology to-day ! Dr. Burdon Sanderson, treating of asphyxia, says : "Oneof the 
effects of diminishing the proportion of oxygen in the blood is to excite the vasomotor 
centre, and thus to determine general contraction of the small arteries. The immediate 
consequences of this contraction is to fill the venous system. " As the process advances, 
" the heart's contractions become more and more ineffectual till they finally cease, leav- 
ing the arteries empty and the veins distended." (Handbook, etc., p. 333.) 
There is no mention here of arterial relaxation or dilation to facilitate the outflow 
of blood. On the contrary, "the immediate consequences" of "a general contraction 
of the small arteries" is "to fill the venous system," and in a few minutes "the arteries 
are empty and the veins dilated," the animal being dead. This is precisely the condi- 
tion which we have seen in a former page to be the direct result of destruction of the 
nervous centres. It is a process which invariably prevails in the dying and is complete 
iu death. Thus, according to Paul Bert, quoted by Prof. Kuss, " death is always owing 
to asphyxia." (" Phys.," p. 330.) 
Why has it been assumed by physiologists that in this rapid sinking into death the 
nervous centres are undergoing an unusual excitation? Because, as we have just seen, 
there is "a general contraction of the small arteries," and other spasms and contrac- 
tions of the respiratory muscles fixing the chest and arresting respiration ; and in accord- 
ance with the theory of the day, these spasms and contractions of the muscles depend 
on active discharges of nerve force, stimulating the muscles to contact. How is this 
assumed extraordinary activity of the nerve centres to be accounted for in an animal 
actually dying? There is a "physiological law" which declares that the activity of an 
organ is directly dependent upon its receiving a due supply of arterialized blood ( Dr. 
C. B. Radcliffe); and Dr. W. B. Carpenter has said of venous blood, that "it exerts a 
depressing influence upon the nervous centres," from which they are at length " com- 
pletely paralyzed." ("Hum. Phys.," p. 537.) 
One would have imagined that bad blood, deficient in oxygen and loaded with car- 
bonic acid, would have been the very last thing which a physiologist would have chosen 
as a pabulum from which to generate an excess of nerve force ! and, doubtless, the 
choice was embarrassing enough. But necessity compels. The exigency of the theory 
is inexorable. Muscular contraction without nervous stimulation is deemed impossible, SECTION VIII PHYSIOLOGY. 
265 
and there being nothing else to fall back upon, it has been assumed that impure, non- 
arterialized blood plays the part of a stimulant to the nervous centres. 
Accordingly, we find a recent and popular writer-Dr. J. Milner Fothergill-in his 
' ' Antagonism of Therapeutic Agents, ' ' declaring that ' ' the more venous the blood the 
greater the activity of the respiratory centre. The effect of venous blood is to augment 
the natural explosive decomposition of the nerve cells. . . . The effect of defective 
arterialization causes more rapid as well as deeper breathing; more perfect and exten- 
sive respiration is set up until properly oxygenated blood is procured." This author 
would almost lead one to believe that a kindness was done to the rabbit in having its 
vagi cut. He says: "When the vagi are cut, the respiration is modified; it becomes 
deeper and more prolonged, fuller and more complete." (p. 88.) 
But, unfortunately, this view of an apparently improved respiration is wholly delu- 
sive ; for, as Dr. Burdon Sanderson tells us, ' ' notwithstanding the vigor of the respira- 
tory movements, the blood becomes more or less venous,"-the animal is dying, and 
does die, "commonly before the end of the first day." (Handbook, p. 317.) 
Let it be kept in view that the theory of the day explicitly teaches that ' ' the mus- 
cles receive from the nervous system a preternatural stimulus to action" (Dr. Pereira, 
Vol. ii, p. 541), and that spasm and convulsion "are dependent upon excessive activity 
of the spinal centres" (Dr. W. B. Carpenter, lb., p. 846), and we shall see presently to 
what apparent absurdity this doctrine has led. In one of Kussmaul and Tenner's 
experiments, the carotid arteries are ligatured, with the effect of inducing "immediate 
loss of consciousness and general and violent convulsions," which are promptly recov- 
ered from, and nervous control over the muscles restored, as soon as the ligatures are 
untied and blood is admitted to the brain. Dr. M. Foster's view of this experiment is, 
that here "the nervous centres being no longer furnished with fresh blood, become 
rapidly asphyxiated through lack of oxygen." And yet, strangely enough, he holds 
that in this almost fatal condition of ' ' rapid asphyxiation ' ' the nervous centres are 
undergoing stimulation! for he adds: "similar anaemic" convulsions are seen after 
sudden and large loss of blood from the body at large; the medulla being stimulated 
by the lack of arterial blood. " ("Phys.,"p. 441.) Surely such a view as this may 
be gravely challenged, even when put forward on high physiological authority. Dr. 
M. Foster remarks in another page, in his chapter on "Death," that "blood is not 
only useless but injurious unless it be duly oxygenated." (p. 833.) And again he 
says of venous blood that if it "continues to be driven through a muscle the irritability 
of the muscle is lost even more rapidly than in the entire absence of blood. It would 
seem that venous blood is more injurious than none at all." (p. 126.) Why should 
nerve function be augmented by what is useless and injurious, not only to muscle, but 
to every other tissue in the body ? 
The Cheyne-Stokes Respiration.-What seems a lower depth of absurdity, if possible, 
has yet to be reached in the explanations of the Cheyne-Stokes respiration. I quote 
here from Dr. L. Sansom's "Physical Diagnosis of the Heart," by whom Traube's 
theory on this subject is said to be " the most plausible." According to Traube, "the 
first thing which occurs is the establishment of a condition of impaired irritability of 
the respiratory centre through mal-oxygenation; the long respiratory arrest gives time 
for the accumulation of carbonic acid in excess in the blood. Arrived at a certain 
maximum this begins to stimulate, slowly and imperfectly at first and afterward in 
increasing degrees, the centre, so that it develops the respiratory efforts till they cul- 
minate in dyspnoea. Then as the centre ceases to be stimulated or becomes exhausted, 
dyspnoea again supervenes. " (p. 37.) 
It will be observed that here the deficiency of oxygen and subsequently the presence 
of carbonic acid are made to play opposite and antagonistic parts! The lack of oxygen 
(instead of stimulating the medulla, as supposed by Dr. M. Foster) first enfeebles the 266 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
respiratory centre, in the medulla, and then, the same blood, still deficient in oxygen, 
but now loaded with carbonic acid, counteracts the previous depression, and tones up 
the weak nerve centre, so that, ere long, it displays extraordinary activity. But, 
unfortunately, this exhilarating pabulum-carlxmic acid-is soon exhausted, and the 
nerve centre resumes its former feebleness till a new supply can be procured. The 
physiologist is certainly quite impartial, and allows the rivals to have their " innings " 
turn about. How such nonsense as this "most plausible theory " could find a place in 
physiological literature seems explicable only on the exigency of the hypothesis so 
long in vogue. 
Filehne's theory in explanation of this state is more complicated, and at least 
equally absurd. Instead of the respiratory centre being stimulated (as Traube says), 
it is the vasomotor centre which is excited by the presence of carbonic acid. Arterial 
contraction follows, till "a gradually increasing anaemia of the respiratory centre " is 
brought about. This anaemic condition excites the respiratory centre, " and inspiration 
becomes more and more deep, ' ' till oxygen is supplied to the blood ; 1 ' the arterial 
spasm is thus relieved," owing to the freshly oxygenated blood failing to stimulate the 
vasomotor centre (so as to contract the arteries), as the carbonic acid had previously 
done. With the relief of arterial spasm, and a consequent normal dilation of the 
arteries, "theanæmia of the respiratory centre passes off, and with it the exaggerated 
impulse to respiration, and breathing jonce more becomes superficial." (p. 137.) In 
other words, the respiratory centre functionates best when it is supplied not only with 
non-arterialized blood, but when it has too little even of that; as soon as the anaemia 
passes off, and this nervous centre gets a fair supply of blood, it ceases to act-suspends 
business-till the better times of bad blood and deficient blood come round again, 
when it is moved to activity once more! 
There is still another explanatory theory to be noticed, which I find referred to 
editorially in the Canada Lancet for February, 1886: "Bramwell, who follows the 
teachings of M. Foster and others, supposes that the respiratory centre consists of two 
portions, one accelerating (or motor), and one inhibitory. He further believes that 
these two portions are acted on in opposite directions by the blood, whether arterial 
or venous. Thus, while venous blood stimulates the discharging cells of the centre 
and depresses the inhibitory portion, arterial blood acts in exactly the opposite 
direction. ' ' 
"At the close of the period of apnoea, the discharging portion of the centre 
is stimulated by the venous blood," withits excess of carbonic acid, and this same 
blood, at the same time, is depressing the rival, or inhibitory part of the centre. The 
motor or discharging portion of the centre triumphs; respiration becomes established and 
even exaggerated. Unhappily the victor fails to " hold the fort." As soon as the blood 
becomes ' ' fully oxygenated, ' ' the 11 inhibitory portion becomes stimulated, and gradu- 
ally overpowers the discharging portion," so that "the respirations grow weaker and 
weaker until the state of apnoea results." Then the suspension of breathing restores 
the venous character of the blood and accumulates a store of carbonic acid, the stimu- 
lation of which reanimates the centre previously depressed by the presence of oxygen 
in the blood. Such appears to be the scope of this theory. 
In this, as in the previous explanations, arterial blood is made to play the part of a 
depressor and paralyzer of the respiratory process, which it is constantly tending to 
arrest; but while paralyzing one portion of the respiratory centre it is stimulating 
another; and a similar double character is attributed to the action of venous blood. 
Thus during the brief time from the beginning of apnoea to the culmination of dyspnoea 
-a period rarely exceeding one minute-the blood passing to the brain is called upon 
to exert four different and even diverse effects; first as venous blood stimulating one 
part of the respiratory centre and paralyzing another portion of the same centre; SECTION VIII-PHYSIOLOGY. 
267 
reverse effects being produced a few seconds later by the same blood on its becoming 
oxygenated. 
One is really at a loss to understand how such an explanation could have been 
admitted to a place in physiological literature. Again, it is the exigencies of an erro- 
neous theory which have led to such a complicated and unsatisfactory hypothesis. 
If it be asked how the state of apnœa is induced by forced vigorous respirations, 
if it be not due to an excess of oxygeu introduced into the blood, and how the opposite 
condition, or demand for air by breathing, seems to attend the absence of oxygen and 
the presence of venous blood, I can only answer as to the last that if no better explana- 
tion than that venous blood is a stimulant has yet been found, some better explanation is 
surely to be looked for. And as to the state of apnœa referred to, I find Dr. Austin 
Flint stating that, " according to Hoppe-Seyler, apnœa, in the limited sense above men- 
tioned, is to be attributed, not to an excess of oxygen in the blood, but to fatigue of the 
respiratory muscles." (" Prac. of Med.," 5th Ed., p. 70.) 
A New Theory Suggested.-Dr. Sansom regards the condition of the respiratory 
centre in this case as one of paresis and direct exhaustion. He shows that during the 
apnœal period "the arteries are strongly contracted." The proof of this is found in 
the rise of arterial tension; in the depression of the " great fontanelle " of the head, 
and also in the arrest of the process by the inhalation of nitrite of amyl, which dilates 
the arteries. On the theory of these pages, arterial contraction is due to vasomotor 
nerve depression or paralysis; and accordingly we find here that the vasomotor centre, 
as well as the respiratory centre, is depressed in function. It has been amply shown 
above, that contraction of the arteries occurs in the dying and is complete in death. It 
is also one of the prominent phenomena during the last stages of asphyxia and is invari- 
ably attended by venous fullness. The condition present during the stage of apnœa 
in the Cheyne-Stokes respiration, with its contracted arteries and dilated veins, appears 
to correspond very closely to that present as death approaches and in the latter stages 
of asphyxia. The original paretic and exhausted condition of the respiratory and vaso- 
motor centres is aggravated by the further depression caused by mal-oxygenation of the 
blood; which, when venous and loaded with carbonic acid, is invariably a depressing 
and never a stimulating agent to nerve function. Vasomotor nerve failure induces con- 
traction of the arterioles, systemic emptiness and venous engorgement, as the foregoing 
examples abundantly prove; and as a consequence, the great mass of the blood 
"becomes lodged and hidden, as it were " in the great venous trunks. At that moment 
death is very near, but as the heart continues to beat, it is fair to assume that a small 
quantity of blood still finds its way through the lungs, and, from its very scantiness, 
is capable of being aerated by means of the exchanges of gases still going on in the 
lungs, owing to the presence of residual air, during the temporary, partial or complete 
arrest of respiration. As a consequence, the quantity of blood reaching the nerve 
centres, though small, is at least partially oxygenated, and serves to revive the function 
of these centres " imperfectly at first," but with momentary improvement. 
The effect of this revival on the vasomotor centre is to facilitate the dilatation of 
the arterioles; in which the pulmonary vessels share, permitting, ere long, the inrush 
of venous blood from the distended vena cava and portal system, and its transmission 
onward through the heart and lungs. 
This corresponds to the period of increase in respiratory function, in which the 
laborious efforts of a feeble mechanism have been mistaken for an "exaggerated 
impulse " from excited and over-acting or " exploding " nerve centres. 
Meanwhile, impure blood from the venous reservoirs (finding an entrance through 
the now fairly dilated pulmonary vessels, ) begins to fill the lungs in such a quantity 
(as it is drawn onward by an inequality of pressure, toward the as yet unfilled arteries), 
that the whole mass of blood, failing to be arterialized with sufficient rapidity, again 268 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
becomes unfit for the maintenance of nerve function and the perpetuation of processes 
depending upon it. 
In such a case, a previously weak organ or centre is the first to suffer. The medulla 
oblongata is such an organ in this case, and its contiguous centres for respiration and 
circulation fail together ; bad blood and deficient blood, acting on centres previously 
paretic, or enfeebled, have done their work, and again the respiration is suspended. 
The vasomotor centre is again so functionally weakened that it loses control of the 
arterial muscle-the "inherent contractile force," which all physiologists assign to 
muscular tissue, thus freed (as in the examples enumerated above), induces "thestrong 
arterial contraction " referred to by Dr. Sansom, which contraction of the artery is all 
the stronger the nearer nerve force is to cease in the extinction of life. 
This arterial, or systemic contraction, again empties the lungs and refills the venous 
reservoirs, from which the blood is again drawn, at first slowly and then again more 
rapidly, as the process repeats itself. 
Here, then, is an explanation of the Cheyne-Stokes respiration, based upon sound, 
though as yet unacknowledged, physiological principles, according to which paretic and 
enfeebled nerve centres are helped by their appropriate pabulum-oxygenated blood- 
and are overwhelmed and have their function suspended by what is naturally calcu- 
lated to poison and paralyze them, impure, venous blood, deficient in oxygen and 
loaded with carbonic acid. 
The Intestinal and Uterine Muscles.-In sustaining the contention that, as a rule, 
muscles of the involuntary class contract, not when stimulated by their appropriate 
nerves, but when deprived of nerve energy, I have not yet alluded to the involuntary 
muscular fibres of the intestines and uterus. The antagonism of nerve and muscle is 
not here so evident as in the cases already cited, but here the relations of nerve and 
muscle have not as yet been completely investigated. (Dr. L. Brunton.) 
Dr. M. Foster states that section of the vagi " renders difficult the passage of food 
along the oesophagus," and causes " a spasmodic contraction of the cardiac orifice of the 
stomach ; in other words, the tonic action of the sphincter is increased ; " (" Phys.," 
pp. 346, 347),-facts which sustain what has been already stated above as to the non- 
paralyzation of the muscles concerned, after section of their nerves. The peristaltic 
movements of the intestine, he states, may occur "wholly independent of the central 
nervous system," and are " at bottom automatic" (p. 348). We have it on the authority 
of the late Dr. W. B. Carpenter, F.R.S., that " the intestinal tube from the stomach to 
the rectum is not dependent upon the nervous centres either for its contractility or for 
its power of exercising it, but is enabled to propel its contents by its own inherent 
powers." (" Hum. Phys.," p. 410.) So also of the uterus, the contractions of which 
are not due to a reflex activity of the spinal cord, but to its own inherent power of con- 
traction ; parturition having taken place after destructive injury and paralysis of the 
cord, and even after somatic death. (Ib., pp. 979, 980.) In these cases, also, the 
nerve would seem to be useless as the ally of the muscle, but would play an important 
part in controlling and regulating, by antagonizing, its contractile energy. 
I must notice, in this connection, an observation of Dr. M. Foster regarding the 
bladder. He says : " The escape of the fluid [from the bladder] is, however, prevented 
by the resistance offered by the elastic fibres of the urethra, which keep the urethric 
channel closed. Some maintain that a tonic contraction of the sphincter vesicæ aids in, 
or, indeed, is the chief cause of, this retention. The continuity of the sphincter vesicæ 
with the rest of the circular fibres of the bladder suggests that it probably is not a 
sphincter, but that its use lies iu its contracting after the rest of the vesical fibres, and 
thus finishing the evacuation of the bladder. On the other hand, the fact that the neck 
of the bladder can withstand a pressure of twenty inches of water so long as the blad- 
der is governed by an intact spinal cord, but a pressure of six inches only when the SECTION VIII-PHYSIOLOGY. 
269 
lumbar cord is destroyed or the vesical nerves are severed, affords very strong evidence 
in favor of the view that the obstruction at the neck of the bladder to the exit of urine 
depends upon some tonic contraction maintained by a reflex oi automatic action of the 
lumbar spinal cord. " ( " Phys., " p. 448. ) 
But this experiment admits of a very different inference. We have just seen, on 
the authority of Dr. M. Foster, that section of the chief motor nerves of the stomach 
"increases the tonic action of the sphincter" of the stomach, as we had before seen it 
does of the entire contractile tissues of that viscus. We have a right to look for a simi- 
lar increase of tonic contraction in the bladder, when deprived of its nervous connec- 
tion with the spinal cord, or when the latter is paralyzed. Admit that here, as in the 
examples cited above, the spinal nerves exercise a restraint over the contractile fibres 
of the bladder, tending to prevent its contraction. With this restraint intact, the 
bladder is able to bear a pressure of twenty inches of water before the sphincter is over- 
come ; whereas, with nerve influence withdrawn by section or paralysis, and the mus- 
cular fibres of the bladder set free to contract (as in the case of the oesophagus and 
stomach), the resistance at the outlet, though also relatively increased, is overcome by 
the superior expelling force from above, with the aid of only six inches of water 
pressure. 
The same principle applies to involuntary discharges from the rectum, which Drs. 
Todd and Bowman say is due not to paralysis of the sphincter, against which the feces 
are driven, but to the "active pressure of the parts above which are not paralyzed." 
("Path. Anat.," p. 180.) The "parts above" are the intestinal muscles, which, in 
the last stage of exhausting disease (when such discharges usually occur), have attained 
their freedom, just as the arterial muscles do under like circumstances, owing to the 
general decadence of nervous energy. 
Vomiting of Pregnancy.-With the evidence before us as to the contraction of the 
gastric muscle on severance of its nerves, vomiting in general may surely be regarded 
as due to nerve depression rather than to nervous excitation. An additional observa- 
tion in proof of the same is to be found in the fact that injury of the vagus may produce 
constant vomiting (Bryant's "Surgery," Amer. Ed., p. 208) ; and further, that vomit- 
ing is mentioned by Dr. C. Bastian among the symptoms of hemiplegia. ("Brain 
Disease," p. 56.) An explanation of the vomiting of pregnancy would be found if we 
might assume that a monopoly of nerve energy was being expended in the uterus, 
owing to the extraordinary development taking place in that organ, thus starving the 
gastric nerves, so to speak, which, no longer able to restrain the gastric muscle, per- 
mit the untimely and abnormal contractions of that viscus. That this occurs chiefly in 
the early months of pregnancy might be accounted for by the unusual demand rather 
suddenly made upon the nervous resources, which tend to equalize their expenditure, 
as the months go on, and the organism becomes accustomed to its new condition. 
How Arterial Sedatives Act.-Ergot of Rye is an agent which produces, in a marked 
degree, contractions of involuntary muscular fibre everywhere, but whose effects are 
especially seen in the arterioles and uterus. Must not a uniform law or rule govern 
the occurrence of such contractions? We have seen that they occur best under a 
deprivation of nerve action, and are never so complete as in the general death of the 
body. How, then, can ergot be regarded as à stimulant ? Who would ever think of 
administering it in cases of faintness and exhaustion as a restorative of nerve energy ? 
Must it not act, like nerve section and nerve paralysis, in lessening the tone of the vas- 
cular and motor nerves, so setting free the contractile energy of the arterial and uterine 
muscles, which contract accordingly ? 
Dr. Sidney Ringer grows enthusiastic over the action of aconite in acute congestion 
of the tonsils, and that, too, in doses too small to reduce the action of the heart. 
Aconite undoubtedly causes contraction of the arterioles, and accordingly on the theory 270 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of the day it must be classed as a stimulant, as it actually has been by some authors, 
Dr. Edward Meryon, M.D., F.R.C.P., for instance, who holds that "it stimulates the 
dormant fibres of Remak, and by so doing diminishes the calibre of the arterioles." 
("Rational Therapeutics," p. 52.) Errors of this kind must be charged to the mis- 
leading guidance of an erroneous theory. Aconite is a profound paralyzer, and, in 
small doses, by lowering the activity of the vasomotor nerves, it frees the contractile 
power of the muscular bands of the arterioles, which contract accordingly, lessening or 
curing congestive states. 
Is not this precisely the rôle of the galvanic current, when brought to play upon the 
cervical sympathetic, say in exophthalmic goitre ? The thyroid gland and its appen- 
dages are being overfed by dilated arteries. Bring about contraction of these arterial 
tubes, by lowering the activity of the vasomotor nerves in the way just indicated, and 
the congestion and hyperplasia are relieved, if not cured. 
But the electric current, for therapeutic purposes, has been classed as a stimulant ! 
So has strychnia ; so ought to be prussic acid, for it, too, causes spasms and convulsions 
of muscle ! So is fatal hemorrhage. All stimulants, as well as aconite, on the theory 
of the day ! 
It would require a volume to elucidate these points, and I must condense what I 
have to say into a few paragraphs. 
Strychnia a Paralyzing Agent.-Dr. Harley has shown that strychnia probably acts 
by preventing the oxygenation of the blood, which Dr. C. B. Radcliffe very properly 
holds cannot be the rôle of a stimulant. Dr. Ringer tells that "after traumatic and 
strychnia tetanus the functions of the motor nerves and muscles are depressed ; the 
motor nerves conveying impressions imperfectly." But may not this motor nerve 
depression be due to a reaction from previous over excitement ? Dr. Ringer says no ! 
and adds, ' ' Strychnia directly depresses motor nerves, for large doses kill without 
exciting convulsions, when the motor nerves are found to have lost their conductivity," 
("Therapeutics," 5th American Ed., p. 499) which in physiological language means 
that the nerves are paralyzed. 
Dr. W. A. Hammond has recounted an experiment performed by himself and Dr. 
S. Weir Mitchell which, he says, " shows that the action of strychnia is to destroy the 
nervous excitability from the centre to the periphery." ("Dis. Nerv. Syst.," p. 539.) 
Dr. Ringer further furnishes strong evidence that paralysis, and not over-action, is 
the condition of the nerve centres in tetanus. He instances ' ' certain poisons, like 
gelseminum and buxus sempervirens, which produce at the same time both weakness of 
natural coordinated reflex action, cord paralysis and tetanus." He says "it is impos- 
sible that the tetanus should depend on stimulation of the cord, for we have seen that 
the tetanus was preceded by considerable depression of the cord and continues until 
the depression ends in extinction of all cord function;" or, as he says again, the 
tetanus "occurred in adying cord." (London Lancet, Feb. 17th, 1887, p. 228; "Braith. 
Rétros.," July, 1887, p. 98.) 
In strychnia poisoning, death occurs from asphyxia (Fothergill, " Antag. Ther. 
Agents," p. 55), with its contracted and empty arteries and engorged veins-the 
precise condition of the vascular system produced by destruction of the spinal cord, as 
in pithing, as already shown in a previous page. Do not the foregoing facts show that 
strychnia does not kill as a stimulant, or excitant, of the spinal cord? Moreover, 
medical literature clearly shows the value of alcoholic stimulants in strychnia 
poisoning, but I cannot delay to quote it. On the other hand, chloral hydrate, which 
has some reputation in these cases, is "not by any means antagonistic" to the action 
of strychnia. It acts by simply lessening the contractile energy of the muscles, like 
other anaesthetics, by deoxidizing the blood, and thus retarding the chemical processes 
in the muscle, whereby its contractile force is generated. In this way the convulsions SECTION VIII-PHYSIOLOGY. 
271 
are arrested, and time gained for the elimination of the poison. But dangerously large 
doses-seven or eight grammes-(about two drachms)-are required for this purpose. 
(Lyman's " Anæsthetics, " Wood's Library, pp. 264, 267, 275.) "Strychnia affects 
paralyzed sooner than unparalyzed muscles," writes Dr. Ringer : but this is not exact. 
Strychnia does not affect the muscles at all, as Dr. Ringer himself shows; and the 
muscles are not paralyzed in the cases to which he refers. What he means is that 
strychnia induces twitches and spasms in muscles whose nerves are enfeebled, sooner 
than in muscles whose nerves are acting normally. Why is this ? If strychnia were a 
stimulant, would it not sooner excite vigorously acting nerves than enfeebled ones ? But 
since its effect is to cause "depression of the motor nerves," nerves already suffering in 
this way have their vital activity more easily extinguished, and their muscles set free, 
than is the case with healthy nerves. The same thing is equally true of the other 
paralyzer, electricity. Twitches, tremors, spasms and tetanus are all but varying 
stages of nerve paralysis and of muscular freedom. 
Electricity a Paralyzing Agent.-Prof. Tyndall tells us that a mere trace of iron in 
the coils of a galvanometer, of even such splendid instruments as those used by Prof. 
Du Bois Reymond in his researches on animal electricity, caused a fallacious deflection 
of the needle, to the extent of thirty degrees and more. ( ' ' Heat as a Mode of 
Motion," p. 34.) It is therefore not to be wondered that erroneous conclusions were 
sometimes arrived at in experiments so beset with fallacies, even when conducted 
apparently with the greatest care. 
So mysterious a force, which exhibits itself alike in the lightning's flash, in a tiny 
spark and in the quiver of the eminently sensitive protoplasm of a muscle, might well 
excite wonder and enthusiasm. As investigation proceeds, however, the exaggerated 
ideas as to the important part played by electrical currents in the phenomena of nerve 
and muscle, and even of life itself, which prevailed some years ago have been rapidly on 
the decline among students of electro-physiology; but will doubtless linger long in the 
popular and even in the professional mind. 
But electricity is not nerve force, nor can it cause the generation of nerve force, 
which is impossible in a mere nerve trunk separated from its nervous centre. This 
must be obvious. If it produce effects equivalent to a loss of vital action such as 
occurs in the death or destruction of portions of the nervous system, it must be classed 
as a sedative and not as a stimulant. In the experiments about to be mentioned the 
currents employed are those used for ordinary physiological and therapeutic purposes. 
The effect of such a current applied to the inferior laryngeal nerves is to induce 
spasm of the muscles of the glottis. "The rima is completely closed." (Dr. B. 
Sanderson, Handbook, p. 308.) That is to say, it does precisely what we have seen 
above is done by section and paralysis of these nerves. Applied to the lower ends of 
the vagi it causes contraction of the oesophagus and stomach, and 1 ' in most cases 
vomiting" (Meyer's " Prac. Elec." Hammond, p. 87), just, as we have before seen, 
results from section of those nerves. We have had proof that section of the spinal cord 
and of vasomotor nerve trunks induces contraction of corresponding arterioles. Similar 
effect is produced by electrization of the same parts, the calibre of the arteries being 
sometimes reduced to one-sixth of their normal size. (Weber-Meyers, lb., page 88.) 
Dr. M. Foster tells us that section of the spinal cord at the medulla, or in the dorsal 
region, arrests the secretion of urine; and such a section of the cord is of course a para- 
lyzing act. He also tells us that electrization of the spinal cord below the medulla 
also arrests the secretions of urine. Then is not this a paralyzing act also ? It is un- 
necessary to multiply examples. 'Shall we continue to call an agent a stimulant and 
refer to it as an excitant of nerve activity, the ordinary effects of which on nerves are 
equivalent to nerve section, nerve paralysis and death ! 
Mild Currents Paralyze.-It is sometimes said that powerful currents may paralyze 272 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and even kill, but that mild or weak currents merely stimulate or excite. Is there any 
proof of this? Where in the records of electro-physiology do we find a claim for 
opposite effects from weak and strong currents? It is true'that we are cautioned against 
the depressing effects of long-continued applications of even mild currents. But this 
is not to the present point. The short seance, with its mild currents, may and prob- 
ably does afford a simulation of increased vigor, but this is mainly due to the moderate 
exercise which it gives the muscles and their consequently improved nutrition ( Drs. 
Beard and Rockwell) ; perhaps also in some degree to the mental impressions of the 
patient. The longer seances, with stronger currents, are fatiguing and exhausting in 
proportion as they are depressing or paralyzing. 
Is it not true that the weakest current which can affect a muscle at all causes a 
momentary contraction of the muscle; and that the strongest current that can be borne 
during life, or that can be brought to play upon a still irritable nerve and muscle after 
death, simply produces a more vigorous effect of the same kind ; the contraction 
becoming continuous in spasm or tetanus? It is never contraction on one hand and 
relaxation on the other, unless, indeed, other conditions intervene and muscular con- 
tractile energy is at an end. As a matter of fact, weak and strong currents act pre- 
cisely in the same manner, and differ only in the lesser or greater contraction of the 
muscle which they produce. The process is a uniform one, as indeed it must be, since 
a purely physical force cannot change its character, and play fast and loose in the mode 
of its operation. 
The treatises on this subject bear ample evidence of the paralyzing effects of elec- 
trization when even weak currents are used, as could only be the case for therapeutic 
purposes. Althaus found that the electric current produced an anaesthetic and paralyzing 
effect on the ulnar and sciatic nerves. Drs. Beard and Rockwell tell us that " in rhin- 
itis, pharyngitis and laryngitis,"-where only very mild currents are admissible,- 
' ' they have for years been accustomed continually to make use of the benumbing effects 
of electrization." ("Med. and Surg. Elec.,"p. 123.) Even "weak electrization of the 
upper part of the neck may arrest respiration," as well as produce spasm of the glottis 
and of the muscles of inspiration. (Z6., p. 133.) Currents necessarily weak, because 
applied to the neck of " a sensitive young lady," induced anaemia of the brain, with 
drowsiness and other effects indicative of arterial contraction. {Ib., p. 134.) Other 
authors equally allude to the "paralyzing effects of the constant current,"- 
(Valentine, Matteucci, Eckhard and Meyers.) 
From these considerations I hold that there is no evidence whatever that weak 
and strong currents produce opposite effects, or that one may paralyze and the other 
stimulate. 
Direct and Inverse Currents.-A great deal has been written about the different 
effects of direct and inverse currents. Dr. J. Russell Reynolds, in reply to the ques- 
tion, " What current should I use to relieve pain and spasm, the direct or inverse? " 
answers: " All I have to say is that so far as I have seen it does not make the smallest 
difference. Theoretically it makes a very great difference, but practically it makes none. ' ' 
("Clinical Uses," etc., p. 18.) Now, I think that the evidence showing that both 
these currents are paralyzing is indisputable. Take the direct current first. A nerve 
muscle preparation is prepared. To the middle of the nerve trunk a salt solution or 
the poles of an induction battery are applied, and in either case the effect is so regu- 
lated as just to fail to cause a contraction of the muscle. If, now, the poles of a gal- 
vanic battery are applied to the distant end of the nerve trunk, the positive pole furthest 
from the muscle, so as to produce a direct current, throwing the lower end into cate- 
lectrotonus, the muscle will contract at once. Hence the direct current is said to 
increase the irritability of the nerve. But electricity is not nerve force, and nerve 
force cannot be generated in a mere nerve trunk. The true change in the nerve is not SECTION VIII-PHYSIOLOGY. 
273 
one of increased strength or vigor; it is simply that the feebly paralyzing action of the 
salt solution or of the induction battery has been supplemented or reinforced by the 
additional paralyzing wave of the direct current, and nerve force is for the moment 
annulled. What is just asserted is nothing new. Thus, " According to Volta, both 
directions of the current are depressing in their effects. " (M. Meyer, p. 57.) Prof. 
Matteucci found that "the direct current" not only " diminished the excitability of 
nerves," but produced in them "a temporary paralysis." (Braith. "Epit.," Vol. II, 
p. 661.) Dr. W. B. Carpenter wrote, " The direct current weakens and at last destroys 
the excitability of a nerve." ("Hum. Phys.," p. 351.) So much for the direct 
current. 
The inverse current produces in the nerve trunk, between the electrodes and the 
muscle, a condition of analectrotonus, which is admittedly one of ' ' diminished irrita- 
bility," which term is in itself an acknowledgment of lowered vital activity, which 
can only be accounted for as a degree of paralysis, and is induced by weak as well 
as relatively strong currents. Dr. C. B. Radcliffe states of M. Eckhard : "This very 
able physiologist has ascertained that so long as the inverse galvanic current is closed it 
is impossible to produce contraction of the muscle by pinching, pricking or otherwise 
acting on this part of the nerve . . . which is consequently in a state of sus- 
pended irritability. " ("Epilepsy," etc., p. 75.) This is a state of paralysis, because 
' ' a nerve that is deprived of its irritability can neither receive impressions nor trans- 
mitthem." (Zö.,78.) 
Drs. Beard and Rockwell say that "in regard to the differential action of the 
ascending and descending currents there has been an almost infinite amount of shallow 
observation and impulsive writing. " These writers offer ample evidence that the 
effects in question are due, not to current direction, but to the physical effects of the poles, 
at one of which acids accumulate and alkalies at the other. 
Two Experiments.-Here are two experiments which show that the combined effects 
of strychnia and electrization are equivalent to .the destruction of the spinal cord. In 
a rabbit undergoing the convulsions of strychnia poisoning the spasms will be at once 
arrested on breaking up the spinal cord by a wire thrust into the spinal canal. If instead 
of destroying the spinal cord in this manner it be subjected to electrization the spasms 
will be averted, or arrested if already present. The rabbit dies, but without the char- 
acteristic spasm. (Matteucci, Pereira, Radcliffe.) Is a powerful electric current needed 
here ? Not at all. Quite a moderate current will suffice ; because the strychnia poison 
is causing general contraction of the arterioles (Fothergill), filling the veins and deoxy- 
genizing the blood. Asphyxia is also setting in from the same cause, joined with fixa- 
tion of the chest by spasm of its muscles, whose motor nerves are being paralyzed. 
(Ringer.) Electrization produces parallel effects and intensifies the fatal processes 
already in operation., A weak current suffices to complete the arterial emptiness, the 
venous engorgement and the non-oxidation of the blood. The spasms cease, probably, 
because such blood as is now present is inimical to the life of the muscle, and destroys 
its contractile energy more rapidly than no blood at all. (Foster, "Phys.," pp. 126, 
833.) 
If the theory of the day were true the rabbit ought not to have died ! With the 
stimulating and vitalizing action of an electric current added to the previous exhilara- 
tion of strychnia stimulation the rabbit should have lived and flourished, in the 
interests of the theory, which alas ! as usual, is found to be out of harmony with the 
facts. 
Why does Dr. J. Russell Reynolds say that "it would be very unwise to use any 
form of electricity during the period of shock " ? (" Leet, on Clin. Uses," p. 84.) Why 
do eminent authorities discourage its employment in cases of suspended animation, as 
in apparent death from drowning ? (Dr. Ringer. "Ther.," p. 792.) Why does Dr. B. 
Vol. Ill-18 274 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
W. Richardson, F.K.S., of London, write: "I feel it too unreasonable to recommend 
galvanic action as a means of resuscitation in threatened death from chloroform " . . 
fearing lest under the semblance of restoring life he should clench death ! (Medical 
Times and Gazette, 1861 ; Braithwaite, Jan., 1873, p. 256.) These are precisely the 
conditions under which a "stimulant, tonic and vitalizer " should be eagerly sought 
for and diligently employed ! It is evident that electrization is none of these, and 
therefore it is forbidden " in any form." 
I think I am justified in claiming for the foregoing facts that they prove, as fully as 
any doctrine in physiology can be proved, that electrization as ordinarily employed is 
a paralyzing process. 
Beneficial Effects of Electricity.-Electricity is no doubt a valuable therapeutic agent, 
and, like other paralyzing agents, does good in appropriate cases. But its beneficial 
effects may all be accounted for in strict accordance with its rôle as a paralyzer of nerve 
activity. Thus, it eases pain in a perturbed nerve by temporarily paralyzing it. It 
lowers the activity of the vasomotor nerves, and by thus setting free the contractile 
energy of the muscle it reduces the calibre of the arterioles, lessening or curing conges- 
tion, and consequently starving the hypertrophic growths. In other cases, by a 
momentary arrest of nerve action in the motor trunks, it induces prompt spasmodic 
contractions in the muscles, thus exercising them, and by attracting blood and pabulum 
to wasted muscles or tissues in the same way, it improves their nutrition. In chronic 
indurations and hyperplastic growths the purely chemical effects of the opposite poles 
or electrodes so modifies the nutritive activities of the tissues as to prove beneficial in 
restoring a more normal condition. Thus the curative effects of electrical treatment 
are all accounted for in strict accordance with its rôle as a paralyzing agent. To pro- 
claim it, therefore, as " nature's own tonic," or to laud it as a " vitalizer " or extol it 
as the ally of nerve force, may be pardonable in the instrument makers, but is to be 
condemned on the part of scientific medicine. 
How Therapeutics has Suffered.-It Vas sometimes been remarked that the depart- 
ment of therapeutics lags behind other branches of the medical art. Perhaps it will be 
pardoned if I venture to suggest that therapeutics has suffered greatly from the adop- 
tion of the dictum that electricity is a stimulus to nerve function. How much of a huge 
and hypothetical inhibitory system has found, perhaps, its chief support in this very 
error. When electricity stopped the heart, some mechanism had to be found for the 
arrest of its action by a stimulus. On what must the excitation expend itself? Not 
on the proper motor ganglia of the heart, which a stimulus would drive faster. To meet 
the exigency of the theory, it was necessary to imagine a purely hypothetical system of 
inhibitory nerves, the excitation of which, by antagonizing the proper motor ganglia of 
the heart, would bring it to a standstill. It is worthy of notice that in this experiment 
' ' the most marked effects are produced when the electrodes are placed on the boundary 
line between the sinus venosus and the auricles." (Dr. M. Foster, "Phys.," p. 232.) 
Now, this is the precise location of the chief motor ganglion of the heart in the frog,- 
the animal in which this observation has been made, so that the assumed stimulus has 
to pass over the proper motor ganglion in order to reach the supposed inhibitory ganglia, 
further away in the septum dividing the auricles ! It needs explanation why, under 
these circumstances, the "stimulus" should ignore the motor ganglion in order to 
excite its rivals, which are further out of reach of the current. 
The theory of the day on this subject, or rather the "temporary hypothesis," as 
Dr. M. Foster calls it, necessitates that the action of drugs be wrought out amid the 
struggle for supremacy between two rival nerve factions or camps, as it were, with 
results which are far from encouraging. For instance, a recent physiological work on 
the "Action of Medicines," informs us in the opening paragraph regarding belladonna, 
that ' ' it paralyzes the motor nerves in frogs at the same time that it excites the spinal SECTION VIII-PHYSIOLOGY. 
275 
cord ; after they recover from the motor nerve paralysis the tetanic symptoms of spinal 
stimulation appear ! " 
Would it not be well to try how far the results might be simplified on the view that, 
under the circumstances, the heart's action ceased from paralysis of its motor ganglia ;- 
thus dispensing for a time with this part of an inhibitory incubus, which threatens to 
become unmanageable through its very complexity ? 
The Voluntary Muscles.-The foregoing considerations have reference especially to 
the relations of nerves to involuntary muscles. Why it is that muscles of the voluntary 
or striated class do not also pass promptly into a state of spasm or contraction when 
their motor nerve trunks are cut, or when the body is dead, I am unable to explain ; 
unless it be admitted that here the motor nerve trunks are more than mere carriers of 
nerve force-are in fact, with the nuclei and nerve plates at their endings, miniature 
magazines of nerve energy, which continue for a time to restrain the muscle after sec- 
tion of the nerve trunk or after somatic death. 
Post-mortem Muscular Contraction.-If such an hypothesis were admitted it would 
serve to explain certain phenomena for which an explanation is necessary, such as the 
remarkable contractions of muscles which are known to occur in certain cases after 
death. There can be no doubt that the activity of both nerve and muscle survives 
for a time the death of the organism. The life of the nerve which is more intimately 
■dependent upon vital conditions succumbs before that of the less vital and more endur- 
ing contractile power of the muscle. (Foster, " Phys.," p. 121.) And as one fasciculus 
nr one muscle or one group of muscles attains its freedom the contraction which follows 
gives rise to the movements referred to. 
Rigor Mortis.-Is a muscle contracted or shortened when it passes into rigor mortis ? 
All observers agree that such is the case, and Dr. M. Foster tells us that the shortening 
and contraction "may be considerable." ("Phys.," p. 94.) Is this contraction and 
shortening the last act of the muscle in dying, or does it occur after the actual death 
of the muscle-that is, in a dead muscle? Let us consider the latter view first, since 
it appears to be the one in favor by our physiological teachers at the present time. 
If the muscle be dead, not only is its nerve force extinct, because nerves die first, 
and, consequently, there can be no stimulus from nerve energy to cause the muscle to 
contract, and, further, the chemical changes in the muscle which generate its contractile 
force must also have ceased to operate, so that its contractile power is at an end. In 
the assumed absence of contractile energy it has become customary to attribute the 
death stiffening to coagulation of the muscle plasma in the muscle. This would account 
for the rigidity of the muscle, but would fail to account for the contraction and shorten- 
ing admittedly present. Muscle plasma, in the living muscle, bears the same relation 
to the myosin of dead muscle that certain albuminous substances in the circulating 
blood do to fibrin, after blood is drawn off in a vessel. According to Dr. Lionel Beale, 
fibrin is " non-living matter, and is the product of the death of albuminoid bioplasm." 
("Disease Germs," pp. 136, 137.) If this be true of fibrin, it may fairly be assumed 
to be true also of myosin, which closely resembles the former. Coagulated plasma, or 
myosin, is dead, and if the muscle also be dead, and its inherent contractile power at 
an end, in what manner does dead myosin acting on a dead muscle produce so perfect a 
counterfeit of muscular contraction, that one of the keenest observers of the day pro- 
nounced it "The most steady and persistent contraction which muscle can possibly 
exhibit," (Anstie, "Stim. and Narc.," p. 70); so perfect a counterfeit, indeed, that our 
eminent English physiologist, the late Dr. Carpenter, employed the microscopical 
appearances of muscle during rigor mortis as the chief basis for his description of the 
changes taking place in ordinary muscular contraction, as he himself has told us. 
("Hum. Phys.," 5th Amer. Ed., pp. 307, 308.) 
Again, the reaction of a living muscle in repose is neutral, or alkaline, but after 276 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
exercise, or tetanus, the reaction becomes acid, an effect in some way depending upon 
the chemical processes in the muscle associated with its contraction. In rigor mortis 
the reaction becomes "most distinctly acid" also. But if the muscle be already dead 
and these chemical changes at an end, what is the source of the acidity? To the pres- 
ence of this acid, the coagulation of the myosin and the rigidity of the muscle are of 
late attributed. But since the acidity is the result, or effect, of muscular contraction in 
the living muscle, how can it be the cause or starting point of the contraction and stif- 
fening in the dead muscle ? 
Dr. Lauder Brunton finds that muscle plasma " coagulates too quickly in the mus- 
cles of warm-blooded animals to allow of its preparation from them." Now, rigor 
mortis does not usually set in for several hours after death-Dr. Brown-Sequard found 
it to be ten hours in four rabbits-and its onset may even be artificially delayed. The 
statement, therefore, is only explicable on the supposition that coagulation of the muscle 
plasma and rigor mortis do not occur together-that is, as cause and effect. It would 
seem to be implied that the muscle plasma coagulates too early to be the cause of rigor 
mortis. Dr. Brunton further shows that the muscle plasma may coagulate without pro- 
ducing rigor mortis. In an experiment, detailed on page 363 of the Handbook, it is 
shown that, if half a fresh muscle be immersed for a few minutes in water at a tempera- 
ture of 104° Fah., the reaction will be acid, as Dr. Brunton says, "from development of 
rigor mortis. " The other half of the muscle is to be placed for a similar time in boiling 
water; and here the reaction "will be alkaline." Dr. Brunton adds: "Before rigor 
mortis had time to set in the albumen of the muscle was coagulated. This coagulation 
set free a quantity of alkali, hence its reaction." Dr. Brunton's exposition of this 
experiment, if correct, would be fatal to the myosin hypothesis, since if the coagula- 
tion of the muscle plasma be attended by an alkaline reaction, while in rigor mortis the 
reaction is strongly acid, the former could not be the cause of the latter, and they must 
be regarded as separate and distinct processes. 
The foregoing difficulties certainly seem to create distrust in the myosin hypothesis; 
and we now turn from it, with its dead muscle and inert myosin, to the other aspect of 
the case, under which the complete cessation of nerve activity and the final contraction 
of the muscle marks the onset of rigidity. "The rigidity, the loss of suppleness and 
the diminished translucency, ' ' observable in the muscle in this state, are reasonably 
accounted for by the condensation of tissue, which is here permanent, as the contraction 
is continuous. That a certain relaxation subsequently occurs, during which meat or 
game, which is at first tough, becomes more tender and toothy, is attributed by M. 
Rosenthal to the action of the acid referred to, which relaxes the connective tissue which 
holds the fibres together, so that the latter separate more readily. ("Muscles, etc.," 
p. 87-8. ) This is but the beginning of the chemical change which ends muscular con- 
tractility in the ruin of putrefaction. The following remarkable series of conditions are 
common both to muscular contraction and to rigor mortis. In both the reaction becomes 
acid. In both carbonic acid is set free in the muscle. In both the temperature rises- 
often markedly so in rigor mortis. In both the muscle is contracted and shortened ; in 
some cases, as in death from cholera, ' ' rigor mortis may be said to be simply a con- 
tinuation of the cramps and contractions occurring during life." ("Wood's Prac.," 
Vol. I, p. 717.) In both, glycogen is converted into sugar. Do not all these coincidences 
in appearances and effects point strongly to a similarity of processes in muscular con- 
traction and cadaveric rigidity? Of course the parallel is not complete in every par- 
ticular. It is said that the muscular sound emitted during ordinary muscular contrac- 
tion is absent. This sound is attributed to vibration of the muscle substance. Might 
it not be due in part to the altered circulation in the ordinary muscle during contrac- 
tion, for it is well known that the blood channels, under certain circumstances, give 
out a musical note ? In rigor mortis, of course, the circulation of the blood ceases, as SECTION VIII PHYSIOLOGY. 
277 
does also the removal of waste products. That the muscle substance continues to vibrate 
in rigor mortis is evident, because chemical changes are still taking place there, as is 
shown by what is said above, and especially by "a marked accession of heat" (Foster, 
p. 542); and "heat is only another form of motion." (Rosenthal, p. 42.) So that, 
after all, it would seem as if the atoms of the muscle continue to vibrate, even though 
no sound is audible. 
That indefatigable observer, Dr. Brown-Séquard, some time ago, related to the 
Biological Society of Paris some experiments he had made, by a special instrument, 
to determine the movements of single muscles in the body after death. He found that 
there was a very considerable degree of contraction and relaxation, as much, for exam- 
ple, as two and a half millimetres in a muscle measuring only six millimetres in length. 
He thought that the results of his experiments disproved the theory of coagulation in 
the muscular tissue as the cause of cadaveric rigidity. (W. Y. Med. Hee., Jan. 9th, 1886.) 
I am not necessitated to prove that rigor mortis is due to post-mortem contraction 
of the muscles; but in the absence of any other satisfactory explanation of this state, I 
am entitled to refer to it in support of my thesis; and I would ask those who dissent 
from this view, and who, in consistence with their theory, must hold that nerve stimu- 
lus is necessary to muscular contraction, to account for the presence of nerve force under 
the conditions referred to. 
Spasms in Voluntary Muscles.-It would, perhaps, be no difficult task to show that 
even voluntary or striated muscles pass into a state of partial spasm or contraction dur- 
ing life, much offener than might at first sight appear, under a form of "irritation," 
which may very properly be regarded as consisting in a lowering of nerve activity. 
"Irritation" is not increased nerve action. A splinter under the nail is attended 
by a loss of tactile sensibility. A mote in the eye irritates, but it obscures vision. 
Why should indigestible food oppressing the digestive functions of a child be regarded 
as a source of increased nervous "discharges"? Such sources of irritation ought to 
be considered as depressing rather than exciting nerve action; a view of the case for 
which authorities have been already quoted, and others are to follow. 
Dr. Anstie wrote: "Convulsive action of the muscles, as every one knows, are very 
common complications of neuralgia," and the same acute observer held that "pain is 
not a true hyperæsthesia; on the contrary, pain involves a lowering of nerve function." 
("Neural.," p. 12.) 
Dr. Hilton, in his work on " Rest and Pain," points out that the irritation of peri- 
tonitis induces contraction of the abdominal muscles. In the same way, pleuritis ren- 
ders the chest walls fixed by spasmodic contraction of its muscles; while the muscles 
of an inflamed joint, he says, "are invariably contracted, and continually tend to 
increased flexion of the limb, not because such a position is easiest for the patient, 
which is not always the case, but owing to a reflex perturbation transferred to the mus- 
cles of the adjoining surface." (p. 96.) That peripheral irritations do produce nerve 
paralysis must be admitted, on the authority of Dr. Brown-Séquard. ( '1 Leet. Cent. 
Nerv. Syst.," pp. 160, 170), and others. 
What is the "irritation" in these cases but a mild form of nerve paresis, just as 
" the irregular muscular action " which shows itself in tremor, fibrillary contractions, 
or in spasm, denotes the failure of the ordinary nervous restraint over the correspond- 
ing muscles. 
Why should "morbid conditions of the medulla oblongata," avowedly depending on 
" defective nutrition," be supposed to give rise to "explosive and atactic manifesta- 
tions of nerve force" (Anstie, "Neural.," p. 156), when they are much more natur- 
ally explained as depending upon nerve failure ? The weak point in the theory of the 
text-books is, that nerve force is required to be displaying the full activity of robust 
health, and even more, in exaggerated "discharges" and "explosions" at the very 278 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
time there is the most undoubted evidence of nerve failure and exhaustion. Why, in 
cases of ' ' early and late rigidity ' ' of muscles, should a clot in the brain be held to be 
an exciting irritant, seeing that the brain tissue is wholly insensitive, and may be cut, 
pricked or seared with a red-hot iron without eliciting any signs of pain ? It is difficult 
to express here the multitude of facts which show the very frequent association of 
paralysis and spasm in disease of the brain and spinal cord. The paralysis is of the 
nerve and the spasm of the muscle-conditions very embarrassing to the theory of the 
day, but consistent and harmonious states in the theory of these pages. Is there not 
much significance in the statement of Seguin, that "a lesion of the lateral columns of 
the spinal cord produces paralysis with contracture " of muscle. Why? Because, as 
Dr. Brown-Séquard has shown, " the motor fibres run on the exterior of the cord in its 
antero-lateral columns." (Erichsen, "Conçus. Spine," pp. 29, 30.) Motor nerve disease 
and destruction induces contraction of the muscle, which later on becomes atrophied, 
partly, no doubt, from inaction. 
It is on record, too, that while injury of the vagus nerve induces contractions of the 
gastric muscle, injuries of the spinal accessory nerve are attended by spasms of the 
trapezius or sterno-mastoid muscles. (Bryant's "Surgery," p. 208.) Other examples 
of a similar kind are not lacking. 
One might imagine that Dr. B. W. Richardson, F. K. s., intended to endorse the 
theory of these pages when he wrote as follows regarding the convolutions of the 
drowning. He says: "The convulsive movements that are seen are unconscious move- 
ments ; they are the same as those which mark the period of stupor, in death by hang- 
ing, by noxious vapors, by concussion ; and they are simply the results of action of 
muscles from which the controlling power of the nervous centres has been removed." (Braith- 
waite, July, 1871, p. 255.) [Italics mine.] Dr. Henry M. Lyman, A. M., M. D., 
would appear also to have had a commendable distrust, if not an entire disbelief, in 
the theory of the text-books, when, in referring to "a temporary increase of muscular 
movement directly caused by the abolition of some special source of nervous impulse," 
he says: "Witness the tremendous liberation of muscular movement which follows a 
paralysis of the influence of the brain, by the sudden decapitation of a fowl, for exam- 
ple." (" Anaesthetics," Wood's Lib., p. 26.) [Italics mine.] 
One of Dr. Ferrier's experiments is so much in point here, that, at the risk of being 
tedious, I cannot forbear a brief reference to it. The right brain of a monkey had been 
exposed and subjected to faradisation. Next day the animal "was found perfectly 
well." " Toward the close of the day following, on which there were signs of inflam- 
matory irritation and suppuration, it began to suffer from choreic spasms," which rap- 
idly assumed an epileptiform character. Next day hemiplegia became established, with 
the usual symptoms of "paralysis of the left arm and partial paralysis of the left leg." 
" On the day following paralysis of motion was complete over the whole of the left side, 
and continued so till death, nine days after." Dr. Ferrier says, " In this we have a 
clear case of vital irritation producing precisely the same effects as the electric current, 
and then destruction by inflammatory softening resulting incomplete paralysis, etc." 
(" Functions of Brain," pp. 200, 202.) 
On Dr. Ferrier's view, the stage of apparent inflammatory action was accompanied 
by increased production and discharge of nerve energy, as seen in the choreic and epi- 
leptiform spasms. But " Recent studies show that the inflammatory process is a 
destructive and depressive one, so far as the tissues are concerned ; that it does not 
irritate and kindle into increased activity the protoplasm of the cells, but rather the 
reverse." (Editorial, A7. Y. Medical Record, January 30th, 1886, p. 128.) So that it 
is now definitely understood that the inflammatory process in brain tissue does the 
reverse of Dr. Ferrier's view, and paralyzes rather than excites nerve energy. 
Observe here, that the spasms of the muscles, on Dr. F.'s own showing, began to SECTION VIII PHYSIOLOGY. 
279 
occur contemporaneously with the ' ' signs of inflammatory irritation and suppuration, ' ' 
and as this term " irritation " (on so good an authority as the able editor of the N. Y. 
Medical Record),must now be interpreted to mean depression and lowering of cell activ- 
ity, it follows that the spasms referred to occurred from the absence or failure of nerve 
energy, and not from its undue excitation. Observe, too, that Dr. Ferrier held that 
this " vital irritation," as he saw it, but which we now know is depression or paralysis, 
produced ' ' precisely the same effects as the electric current. ' ' Another evidence of the 
paralyzing character of electricity ! 
The Epileptic Paroxysm.-With the experiments on the cervical sympathetic and 
splanchnic nerves before us, how can we say that the anaemia, or rather ischaemia, of 
the brain, which ushers in the epileptic seizure, is due to "excessive action of the 
spinal centres," compelling the spasm or contraction of the arterial muscles on which 
this ischaemia depends ? Have we not had proof that the arterioles contract best when 
their vasomotor nerves are cut, or are paralyzed, or dead; and if so, are we not bound to 
hold that not excess but failure of nerve power is the proximate cause of the epileptic 
paroxysm ? And is not the question of such excess or failure of nerve force a most 
practical one in determining the treatment ? 
How far is our comparative failure to cure this terrible disease due to our approach- 
ing it under the ægis of an erroneous theory-that nerve force here needed to be 
depressed rather than exalted ? It is well for mankind that in this, as in some other 
instances, our practice has sometimes been directly at variance with the theory of the 
day. Thus we find Dr. Anstie assuring us that " our best anti spasmodics are stimu- 
lants ' ' : and that ' ' alcohol is one of the best remedies possible in the convulsions of 
teething in children." (" Stim. and Narcot.," pp. 113, 129.) 
No "Morbid" Nerve Force.-Spasms and convulsions frequently take place in the 
very act of dying, and under circumstances in which nerve force ought to be regarded 
as at a low ebb ; as, for example, in ursemic blood poisoning. It is customary in some 
quarterstoattribute these or other spasms to " a morbid irritability " or " a morbid 
nerve force"; as if the central nervous ganglia were capable of producing two kinds 
of nerve force, one normal and the other "morbid," and the spurious variety of attain- 
ing extraordinary power just in proportion to the complete failure of nerve force proper. 
A little reflection, I think, will show that this is untenable. Nerve force may be 
increased or diminished : its condition may be one of excess or of failure, but that it 
may present a duplicate of itself, and its alter ego produce effects for which nerve force 
proper is inadequate, and yet is responsible, is surely yielding too much to the exigency 
of an erroneous theory. 
Medical literature presents numerous examples of this appeal to a "morbid nerve 
action," and it is rather surprising to find such a writer as the late Dr. Anstie referring 
to ' ' the explosive disturbances of nerve force which give rise to the convulsions of teta- 
nus " as " something quite different in kind '' from healthy nerve action. • ( " Neural., ' ' 
p. 8. ) Now, if a nerve centre be thrown into action otherwise than by the exercise of 
its normal activity, then it is no longer the nerve centre which is acting, but a power 
extraneous to itself ; a modern Archæus for which scientific medicine ought to have no 
place. And if tetanus be really due to an explosive activity of the nervous centres 
which are discharging nerve force with unwonted activity, surely to administer stimu- 
lants in such a case ought to be injurious, if not fatal ! And yet we find that Dr. W. 
A. Hammond, of New York, has produced statistics in which " stimulants " stand at 
the very head of the list of curative agents in tetanus. (" Dis. Nerv. Syst.," 4th Ed., 
p. 541.) Here again the theory of the day is surely out of joint with the clinical 
facts. 
Chloroform and Relaxation of Anaesthesia.-I have been asked how the rigidity, at 
first, and subsequently the relaxation, of the muscles during anaesthesia are to be 280 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
accounted for on this theory. The answer is easy. The rigidity is due to the partial 
paralysis of motor nerve influence, setting the contractile power of the muscle free to 
act. This occurs at a comparatively early stage of the process. The relaxation which 
attends complete anaesthesia is due to the loss of contractile power on the part of the 
muscle, owing to the absence of oxygen in sufficient quantity in the blood ; for chloro- 
form tends to prevent the oxygenation of the blood (Ringer's "Ther.," p. 286), and 
renders it venous in character. In this way the chemical processes on which the gene- 
ration of contractile force in the muscle depends are retarded. (Lyman's "Anaes- 
thetics," p. 28; Bryant's "Surgery," Amer. Ed., p. 318.) Dr. M. Foster states that 
" blood is not only useless, but injurious, unless it be duly oxygenated. " And again, 
" if venous blood be driven through a muscle the irritability of the muscle is lost even 
more rapidly than in the entire absence of blood." (" Phys.," pp. 126, 883.) This, I 
think, will be accepted as a satisfactory explanation, in strict accord with physiological 
facts. The relaxation, however, is not so great but that faradisation of the muscle will 
induce a further degree of contraction ; showing that the contractile energy of the 
muscle, though weakened, is not lost. That the contractile power of the muscle is thus 
lowered offers a bar to the prolonged or complete administration of chloroform during 
parturition, for obvious reasons. 
The mode in which anaesthetics induce arterial contraction, as explained by Dr. 
Henry M. Lyman, may be quoted as follows : ' ' Chloroform acting through the blood 
upon the nervous apparatus in the walls of the vessels, tends to paralyze the sensory 
endings of the nervous fibrils. This means a diminution of the normal impulses, which 
should continually reach the central intraparietal ganglia," in consequence of which 
"the motor cells no longer experience the inhibitory influence which they should receive 
from the periphery of their territory, and a liberation of a motor impulse excites mus- 
cular contraction, and we have vascular spasm," etc., as the result. ( " Anæsthesia, 
etc.." p. 27.) This, of course, is purely hypothetical. The motor nerve fibrils in the 
muscular bands are ignored altogether, while a purely imaginary " inhibitory " system 
is invoked to meet the exigency of the occasion. How much better to hold that the 
motor nerve fibrils also are more or less paralyzed, and the arterial muscle directly set 
free to contract ; thus dispensing with the inhibitory apparatus altogether. 
The Nerve-Muscle Preparation.-It is impossible here to enter on a critical analysis of 
the experiments on nerve and muscle, which a careful examination will show to be 
wholly consistent with the views here advocated. When in a preparation 
the muscle is made to contract by applying to the nerve trunk the shock of electricity, 
the corrosion of a chemical agent as a quick stroke, what is there to show that the 
effect on the nerve is not to cause a temporary cessation of nerve influence, rather than 
the production of a stimulus ? There is really nothing, and the character of the impulse 
is merely a matter of inference. Even in what is called the rheoscopic frog, where 
contraction in one muscle imparts an influence whereby another muscle is made to con- 
tract, the molecular or electrical wave may as well be paralyzing as stimulating. 
This Theory not New.-In hastening to conclude, let me state that, whether this 
theory of the antagonism of nerve and muscle be true or false, I am not entitled to the 
praise-or blame-of originating it. It was broached so long ago as 1832, by Dr. West, 
an English physician, and is said to have met with some countenance from Sir Charles 
Bell. Dr. C. B. Radcliffe, F. R. S., in his work on "Epilepsy, Paralysis and Pain," 
has warmly adopted the views of Dr. West, and offers some strong evidence in support 
of the proposition, that ' ' there is reason to believe that ordinary muscular contraction 
is associated with a deprivation of nervous influence, and not with a contrary state of 
things. ' ' (p. 95. ) I have here endeavored to support the same thesis, but with evi- 
dence drawn from other sources. 
Objections to this Theory.-1. It has been objected to this theory that " a muscle can SECTION VIII PHYSIOLOGY. 
281 
contract when irritation is directly applied without the intervention of nerves. ' ' Now, 
I am not in the least disposed, or obliged, to dispute this assertion, for reasons which 
will appear later on. My thesis has much to gain, and nothing to lose, by the fullest 
admission of the independent irritability of muscular tissue. But it is exceedingly 
difficult, if not at present impossible, to say when a still irritable muscle has been 
deprived of ' ' the intervention of its nerves. ' ' Certainly such is not the case in the 
experiments cited by Dr. M. Foster, in the Handbook heretofore referred to, where 
the experimenter, in order to produce the ideo-muscular contraction, is to choose ' ' a 
muscle which has been much exhausted by treatment or by long removal from the 
body," and to "wait till neither muscle nor nerve give any ordinary contraction with 
an electric stimulus. " It cannot be held to be proven that in such a nerve muscle there 
is not still remaining a force in the weakened nerve sufficient to control the equally 
weakened muscle. 
Curare and the Motor Nerve Endings.-2. It has also been objected that, while the 
motor nerve endings are paralyzed by curare, the muscle does not contract, as it ought 
to do if this theory were correct. To this I have to reply, that if the muscles are not 
found contracted it is partly due to the insufficiency of the poisoning of the motor 
nerves, and partly to the fact that curare diminishes the contractile energy of the 
muscle. (Rosenthal, "Muscles, etc.," p. 254.) Nicotine and conine act precisely like 
curare (lb., p. 253), and in the final action of these three poisons, motor nerve paralysis 
and spasm, or convulsion of the muscles, occupy a prominent place. (Ringer.) The 
special results vary, of course, in different animals. Nicotia sometimes acts like an 
anaesthetic (Stille and Maisch, p. 372) ; and the same is doubtless true of the others. 
Now, anæsthetics induce muscular relaxation by deoxidizing the blood ; and nicotine 
is known to disorganize the red corpuscles which are the oxygen carriers. It is doubt- 
less in this way that, under the slow action of these poisons, muscular relaxation is 
brought about. If death be rapidly produced by curare, convulsions occur. (Stille 
and Maisch.) Here the motor nerves are paralyzed before time has been afforded for 
the poison to lower the irritability of the muscle, which passes into tonic or clonic 
spasms according to its freedom, thus behaving as it "ought" to do. Is not this a 
sufficient answer to the objection ? 
But more remains to be said. The experiments with curare are not so conclusive 
as to be beyond the reach of criticism. They were intended to prove the independent 
irritability of muscle, which is now generall y an accepted fact among physiologists. 
M. Rosenthal asserts that these experiments (and those of Kuhne upon the sartorius 
muscle) do not prove this ; which is equivalent to stating that it is not proved that 
curare paralyzes the motor nerve endings. 
More direct evidence upon this point is that of Dr. Onimus, who, not long ago, 
' ' read a paper before the Academy of Medicine, Paris, upon electro-muscular contrac- 
tility and the action of curare. Contrary to the opinions of M. Claude Bernard, Dr. 
Onimus believed that curare does not act on all parts of the motor nerves, but only on 
their trunks ; the nerve centres and terminal filaments being unaffected. " (N. Y. Med. 
Eeeord, 1880, p. 73. ) 
In view of these authoritative opinions (and doubtless of others to which I have 
not access), it is evident that this objection falls to the ground and loses the weight 
which otherwise might attach to it. 
But suppose it were established beyond doubt that the influence of the nerve were 
completely eliminated from the muscle in any case, and that the contractile protoplas- 
mic masses of the muscle were left wholly to themselves, and their life being not 
yet extinct, that they gave token of that still flickering life when comparatively rudely 
assailed by a a shock of electricity or a corrosive or injurious agent,-what then ? Such 282 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
signs of irritability, elicited under such circumstances, would not militate against my 
thesis ; for such would be the behavior to be expected from still living protoplasm, 
wherever found, and would in no way disprove the contention that in the association 
of nerve and muscle in the organism the rôle of the nerve is to restrain or control the 
protoplasmic energy of the muscle so long as their mutual relations continue. For, 
after all, " the contraction of muscular tissue is, in fact a limited and definite amœboid 
movement, in which intensity and rapidity are gained at the expense of variety." (Dr. 
M. Foster, "Phys.,"p. 63.) 
Indeed, I think the rational view of the situation j ust depicted turns the argument 
the other way ; and tends to show that in the joint rôle of nerve and muscle the func- 
tion of the nerve is not to goad or stimulate the muscle to contract. To suppose this is 
to assign to nerve energy the relative value of the fifth wheel in the coach. Such endur- 
ing power of contractility as the muscle here exhibits evidently needs no supplementary 
aid from the nerve. What it really does need, however, is restraint, control and co- 
ordination for the purposes of the organization of which it is a part. 
Other Objections.-A further objection has been suggested, on the ground that on 
a nervous impulse reaching a muscle, an electric current is generated during the period 
immediately preceding the contraction of the muscle ; but this is an objection which 
is only of any force on the assumption that electricity is a stimulant. There is noth- 
ing in the action taking place here to show that the electric current is a stimulant 
rather than a paralyzer. There is simply a " freeing of the forces in the muscle," just 
as the spark of electricity frees the forces bound up in gunpowder, and so fires the 
train. (Rosenthal, p. 250.) 
As for the additional plea that nerve force and muscle force are too much alike for 
us to consider one a paralyzing and the other a contracting agent ; that is merely beg- 
ging the question. Nothing wliatever is known regarding the nature of these forces ; 
and the intimate structures of nerve and muscle are so widely different as to j ustify 
the idea that the product, so to speak, of each, is equally diverse. 
This theory has been objected to as a proposed addition to the inhibitory system of 
the text-books. This is a mistake. If the views here enunciated were adopted, the 
huge incubus of the present inhibitory hypothesis could be in great part swept away, 
to the great advantage both of physiology and therapeutics. 
If it be claimed that on the cutting of the spinal cord or of a nerve trunk, the 
" irritation '' set up at the point of cutting, or the generation of electrical currents as 
the result of chemical change in the transverse section, act as a stimulus, and that 
contraction of the corresponding muscle is thus produced, such a claim must be 
regarded as untenable, for the following reason : The acts just referred to cannot be 
stimulating acts, because they are attended by precisely similar effects as are produced 
in the muscle by death from any cause, in which condition, it is needless to say, nervous 
activity is not increased. The proof of this has already been sufficiently vouched for, 
and need not be repeated here. 
Of course, I do not pretend that all difficulties vanish in the light of the theory 
here advocated. There are very serious, if not insurmountable, difficulties in the 
theory of the text-books, as the facts of the foregoing pages fully show. What I 
claim is, that the view here presented rests on a rational basis, and, though presented 
very inadequately, aud under many disadvantages, has the merit of furnishing a key 
to many obscure phenomena in the organism, and is entitled to the fair and candid 
consideration of the members of our profession. 283 
SECTION VIII PHYSIOLOGY. 
DISCUSSION. 
Dr. Love, of Atlanta, Ga., said :-Mr. President, I had hoped that some other 
member of this Section would have taken the lead in this discussion. I thank Dr. 
Poole for presenting that paper-thank him in my own individual behalf, and thank 
him particularly for presenting it in printed form, as he has. I have examined the 
copy I hold in my hand, and it shows no little research-research on a subject of 
much interest to physiologists-yes, to the profession. I hold that when a man has 
taken the trouble-and it is no little trouble-to make the research, gather the points, 
weigh the issues, draw the deductions and compile the conclusions and suggestions 
that Dr. Poole has in this paper, he deserves an expression of opinion from the 
members of the Section, but I had hoped that some one other than I would have 
been the first to lead out in the discussion. 
To attempt to take up such a paper and discuss the points seriatim is simply 
impossible, for want of time ; hence my remarks must be of the paper, and not its 
special points. The manner in which he handles his subject-with gloves off-makes 
me think of Laymon Blanchard's "Quarrel with Old Friends' ' 
But to the paper : I shall appreciate this paper, because on many of the points 
considered in it I have been frequently asked, by leading members of my classes, 
about these inconsistencies ; and for myself I will say, too, that in practice I have 
found myself at a loss in pathology, because the teachings of physiology and the facts 
of pathology present such a want of harmony that, in my mind, they produce con- 
fusion, and I am at a loss to decide satisfactorily to myself. For instance, in one of 
the sections of the paper, treating of the relations of the nerves and non-striated 
muscles, I have come up with cases to which we have been taught to apply the term 
spasmodic stricture of the oesophagus, found at or above the cardiac orifice of the 
stomach. Is that condition of contraction a spasm of the circular fibres or a paralysis 
of the reflex inhibitory power of the nerve that inhibits the normal condition of the 
muscle in the performance of its function of keeping the cardiac orifice closed ? 
What is it, and where is the fault ? Is it in the nerve-increased action that closes 
this muscular end-band-or is it in this nerve-decreased action-paresis-that gives 
the ' ' open sesame ' ' to this gastric portal ? I have met with cases of this character 
about which I could not clear up my pathology, hence could not feel clear in my 
therapeutia. 
Again, in cases of spasmodic croup I have been at a loss. We have two sets of 
muscles there regulating the movement in these crico-arytenoid cartilages, with nerve 
supply from the motor filaments of the inferior laryngeal of the pneumogastric-one 
set holds the glottis open, the other closes it. Now in spasmodic croup, so called, 
what is the action ? Is it spasmodic contraction in the one set, or nerve paresis in 
the other? These are some of the questions which the doctor's "quarrel with old 
friends"-as Laymon Blanchard would express it-is calculated to clear up, by 
springing the issues and settling the physiological questions upon which the solution 
of the pathological problems must be based. 
Still another case in point pops up in my mind just here, to which, if my time 
will permit, I will refer. It is that condition of the bronchial capillaries, the minute 
ramifications-bronchioles-which we so often find so annoying to patient and prac- 
titioner, that comes up reflexly from uterine disturbances or menstrual derangement. 
Now, I am frank to admit that in many of these nervous phenomena, upon the teach- 
ings of the physiologists, when they are brought side by side with the positive patho- 
logical conditions we find to exist unmistakably then and there, the physiological 284 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
explanations are more confounding to me than the pathological facts. Look, if you 
please, to the explanation given by Brown-Séquard in his theory of the cause of the 
rhythmical action of the heart. Stating that he believes that its rhythm depends 
upon the action of carbonic acid, then instituting a series of experiments to prove 
his position, by vivisection and otherwise-the details of which I have no time to 
give-proves much more conclusively that the heart's rhythmic action depends upon 
oxygen than upon the carbonic acid for which he is contending. SECTION VIII-PHYSIOLOGY. 
285 
THIRD DAY. 
Dr. Wm. Abram Love, of Atlanta, Ga., U. S. A., presented a paper- 
ON THE FUNCTION OF THE RED BLOOD CORPUSCLES AND THE 
ORIGIN OF NERVE FORCE FROM THE MAGNETIC 
CONDITION OF THE OXYGEN OF THE 
ATMOSPHERIC AIR. 
SUR LA FONCTION DES CORPUSCULES ROUGES DU SANG, ET L'ORIGINE DE 
FORCE NERVEUSE DE LA CONDITION MAGNÉTIQUE DE 
L'OXYGENE DANS L'AIR ATMOSPHÉRIQUE. 
ÜBER DIE FUNKTION DER ROTHEN BLUTKÖRPERCHEN UND DEN URSPRUNG DER NER- 
VENKRAFT AUS DEM MAGNETISCHEN ZUSTANDE DES SAUERSTOFFES 
IN DER ATMOSPHÄRISCHEN LUFT. 
In our search after truth it will be conceded that demonstrable facts will be accepted 
in evidence, whether such facts have been established as the results of recent research, 
or were the fruits of investigations in the distant past, provided they remain uncontro- 
verted or are still susceptible of demonstration. 
The inquiring mind of man has, in all ages, led him forward in his inquiries into 
the unknown. Such investigations have often led to the discovery of facts in the laws 
governing forces, regulating conditions or establishing principles. These things may 
be recognized as facts, and still may serve no special purpose until such time as they 
may be applied for the accomplishment of certain ends. It was a fact observed from 
the beginning that the application of fire to water would result in the production 
of steam, but many ages elapsed before that steam was harnessed up and made to bear 
our burdens and do our bidding. Michael Faraday, in the earlier part of our century, 
demonstrated, in fact, the principles in electro-magnetism upon which the electro-mag- 
netic telegraph and the telephone were constructed. Still, it was many*years before 
these principles were applied in the development of the apparatus that annihilates time 
and space, and brings mind and mind together from the uttermost ends of the earth. 
Facts are established, principles are discovered, but their value and application is 
often delayed awaiting other discoveries. This same Michael Faraday, about the same 
time, discovered and pointed out the relative magnetic and dia-magnetic intensity of some 
of the gases and their binary compounds. 
It serves my purpose to give you just here his figures. They are- 
Magnetic Intensity. 
Oxygen 17.5 to 3.4 
Air 3.4 
Olefiant gas (C2O2) 0.6 
Nitrogen 0.3 
Dia-Magnetic Intensity. 
Hydrogen 0.1 
Ammonia (NH 3 ) 0.5 
Cyanogen (NC2) 0.9 
It will be readily seen by this table that oxygen is an electric or magnetic bearer, 
varying in its tension from 17.5 to 3.4. 286 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Researches have demonstrated that oxygen, among the gases, takes the place or 
bears the same relation to electro-magnetism that iron does among the metals- 
capable of being charged with electricity, varying in intensity, as given above. 
The well-known experiment of passing a current of electricity through a volume 
of oxygen, converting it into a condition of nascent oxygen or ozone-a state of the 
highest intensity, under the pressure of one atmosphere -is too familiar to you all to 
require further allusion. But what is the effect of the condensation, or the rarefaction, 
of oxygen, or of the atmospheric air? We estimate the amount of oxygen of the air- 
in round numbers, for the sake of convenience-at one-fifth, 20 per cent., with a pres- 
sure of 15 pounds to the square inch. A very little calculation will exhibit the effect 
upon its tension under an increase or decrease of pressure. 
Thus, for example, we have- 
Per cent, of 
Oxygen. 
Pressure. 
Tension. 
One atmosphere 
20 
1 = 
20 
Two atmospheres 
Three " 
20 
2 = 
40 
20 
3 = 
60 
Four " 
20 
4 = 
80 
Five " 
20 
5 = 
100 
Oxygen 
100 
1 = 
100 
One-half atmosphere 
20 
i = 
10 
One-fifth 
20 
t 
4 
( Vide Draper's " 
Medical Physics.") 
From this table it will be readily perceived that the tension of the atmosphere is 
dependent upon two factors: 1st The amount of pressure. 2d. The amount of oxygen. 
With these premises, I shall pass to the question:- 
The Function of the Red Blood Corpuscles.-In treating this subject it is desired to 
present more particularly some thoughts upon the manner in which the red blood cor- 
puscles seem to be the floating medium for transporting the electric or solar force that 
is necessary for supplying nerve force in sustaining and maintaining vital action. 
These thoughts have resulted from experimental investigation, close observation of 
the results of experiments in the hands of others, and the correlation of acknowledged 
facts and established principles, and should they not be considered orthodox, I beg 
you, for the cause's sake, to bear with me patiently and give me the benefit of your 
better lights in this search after truth. 
I will not insult your intelligence by repeating here what is well known to you 
all, of the action and function of the red blood corpuscles; but, as a basis and a start- 
ing point, quote from a text-book acknowledged in this country and Europe. 
Kirke says, ' ' The important use of the red blood corpuscles is in relation to 
the absorption of oxygen in the lungs and its conveyance to the tissues. How 
far the red corpuscles are actually concerned in the nutrition of the tissues is quite 
unknown." 
That the red blood corpuscles are the carriers of oxygen from the atmospheric air 
through the lungs to the tissues, is a fact admitted by all, but when we consider or 
attempt to consider their further function, it is essential that we extend our investiga- 
tion-that we go back and investigate that oxygen; what is it, how does it support life, 
sustain the vital forces and bring about the phenomena of the nervous system resulting 
. from its introduction into the lungs ? 
In anticipation of the question, What is oxygen ? I have given you in the outset 
of this paper, from the researches and discoveries of England's great electrician and 
chemist, that particular magnetic condition of it with which we have to deal in the 
discussion of the subject under consideration. It has been shown that it is magnetic, 
bearing a tension varying from 17.5 to 3.4 under a pressure of one atmosphere, and, as 
demonstrated of atmospheric air, with the increase or the decrease of the density there SECTION VIII PHYSIOLOGY. 
287 
was, in a corresponding ratio, as under Marriott's law, an increase or a decrease of this 
magnetic tension. 
Floating out through our southern balmy air at the evening twilight, in their season, 
may be seen sailing, like meteoric showers, lighting up the way, multitudes of fireflies 
-lightning bugs, as they are called. These little insects interested me in my childhood, 
as they interest all children in the chase after them, and they interest me now, for 
they serve me a purpose in illustration. Placed under the lens, it is found that, with 
each inhalation, their almost transparent tissues become luminous. The light is, when 
first emitted, quite bright and not unlike an electric aura, and, as it fades a little, there 
is seen leaping through the deeper tissues little electric-spark-like lights, as it fades 
away after these intermittent illuminations. I have often fancied that the arterializa- 
tion, the oxygenization, the electrification, if you please, of the blood must be like 
this-an electrification of a free corpuscular tissue on the one hand, and of transparent 
insectivorous connected tissues on the other. I am not prepared to say that such is not 
the case; be this as it may, it will serve my purpose for illustration, and I will beg that 
you bear it in mind as such while we proceed. 
One function of the red blood corpuscle is recognized to be, to bear oxygen from the 
lungs to the tissues, and Draper says, " Although oxygen is necessary for the maintenance 
of life, it must be used in the diluted condition in which we find it in the air. When 
breathed in the unmixed state, stimulates the nervous system strongly, and finally causes 
death. [Italics my own. ] The experiments of Mr. Broughton showed that rabbits died in 
from six to twelve hours when kept in pure oxygen. Despite the noxious action of pure 
oxygen, animals will live in an atmosphere of that gas three times as long as they will live 
in an equal volume of atmospheric air." (Draper's ■" Med. Physics," p. 158.) It is well 
known to you that a dog poisoned by the inhalation of condensed oxygen becomes as 
rigid as if carved from wood. It is equally well known to you that the effects of this 
substance on the human system assimilates very closely the convulsions of tetanus and 
epilepsy, as well as those of the toxic action of strychnia and of phenic acid. As pointed 
out above, with the increase of pressure on or the increase of oxygen in the atmo- 
sphere, we have increase of magnetic tension. 
There may be found a very striking and impressive illustration of this, and its 
effects on combustion as well as on the human system, in the results to the workmen 
who worked in the caissons sunk for laying the foundations for the railroad bridge 
across the Mississippi at St. Louis, a few years since. 
As the workmen descended with their work, the pneumatic pressure in the caissons 
increased apace, until they were working under the pressure of two, and then on to three 
atmospheres. Then the tension was increased from twenty-the normal-up to sixty. 
What was the result of this increase of pressure and of tension ? The candles used 
by the workmen burned out with an increasing rapidity until, at last, under the higher 
pressure, they were consumed in one-fourth the time. On the men, as they descended 
deeper and deeper, with the continually increasing pressure and tension, the effects were 
most deleterious-a train of nervous symptoms were developed, closely resembling 
cerebro-spinal meningitis, from which many of them died in a few minutes or a few 
hours. Here the combustion in the candles increased fourfold-was there a corre- 
sponding increase in the physiological (or, if you please, pathological) combustion in the 
systems of the workmen ? Not at all ; their temperatures did not indicate it-it was from 
a train of symptoms indicating disturbances in the nervous system that their death 
arose. Apropos, M. Bert says, " When I for the first time saw a sparrow under the 
influence of condensed oxygen, and suffering violent convulsions, I thought that the 
intra-organic oxidation must produce exaggeration in the temperature. Imagine my 
surprise when the thermometer showed exactly the opposite result." (Quoted by 
Draper, "Med. Physics," p. 205.) 288 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I will not further multiply these illustrations. Sufficient has been presented here 
to direct your minds to this one point, and that is, that when the blood corpuscles bear 
the oxygen of the atmospheric air from the lungs to the systemic capillaries, and 
thence to the tissues, they bear that oxygen charged with that magnetic force first pointed 
out by Faraday, and that that charge is greater or less, according to the per cent, 
pressure or magnetic tension of the oxygen inhaled. Not only this, but when that 
oxygen is given off in exchange in the systemic capillary system, then and there is 
discharged at the same time that magnetic or electric force which is taken up by the end 
organs or peripheral terminals of the nerves, and becomes to the nerve system its source 
of supply-a feeder force, so to speak-to be modified and stored in the nerve centres 
-the storehouses of the nervous system-for future use. Furthermore, when the 
tension of the atmosphere is increased by any of the causes alluded to above, these 
nerve centres receive an over-charge that may lead to the pathological conditions and a 
train of nervous symptoms that prove more or less speedily fatal. What should this 
teach us as to the function of the red blood corpuscles ? 
If the surcharge from increased tension of the atmospheric air or oxygen breathed 
produces the surcharge in the nerve centres, inducing these pathological effects, must 
we not, on the same line, and by the same process of reasoning, arrive at the conclusion 
that, at a normal tension, the same changes and charges take place, giving a physio- 
logical or normal charge to these nerve centres ? 
Physiologists have taught that a nerve centre is a collection of ganglionic cells, 
capable of originating nerve force, and of receiving and of transmitting impressions. 
I am frank to say that I have never been satisfied with that word-originating-in that 
connection. 
So far I have alluded more particularly to the effects of increased pressure and 
tension. What is the effect of rarefaction and reduction of tension ? The answer to 
this may be summed up into just this-if is equivalent to a reduction of the red blood cor- 
puscles. Either of these conditions lead to a reduction of nerve force. This is illus- 
trated on a large scale by the rarefied air of the great Mexican plateau, where the 
diminished tension brings an anæmic and neurasthenic type to all forms of disease, as 
their physicians will testify. 
There are many symptoms of mal des montagnes and of balloon sickness in the dis- 
turbances in digestion, respiration, circulation and locomotion, resulting from rarefac- 
tion and loss of tension, that would be exceedingly interesting to review and apply in 
support of the argument, did time permit. There are some points in connection with 
the study of malaria that may serve to illustrate this idea, and with your permission I 
will strive to make them in as brief a manner as possible. In doing this, I must quote 
again from Draper. He says (p. 134) : " When it is deemed proper to drain a marsh, 
arrangements should be made to carry the operation out as late as possible in the fall 
of the year, and still leave sufficient time to give the soil an upturning before it freezes. 
Thus, the winter air, charged, as it is, with ozone, may have an opportunity to come in 
contact with the material from which malarial emanations arise and exert its destruc- 
tive action upon it. In no case should a marsh be either drained or its bed exposed 
to the intense heat of the summer sun." 
Now this quotation will serve to direct your mind to a point I desire to make plain. 
This question of malaria is one of no little importance to the people of this country. 
Dr. Draper gives us good advice on the question of drainage, etc., but let us follow up 
the idea. If the marsh is drained in midsummer, a process of vegetable decomposi- 
tion is set up, that is carried on at the expense of the oxygen, and this magnetic force- 
this vital force of the atmosphere-within a given space. In that area a contest arises ; 
on the one hand is a mass of decomposing vegetable matter, demanding this oxygen of 
the atmosphere to oxidize, and the magnetic force to carry on the work ; on the other SECTION VIII-PHYSIOLOGY. 
289 
hand is the man whose blood tissue is demanding the oxygen to oxygenize its corpus- 
cles, and his nerve system demanding the magnetic force to keep up its supply of nerve 
force; and so the contest continues, resulting in the devitalization of the air, by reason 
of the superior affinity of the decomposing vegetable matter for the oxygen. The 
blood corpuscles reduce in vitality, the nerve forces are depressed, and, as a result, 
you have the effects generally attributed to malaria. The vital force of the atmo- 
sphere has been reduced apace with the reduction of the magnetic intensity of its 
oxygen, as is illustrated in the figures of reduction from 17.5 to 3.4, according to the 
demand made upon it. Why leave the drainage for the winter ? For two reasons : 
One, the decomposition, with the reduced temperature, would go on with less rapidity ; 
the other because the atmosphere in winter contained more ozone, was of higher mag- 
netic tension, and could furnish the oxygen and magnetic tension in sufficient quantity 
to carry on the slow process of combustion in the vegetable matter and supply equally 
the demands for the chemico-vital combustion in the man. 
This will account to you for the broken-down blood tissue, the neurasthenic condi- 
tion of the nervous system, and the vitiated condition of functional action in the secret- 
ing glands and membranes in the malarial regions of this and other countries. 
It may not be out of place to contrast, just here, this state of things with that found 
in midwinter, when the eastern winds come to us charged with ozone in a condition of 
the highest magnetic tension. Mark the difference in the effects upon the system. The 
red blood courses its way fully charged, bearing a tension that, within bounds, buoys up 
the system, giving strength of nerve and muscle-that of perfect health. But when 
the surcharge comes we find the nervous system exhibiting evidences of tension often 
terminating in formidable disturbances, as influenzas, cerebro-spinal meningitis, rheu- 
matism, neuralgias, and other diseases neurasthenic in character/ 
I may allude en passant to the experiments going to show that the power of muscular 
contraction is dependent upon and regulated by the condition and the quantity of 
arterial blood supplied to the muscular tissue. There are some questions pertaining to 
the correlation of physical and vital forces, presented by those who delight to make 
experiments and observations upon such subjects, that, as I conceive, may be more 
satisfactorily solved by the adoption of these views regarding the functional action of 
the red blood corpuscles than by any other line of investigation it has as yet been my 
good fortune to strike, with all the researches that years and their opportunities have 
enabled me to make. 
And now, in conclusion, allow me to say that in presenting this paper, I do so being 
myself in search of truth. In tracing, as I do, the origin of nerve force, or rather, I 
should say, the means for its supply and perpetuation, back through the red blood cor- 
puscles to the electricity of the atmospheric air and, for that matter, to the solar rays, 
if you please, I do so with becoming reverence; for in doing this there is shown not 
only the relation, but that the same power, the same force, that propels the corpuscle 
regulates the solar centre and system from which the force may emanate-all dependent 
upon the fiat of the power that spoke it into being-and brings us into closer relation 
with that power whose many mysteries and mysterious ways we are not yet permitted 
to know. In the great beyond they may not be mysteries. And now, in conclusion, I 
will say "Lex scripta manet." And if what I have written shall meet your approval, 
and you shall in the end, after thorough investigation, adopt these ideas, finding them 
correct, I will have accomplished my object and be glad. But should you see fit to 
differ with me in these views, I will only say that I will be most happy-while prosecut- 
ing this search after truth, in which we are all engaged-I will be most happy to have 
you point me to the error of my way, and show me the better. 
Vol. Ill-19 290 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE PHYSIOLOGY OF ELEMENTARY FIBRES. 
DE LA PHYSIOLOGIE DES FIBRES ELEMENTAIRES. 
ÜBER DIE PHYSIOLOGIE DER ELEMENTAREN FASERN. 
BY J. H. WYTHE, M.D., F.R.M.8., 
Professor of Histology in Cooper Medical College, San Francisco, California. 
In the physiology of a century ago fibres played a very important part. Thus, Haller, 
in his ' ' First Lines of Physiology, ' ' declares that the solid parts of the body consist of 
fibres, arranged in parallel lines or in layers, and an unorganized gluten from which 
the fibres were originally formed. Others regarded the tissues as made up of granules, 
globules, fibres and membranes. In 1835 Dujardin discovered that the lower animals 
were characterized by the possession of a contractile substance, which he termed 
"sarcode." Max Schultze afterward, in 1861, showed that this substance formed not 
only the bodies of the Infusoria, but also the contents of animal cells. He called it 
Protoplasm. For this substance, in its living state, Dr. Beale proposed the word Bio- 
plasm. 
In 1838 Schleiden and Schwann taught the origin of all tissues in cells, and from that 
time the cell doctrine has been considered to be the basis of minute anatomy. Those 
authors considered the origin of the cells to be from a fluid plasma, or blastema, but 
Virchow, in 1852, discovered that the cells have primary vitality, and that each cell 
originated from a preceding one. Hence the aphorism, " Omnis céllula e cellula." 
The cell, as described by these investigators, was a vesicle composed of a transparent 
membrane, within which was a fluid or semi-fluid substance containing a more solid 
body, which was called the nucleus. Within the nucleus, the nucleolus, a still smaller 
body, was sometimes found. Max Schultze showed that an external membrane was 
not an essential part of the cell, but that the individual elements of organization are 
masses of a living, jelly-like substance. Brücke (1861), and afterward Stricker (in 
1868), proved that the nucleus was often absent, and that living matter in the organism 
exists as a pellucid jelly, in which nuclei and granules were secondary products. 
The great improvement made in the optical part of microscopes . since that time, as 
well as in microscopic technology, and especially the methods of staining tissues with 
carmine, logwood, aniline dyes, nitrate of silver and chloride of gold, have led to con- 
siderable advancement in histology. The cell, which was formerly considered to be a 
mass of structureless jelly, is now known to be a network of fine fibres of semi-fluid, 
living matter, having at the junction of the fibres nodules, or large masses of the 
same matter, which give it a granular appearance. In the meshes of this network, 
fluid nutriment and effete matters may freely circulate. A similar living network is 
found in many tissues and organs which are generally described as of more simple 
composition. Heitzman, Elsberg, and others claim that this network is continuous 
through all the tissues and organs of the body. 
In the proliferation of nucleated cells it has been shown by Flemming, Klein and 
others that the fibrils of the nucleus show complicated movements and changes pre- 
vious to the division of the cell itself. 
This general outline of the progress of research is sufficient to suggest that the cell 
doctrine in physiology, based upon former ideas of cell structure, requires considerable 
modification. This will appear more evidently when we consider the number and 
variety of tissues in which elementary living matter exhibits itself in the fibrillar or 
reticular form. SECTION VIII PHYSIOLOGY. 
291 
However important to the animal organism may be the functions of separate masses, 
or particles, of living matter-the so-called cells-microscopical observation reveals to 
us that the tendency of such particles is toward the formation of fibres, and to the 
weaving together of such fibres in various ways, according to the differentiation of 
function. In every tissue a fibrous arrangement is the rule, and not the exception, and 
as we increase the magnifying power or the delicacy of our methods of preparation, this 
morphological fact becomes more evident. It must necessarily have a physiological 
signification. The production of fibre is the highest morphological expression of living 
matter. 
Fibrillar and reticular structure may be found in red and white blood cells ; in epi- 
thelial cells and their nuclei ; in endothelial cells ; in every form of connective tissue ; 
in voluntary and involuntary muscle, and in nerve axes and ganglia. In Klein's 
•'Atlas of Histology," Plate xv shows cells of unstriped muscle, with a central 
bundle of fibrils, or contractile part, connected with an iutra-nuclear network, and 
Melland (Quarterly Journal of Microscopical Science, July, 1885) has demonstrated, by 
his method of gold staining, an intra-cellular network in striped muscle fibre-a series 
of reticulated discs, connected by longitudinal fibrils. Luys says ("The Brain and its 
Functions," 1882), of the cells of nerve ganglia, " that this substance, which we call the 
protoplasm of the cell, is formed by a true tissue organized in a special manner ; that 
this tissue, consisting of very delicate fibrillæ interlaced like the wicker-work of an 
«zier basket, has a tendency to agglomerate toward the nucleus of the cell, which thus 
becomes a true point of concentration ; that the nucleus itself is not homogeneous ; 
that it is endowed with a special structure, radiated in appearance, and that, lastly, 
the nucleolus, considered as the final expression of the unity of the nerve cell, is, in its 
turn, divisible into secondary filaments." These references suffice to show the general 
prevalence of fibrous reticulation and its physiological importance. 
Bioplasm, or living protoplasm, which is the basis of living fibre, is a semi-fluid, 
homogeneous substance, having peculiar motions and properties. In addition to its 
•changes of shape, and movement from place to place, seen by the microscope in every 
amoeboid particle, there are inherent motions of its molecules witnessed by means of the 
flow of accidental granules, or vacuoles, which are carried along by its current. Thus, 
in the hair cells of vallisneria and other plants, the streaming movement may be seen in 
Thread-like masses circulating around the cell cavity. What is known as contraction or 
expansion of living fibre, is simply the relative distance of its molecules from each other, 
and although so elementary a function of living matter, it differs so much from ordinary 
vibration, or contraction in inorganic substances, that no proper comparison can be insti- 
tuted between them. The molecular movements of living fibre vary according to the 
character of the reticulation. Thus, in the axis cylinder of nerves there is room only 
for a simple oscillatory motion, while in the reticular fibres of the sense organs, and in 
the reticulation of living matter in the ganglia, the movements are more complex and 
varied. We can readily conceive that a movement excited in the peripheral network 
may be transmitted by the nerve axis to the ganglionic reticulum, and thence through 
other axes to the muscular fibre, producing what is called reflex nervous action. The 
nodular reticulum of the so-called discs of striated muscle also (shown by Melland), 
when excited to vital contraction by the molecular changes in nervous fibres, will, of 
necessity, shorten the longitudinal fibres between the discs. We may thus explain the 
mode of action in voluntary muscle. In a similar way, Klein's description of involun- 
tary muscle fibre shows how its action may be readily conceived. The present status 
of histology thus tends to remove from the sphere of mystery what has been known as 
nervous influence and muscular action, and resolves them into simple physical contrac- 
tions of an elementary fibre in which the power of life is incarnated. This elemental 292 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
bioplasmic fibre is so generally distributed in the various tissues as to suggest the thought 
that its properties constitute the true physiological unit of organic life. Its power of 
vital contractility will account for nervous and muscular motions, and it needs only to 
consider it endowed with selective power in order to understand the process of secretion 
also. It may be that in the physiology of the future we shall no longer speak of a 
mystical nervous influence, or of muscular contraction, but acknowledge the power of 
living matter to do that which the non-living can never do. SECTION VIII-PHYSIOLOGY. 
293 
FOURTH DAY. 
Dr. W. Hutson Ford, of St. Louis, Mo., presenteâ a paper- 
ON THE NORMAL ACCOMPLISHMENT OF THE ALCOHOLIC FER- 
MENTATION OF HEPATIC SUGAR IN THE ECONOMY. 
SUR L'ACCOMPLISSEMENT NORMAL DE LA FERMENTATION ALCOOLIQUE DU 
SUCRE HÉPATIQUE DANS L'ORGANISME. 
ÜBER DIE NORMALE AUSBILDUNG DER ALKOHOLISCHEN GÄHRUNG DES 
LEBERZUCKERS IM ORGANISMUS. 
More than a hundred years ago (1764) Willis announced that the urine of diabetes 
was saccharine. This malady, not yet distinguished from simple polyuria, was known 
to Celsus, Aretæus and Galen. In confirmation of the statement of Willis, the exist- 
ence of sugar in the urine in grave and lethal forms of diabetes was demonstrated by 
Pool and Dobson, and three years later by Cowley. After this (1778) much attention 
was devoted to the subject, and valuable contributions relating to it were published by 
Polio, Prout, Bell, Nicolas, Guedeville, Dupuytren and Thénard, and Contour (1844). 
From 1841 to 1846 M. Bouchardat contributed several papers, in which he endeavored 
to enlighten the pathology of the affection by an ingenious theory of its origin. 
Bouchardat maintained that the sugar in the urine is derived exclusively from the 
starchy matters of the food, and is formed by a pathological process in the stomach, 
too rapidly for abstraction in the blood, while normally the saccharification of starch 
Is effected throughout the length of the small intestine, so that the resultant glucose is 
absorbed gradually into the blood and commensurately destroyed in that fluid. 
Bouchardat's theory fails to take into account a well-known and characteristic 
feature of diabetes, viz., that when the disease is severe or advanced, the quantity of 
sugar voided is considerably greater than can be accounted for by the starch and other 
carbohydrates ingested. This important consideration, plainly showing that Bouchardat 
had not grasped all the facts, perhaps not even the fundamental ones, furnished the 
earliest motive for the masterly investigations of Claude Bernard, which date from 
1843. 
It was not, however, until 1848 that Bernard published his first results, viz., that, 
1. Sugar may exist in the organism independently of alimentation, and that, 
2. The liver is an organ which produces sugar. 
In 1853 a formal monograph upon the subject appeared, entitled, " Nouvelle fonction 
du foie," and a volume of lectures delivered at the College of France in 1854 and 1855, 
was published in the latter year. Some years later (1857) Bernard announced the 
isolation of the glycogenic matter. 
The cardinal facts established by Bernard, were as follows :- 
1. The blood of the hepatic veins always contains sugar. 
2. The blood of the vena portæ of a fasting animal, or of one fed upon a purely NINTH INTERNATIONAL MEDICAL CONGRESS. 
294 
animal diet, never contains sugar, except as due to accidental reflux from the liver 
after opening the abdominal cavity, or to muscular movements of the animal, etc. 
3. Sugar always exists normally in the tissue of the liver, and only disappears a 
short time before death by inanition, or in certain morbid states. 
4. The systemic blood contains no sugar during abstinence, but does so during 
digestion. 
5. The blood of the liver, hepatic veins, ascending cava and right ventricle is always 
normally saccharine. 
6. Sugar disappears in the lungs in fasting animals ; and in animals in digestion, 
almost entirely in those organs, and eventually, in the blood mass ; no sugar being 
excreted in the normal condition. 
7. The highest temperature of the animal body exists at the point of entrance of 
the hepatic veins into the ascending cava. 
8. The temperature of the left ventricle is slightly lower than that of the right. 
These statements were shortly (1849-1852) verified by Vanden-Bröck, Lehmann, 
Frerichs, Bawmert, Gibbe, Mitchell, and afterward by many other experimentalists, up 
to the year 1858. Previously to 1853, Bernard had greatly extended his studies. He 
investigated the cardinal facts of the glycogenetic theory throughout the animal king- 
dom, elaborating his views and recording the results of his experiments in the mono- 
graph above mentioned, which remains to us as an almost perfect model of physiological 
research. Some years afterward (1857) he published his paper on the isolation of 
glycogen, although the principal facts relating to this substance had been exposed in 
his lectures delivered in 1854 and 1855, already mentioned. 
Glycogen is closely allied to starch and dextrine ; it is a normal constituent of the 
liver tissue, being found in all animals at all times. During the earlier periods of ges- 
tation it exists in the muscles and lung tissue, but not at first in the tissue of the liver. 
When it appears in this organ, its quantity declines in other parts of the organism, from 
which it eventually disappears. It accumulates in the liver in especial abundance 
after starchy and saccharine food. In experiments upon dogs, Pavy found that a diet 
of vegetable food augmented very greatly the quantity of glycogen present in the liver, 
also notably increasing the weight of the liver itself. In the present state of our know- 
ledge, we are authorized to believe that glycogen represents the entire quantity of carbo- 
hydrates ingested as food in herbivora and in omnivore, and likewise, all that part of 
proteinoid food which is not transformed into urea, and the biliary acids, with some 
unimportant exceptions, for glycogen is formed as well in carnivora as in the fasting 
state of other animals. The formula of glycogen is C6 Hi0 O5, being apparently formed 
from the dehydration of starch. The liver contains from 7 to 17 per cent, of this 
substance, according to the nature of the diet. It is continually transformed in the 
liver tissue into hepatic sugar, by the action of the liver cells themselves most probably, 
subject to the influences of innervation ; nevertheless, this transformation continues 
after exsection of the liver and the drainage of the liver tissue of its blood, so that it 
must be attributed to inherent properties of the liver stroma, essentially independent 
of the circulation and nervous system, though greatly modifiable by these influences, as 
Bernard has demonstrated. The liver must thus be regarded as a depot for carbo- 
hydrates, whence they are constantly poured into the circulation through the hepatic 
veins, at an uninterrupted, nearly uniform rate. 
Prior to 1858, Bernard published his quantitative determinations of hepatic sugar in 
the liver in various communications ; he had executed them with extraordinary dili- 
gence and scope for a great variety of animals and physiological conditions. He affirmed 
that the liver contains, on an average, one gramme and a half to two grammes of 
sugar to one hundred grammes of its tissue, in mammals and birds, and in man, from 
analyses of the livers of two criminals, 1 gr. 966 of sugar to 100 of liver tissue. Quan- SECTION VIII PHYSIOLOGY. 
295 
titative statements of this kind, undoubtedly accurate for the conditions under which 
the facts supporting them were determined, were continually made by Bernard, and are 
to be met with in all his writings prior to 1877. His assertions were corroborated by 
experimenters everywhere who operated as they had seen him do, by leisurely slicing 
off a portion of a liver, extirpated without haste, grinding it in a mortar with animal 
charcoal, boiling and filtering. A clear extract so made always contained sugar in the 
proportions asserted by Bernard. The glycogenetic theory, as Bernard had formulated 
it, seemed in all its aspects as firmly established as the laws of gravitation itself. 
In the midst of this security (1858), Pavy published certain experiments, to all 
appearance, wholly subverting it. Pavy claimed to have demonstrated that the liver 
contains no sugar during life, this substance making its appearance after death only, by 
a change of the glycogen which does not occur normally or during life, and consequently, 
that no glycogenetic function, properly so-called, exists as an attribute of the liver. He 
operated by injecting into the liver, through the portal vein, a solution of caustic 
potassa, and by rapidly slicing off bits of the liver during life, and casting them imme- 
diately into a freezing mixture, in both ways designing to prevent a formation of sugar 
subsequent to the operation, the argument being that if, under these circumstances, 
sugar was not to be found, it could not have been present during life. The presence of 
sugar under these conditions could not be demonstrated, or only in what was said to he 
an insignificant amount, and even this was claimed by Pavy to be of post-morten forma- 
tion. These experiments, with some modifications, were repeated by Meissner, Ritter, 
Schiff and Eulenberg, who accepted Pavy's explanation of the phenomena. They 
regarded the traces of sugar sometimes found as due to post-mortem or abnormal influ- 
ences. In 1860, Harley showed in four experiments that when the liver tissue was cast 
into a freezing mixture, and after freezing, sliced into boiling acidulated water, sugar 
was always determinable, though in small quantity. 
Nevertheless, Pavy's views gained a wide foothold; it was generally assumed that 
the so-called glycogenetic function of the liver had no real existence, and that Bernard's 
conceptions of the sequences of chemical transformation occurring in the liver were 
essentially at fault. The presence of sugar in the excreted liver was regarded as a 
post-mortem phenomenon. 
While, during a period of eight years, the physiological world thus went astray, 
those who had witnessed Bernard's cardinal experiments of the absence of sugar from 
the portal blood of fasting or carnivorous animals and its universal presence in the 
blood of the hepatic veins, as well as in the right side of the heart, as I myself, 
with Hardy and other pupils of Bernard, had fortunately been able to do, remained 
unshaken in their convictions, although it was plain that the subject needed at least 
quantitative revision. 
Appreciating this necessity, Flint, of New York, in 1868, endeavored to reconcile 
these conflicting views. He operated by cutting out bits of the liver in dogs during 
life, slicing them into boiling water and examining them by Fehling's test; the time 
occupied was very short, viz. : from 10 to 28 seconds only. Flint was unable to demon- 
strate the presence of sugar in such bits of liver, but he detected sugar in the hepatic 
venous blood within one minute after one of his exsections, concluding in favor of a 
normal hepatic glycogenesis; the sugar being derived from glycogenic matter during 
life and rapidly washed out of the liver by the blood stream. 
In 1870, Lusk obtained results opposed to those of Pavy and others, corroborating 
Bernard's assertions. He found, by repeating Bernard's aspiration of the right ven- 
tricle, that sugar in very definite quantity exists normally in the blood passing through 
it. 
In 1871 Dalton reviewed previous experiments of this kind after a carefully planned 
method. He determined, in a series of twenty experiments, that the liver contains 296 
glucose in quantities varying from 1.510 to 4.375 parts to 1000 parts of liver, the time 
occupied in extraction of the liver morsel, in pulping it and in heating it to 212°, 
varying from 3 to 13 seconds. The dosage found by Dalton, as above given, was 
about one-tenth of that determined by Bernard, and assumed by him to have been 
present during life. Dalton also took occasion to measure the post-mortem glyco- 
genesis of the exsected liver tissue at ordinary temperatures. He found that the 
proportion of sugar determinable in the liver tissue after four or five seconds (mean 
of three experiments) to 1000 of tissue was 2.778; after fifteen minutes, more than 
twice as much, viz.: 6.792; and after one hour, 11.074 (mean of two experiments), 
or very nearly four times as much. He also determined that sugar did not exist in 
the spleen, nor presumably in any other organ, so that the sugar found in the liver 
could not have been derived from the arterial blood sent to that organ, the spleen 
being examined concurrently with the liver, in three experiments, ten minutes after 
the liver tissue was tested. 
These results essentially reestablished the credit of the glycogenic function, at least 
with those who had temporarily failed to appreciate the rigorous cogency of Bernard's 
cardinal experiments, and Dalton formally concluded that sugar exists in the liver at 
the earliest period at which it is practicable to examine the organ ; that the quantity 
existing at this time is at least two and a half parts in a thousand of liver tissue, and 
that the sugar found does not belong to the arterial blood, but is normally present in 
the hepatic tissue. Bernard, finally, in 1877, published a paper in which this subject 
was reconsidered, correcting his earlier dosages of sugar, which had been altogether too 
high, on account of his failure to bear in mind a fact he had himself discovered and 
frequently spoken of, viz. : that the percentage of sugar notably increases in the liver 
after exsection. All of Bernard's earlier dosages, as well as the comparative conclu- 
sions derived from them, to a very considerable extent at least, are thus necessarily 
invalidated, while, nevertheless, the glycogenetic function has become more exactly 
defined and thoroughly substantiated. Sugar is perpetually formed in the liver and 
continuously evected in the blood stream. Had Bernard dosed his morsels of liver 
tissue after having first thrown the entire organ or the parts of it operated upon into 
boiling water immediately after exsection, these controversies could not have occurred. 
He was himself the originator of the method of arresting the progressive formation of 
sugar in the liver after exsection by plunging it into boiling water. I quote from his 
"Leçons," 1854 and 1855, p. 366. Speaking of the increase of sugar in a portion 
of the uncooked liver of a rabbit killed after section of the spinal cord above the 
brachial enlargement, Bernard observes: " It may thus be seen, that by exposing liver 
tissue pulped with water to a temperature of 40° to 50° C., the return of saccharine 
matter is singularly hastened," proceeding to explain how some sugar might thus be 
formed, even while making a decoction, before the liquid is heated to 212° F. "It 
would," says he, "be more appropriate to arrest this process immediately by plunging 
the liver into boiling water, so that it might not pass through an intermediate tem- 
perature capable of determining the production of a certain quantity of sugar which 
would not otherwise have become manifest." 
Our knowledge of the glycogenetic function of the liver may be fairly summed up, 
in brief, as follows:- 
1. The incursion of dextrinoid, amylaceous and saccharine matters, from the 
digestive tract, effects a prompt increase of glycogen in the liver. Under these circum- 
stances a freshly made decoction of the liver is opalescent. Even in fasting carnivora, 
glycogen exists in the healthy liver, and must therefore be formed from proteinoid mat- 
ters, furnished by the blood. 
2. Glycogen is more nearly allied to dextrine than to starch, and is converted into 
sugar by all agencies capable of converting dextrine into glucose, but with a facility far 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION VIII- PHYSIOLOGY. 
297 
greater than is observable for dextrine of vegetable origin. In this facile convertibility 
into an ulterior product, glycogen resembles hepatic sugar itself. 
3. Some zymogenous agency proper to the liver substance may be invoked as the cause 
of this transformation, but even systemic blood is able to saccharify glycogen at the 
temperature of the body. This conversion, normally in continual progress, so that the 
blood escaping by the hepatic veins always contains a notable and very constant pro- 
portion of sugar, takes place in the liver at the temperature of the body with great 
ease and rapidity, bat is speedily checked and eventually arrested by a decline in tem- 
perature. 
4. The glucose thus formed, the resultant product of all the amylaceous and saccha- 
rine elements of the food, as well as all of the proteinoids, excepting such portions of 
these last as are represented by urea, the biliary acids and some bodies of secondary 
importance, is unceasingly washed away by the blood, so that during life the liver very 
probably never contains more than one or two parts of sugar in a thousand of its own 
substance. If the animal is in digestion, the quantity of sugar thus evected by the 
blood is considerably greater than during the fasting state, and much of it passes 
beyond the lungs into the general circulation. This appears to be habitually the case 
with herbivorous animals, which are more or less in digestion at all times; but in fast- 
ing carnivora, most of the sugar is destroyed in the lungs, though a certain small por- 
tion may be regarded as normally present in the systemic blood, having escaped the 
peculiar decompositive influences of the pneumocardiac transit. Arterial blood con- 
tains more glucose than venous, so that glucose would seem to disappear in the systemic 
capillaries, although mainly decomposed while passing through the lungs ; nor does it 
normally escape by any of the secretions. 
As this sugar represents by far the greater weight of the colloidal elements of the 
food, its ultimate destruction, its physiological significance, the mechanism by which 
it disappears, and the phenomena attendant upon the disappearance, have been appre- 
ciated as fundamentally important problems since Bernard first established its invariable 
presence in the liver and blood, and its conversion within the economy into other pro- 
ducts. Among the non-nitrogenous matters of the food, starch, dextrin, pectin, cane 
and fruit sugar are undoubtedly metamorphosed into glycogen and through this into 
hepatic sugar. Gelatine also subserves the formation of glycogen, probably giving rise 
to crystalloidal bodies containing nitrogen at the same time; it thus ranks as inter- 
mediate between the carbohydrates and albuminoids, since it cannot administer to the 
formation of tissue. Fibrinogen disappears as such, at least in the liver, and albumen 
diminishes in the blood passing through the organ, so that we are compelled to admit 
that among the various acts of the liver one function exists of primary importance, by 
which the proteinoids of the economy, most probably after subserving the purpose of 
tissual nutrition, or when actually exceeding the immediate wants of the system or its 
power of storing up nutritive matters, are broken up into the biliary acids, uric acid and 
urea, and glycogen. Thus we find that hepatic sugar and the acids of the bile, with 
urea, together account for all the food absorbed by animals. A recognition of the 
numerous physiological conditions whose concurrent action is indispensable to the 
steady outflow of hepatic glucose into the blood, of the existence of the glycogenic 
function in all animals hitherto examined, of the fact that this function is formally 
elaborated during fœtal life in obvious preparation for an independent existence, com- 
pels us to regard the disappearance of sugar in the organism as a phenomenon replete 
with significance, underlying, as it obviously does, the process of alimentation, and 
necessarily, therefore, all the functions of animal existence. For indeed, this hepatic 
sugar constitutes a temporary halting place in the transformation of the colloids of 
the food into crystalloidal matters, a most significant change in which the forces of 
animal life originate. 298 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The physiological importance of hepatic glucose cannot, therefore, be over-estimated ; 
it must be regarded as the eventual hydrocarbonous resultant of the digestive and 
alimentary processes of hepatic elaboration, and as designedly prepared or harmoniously 
utilized for purposes directly subservient to life itself. Is this importance to be recog- 
nized in the conditions attendant upon the destruction of glucose in the economy or 
surrounding its origin and elaboration? Are the purposes for which animals consume 
starch, sugar, vegetables, and the greater weight of the flesh they devour, subserved by 
the act of hepatic glycogenesis, or by the fact of the conversion of the glucose so carefully 
elaborated into further and ultimate products? Is the destruction of sugar in the 
economy merely a sidelong excretory process, by means of which it may be speedily 
eliminated, and easily separated from the blood, or must we regard it as essentially an 
active one, fundamentally indispensable, and administering to organic necessities upon 
which all cell activity is inherently dependent? 
Soon after oxygen was discovered by Scheele and Priestley, its relations to the act of 
respiration were investigated by Lavoisier, in some of the most admirable experiments 
recorded in science. Priestley also pursued his studies in the same direction, with sim- 
ilar results, so that physiologists announced before long that a hydrocarbon was con- 
sumed in the organism, in the lungs, or, perhaps, elsewhere, and that such a combus- 
tion, though slow and occurring at low temperatures, must nevertheless evolve as 
much heat as if attended by visible inflammation. Liebig finally, by his ingenious 
methods, demonstrated that this hydrocarbon must be derived from the food. 
Hepatic glucose is a typical hydrocarbon, directly combustible, easily broken up by 
dry distillation ; more rapidly fermentescible than any known sugar ; why, therefore, 
should it not constitute the source of the larger share of animal heat by its slow' com- 
bustion within the economy ? After the publication of Bernard's discoveries, it was 
affirmed that the long-sought hydrocarbon was found at last. Mialhe framed his 
theory of the direct destruction of hepatic glucose by the alkalinity of the blood in 
explanation of the phenomena of diabetes, and Alvaro Reynoso published a series of 
experiments, proving, as he affirmed, that this sugar is directly oxidized in the lungs. 
Bernard, however, rejected these theories. He affirmed persistently that hepatic 
sugar was not "consumed" in the lungs, directly or indirectly; that it was not a 
prime source of animal heat by oxidation in the blood-stream, but was changed in the 
lungs, or at any rate in the blood, into new matters, by whose formation heat was not 
evolved. He says " It has been supposed by certain theories, that sugar is destroyed 
for the production of the heat requisite to maintain the proper animal temperature ; I 
think that sugar has other uses to fulfill, of a nature entirely different, and of a much 
greater importance. ' ' He regarded the formation of sugar as the significant epoch of 
its existence, supposing that certain phenomena of what he termed "animal germina- 
tion " were accomplished in the liver at the moment when the animal matter which 
furnishes sugar is decomposed for the production of this substance. "Should we con- 
sider the chemistry of the adult organism only," he observes, "we must place the 
principal part which sugar plays, in its destruction, as has already been imagined by 
some. On the other hand, by the theory of development, we are led to conclude that 
the most important objects for which this substance is present are to be recognized in 
phenomena which occur, not when it is destroyed in the blood, but when it originates 
in.the liver." "It is at the moment of its formation in this organ, that the organic 
elements are likewise created which are destined ulteriorly to complete their evolution 
for the renovation of the animal tissues." (Loe. cit. p. 256.} 
Bernard never relinquished these views, maintaining that sugar is formed in the liver 
or in foetal tissues in order that " animal germs " may be simultaneously evolved and 
developed. He attached little or no importance to the disappearance of sugar in the 
organism, admitting, however, that this disappearance was by a fermentative change SECTION VIII-PHYSIOLOGY. 
299 
of some kind, and inclining, though not very strongly, toward the hypothesis according 
to which glucose is destroyed by conversion into lactic acid. He peremptorily dis- 
missed all hypotheses of direct combustion or oxidation of glucose in the lungs or else- 
where, like those of Mialhe or Reynoso, " We have seen " says he, "that oxidation 
does not explain the phenomena; is it so, however, for a fermentation ? The theory of 
oxidation as an explanation of the disappearance of sugar, from considerations already 
urged (loc. cit. p. 232) as well as from new facts which otfer themselves to strengthen 
this affirmation, is," he says, "more than insufficient." "Direct experiments have 
proved to me that the quantity of oxygen absorbed, when compared with the quantity 
of carbonic acid disengaged, is greater in the non-saccharine blood of the jugular vein 
of a fasting animal than in the blood of an animal sacrificed during digestion and con- 
taining sugar ; or more plainly, non-saccharine blood absorbs more oxygen, and extri- 
cates, relatively less carbonic acid than saccharine blood. The experiments of MM. 
Régnault and Reiset, made upon living animals, have furnished identically the same 
results ; they have shown that the ratio of the oxygen exhaled in the form of carbonic 
acid to the oxygen absorbed is greater during digestion than during abstinence. It 
results from these experiments that the quantity of oxygen introduced into the economy 
is not proportional to the amount of carbonic acid formed." It has been demonstrated 
that a certain amount of carbonic acid is yielded up by the blood under the air-pump, 
as in the experiments of Magnus and Bernard, or is found to have been exhaled by 
the lungs and skin, as in the bell-glass experiments of Régnault and Reiset, which does 
not owe its origin to any systemic oxidative processes ; this fact I shall speak of 
further on, as it is a necessary corollary of the views I first proposed in 1859, and which 
form the motive of this communication. 
Bernard, in continuance of the subject, proceeds to detail some experiments, prov- 
ing very clearly that oxygen possesses no especial influence upon the disappearance of 
sugar in saccharine blood. He found that in two samples of the same blood normally 
saccharine, through one of which a current of oxygen was passed for five or six hours, 
while carbonic acid was passed through the other for an equal period of time (evidently 
at the temperature of the laboratory, although the fact is not noted) sugar did not dis- 
appear. The gaseous currents being pretermitted, after a repose of twenty-four hours, 
sugar was found to have disappeared. Bernard continued the inquiry in the following 
desultory but suggestive experiments :- 
Samples of saccharine blood were placed in contact with various gases (evidently 
at the temperature of the laboratory) confined under bell-glasses, as follows :- 
From the peripheral extremity of the jugular vein of a healthy dog in full digestion, 
some blood was drawn containing sugar in small quantity. 
1st. Twenty-four grammes of this blood was passed into a flask reversed over mer- 
cury, containing 500 cubic centimetres of oxygen. 
2d. The same quantity of warm blood was passed into a similar flask containing 
nitrogen. 
3d. A similar quantity of the same blood was placed in contact with carbonic acid. 
After these arrangements the presence of sugar was again determined in the original 
sample of blood, in undiminished quantity. The blood rapidly coagulated, and was 
commingled with the overlying gas by agitation, becoming, of course, rutilant with 
oxygen, red with nitrogen, and very black with carbonic acid. After two hours, sugar 
had disappeared under the nitrogen, while a portion still remained under the oxygen 
and the carbonic acid. 
Repeating these experiments (at the temperature of the laboratory), he operated as 
before: 1st, with pure oxygen; 2d, with carefully prepared hydrogen ; 3d, with arseni- 
ureted hydrogen ; 4th, with carbonic acid, and 5th, with air. The blood coagulated 
rapidly in all the flasks ; it was shaken up with its overlying gas in each flask, remain- 300 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ing red in all the flasks excepting that containing arseniureted hydrogen, where it 
became very black. After two hours, sugar had entirely disappeared under the arseni- 
ureted hydrogen while it was perfectly preserved under the pure hydrogen. . 
The next day, after twenty hours of contact, sugar was found to have disappeared 
completely under the arseniureted hydrogen and under the pure hydrogen, while 
traces of it remained under all the other gases. 
Bernard comments briefly upon these experiments, though unable to deduce any 
definite conclusion from them as to the influence of the gases employed upon the dis- 
appearance of the sugar. One main fact was, however, plain enough, viz. : that in 
both sets of experiments the sugar had disappeared in from twenty to twenty-four 
hours, at the temperature of the laboratory. In view of this fact and of other consider- 
ations of similar significance, he declared that the disappearance of the sugar is not 
effected in the organism by a combustion or a direct oxidation, but by a fermentation 
"which cannot be arrested while life lasts," proceeding (p. 288) to explain that this can- 
not be by the fermentation of the sugar into alcohol and carbonic acid. " Under the 
influence of beer yeast sugar is transformed into these latter products, while if the yeast 
is disorganized by grinding in a mortar, the sugar is converted into lactic acid." He 
further states that it is impossible that the alcoholic fermentation can occur within the 
organism, because the yeast of beer, its proper ferment, is absent . '1 Should we endeavor, ' ' 
he observes, " to induce such a fermentation artificially, grave disorders would ensue, 
inducing death," going on to relate the history of an experiment in which a mixture 
of sugar and beer yeast was injected into the veins of a dog, the animal shortly dying 
of a grave malady, in which the blood became black, decomposed and viscid. "San- 
guinolent diarrhoeas supervened, death ensuing with symptoms analogous to those of 
the typhoid state." He then rejects the possibility of the destruction of hepatic sugar 
within the economy by the alcoholic fermentation, and still further remarks: "The 
destruction of sugar does not, therefore, occur in this way, but upon the arrival of the 
sugar at the lungs, it may, under the influence of the extreme division of the blood, be 
changed into lactic acid by a transformation involving only a molecular modification 
with the separation of two equivalents of water, in which oxygen would play but a 
secondary part. According to this view, the oxidation by which the carbonic acid 
originates would only occur, perhaps, in the general capillary system. I do not, how- 
ever, think that this combination of oxygen with carbon takes place at the expense of 
matters directly poured into the blood, whether they be the resultants of digestion or 
of elaboration in the liver. I believe, on the contrary, .that these new matters which, 
so to speak, have not yet lived, enter first into organic combinations, displacing the 
older matters, which are excreted in gaseous, liquid or solid forms. I do not believe, 
in short, that any of the phenomena, either of composition or of decomposition, are 
accomplished in the organism in a direct way" (pp. 239 and 240). 
Bernard then commits himself, though not with any special emphasis, to the lactic 
acid theory of saccharine destruction, but without offering any further considerations 
in favor of it, or any experimental proofs of its occurrence. It is true that while 
experimenting upon the presence of sugar and glycogen in the muscles and lungs of 
fœtal calves, he found that if these organs were left in water at a temperature of from 
59° F. to 68° F., after a little while the liquid became very acid, in consequence of the 
development of a considerable quantity of lactic acid, determined to be such by crys- 
tallization of its salts, and evidently derived from the glycogen and sugar which he 
demonstrated in such tissues. 
Lactic acid is always formed where sugars are present in fluids containing albu- 
minoid matters undergoing putrefaction. "The various kinds of sugar, " says Rég- 
nault, ' ' dextrine and sugar of milk, yield a large amount of lactic acid when they are 
mixed with a solution of diastase which has been exposed to the air for some time." SECTION VIII PHYSIOLOGY. 
301 
The diastase of germinating seeds and tubers converts their starch into sugar ; if, when 
this is effected, further development of the grain is arrested by soaking in water, bruis- 
ing and exposure to the air, the diastase soon begins to putrefy, and converts the sugar 
already existing into lactic acid, and, still later, causing the formation of a certain 
quantity of butyric acid. The lactic acid fermentation of the chyme, so frequently 
observed, appears to be due to a tendency toward putrefaction of the contents of the 
stomach, rendered possible by a vitiated condition or deficiency of gastric juice, naturally 
antiseptic, and the high temperature of the animal body. 
The conditions attendant upon the lactic acid fermentation, as far as we know them, 
are certainly not present in the living organism. Bernard has suggested that extreme 
division might be one of the factors inductive of this fermentation in the lungs; but as 
this implies no more than an increased exposure to the action of oxygen, albuminous 
bodies, in the stages of change in which they are always found during the lactic acid 
fermentation, must be demonstrated as coexisting with this condition before admitting 
its validity. Indeed, if, as Bernard states, the alcoholic fermentation cannot occur in 
the organism because its proper ferment, yeast of beer, must be absent, by the same 
logic, the lactic acid fermentation cannot take place in the normal blood or liver, though 
possibly occurring as a pathological phenomenon. 
Lactic acid is commonly formed in milk by a modification of its lactose, attendant 
upon exposure to the air at moderate temperatures in the presence of albuminoids. For 
its manufacture on a large scale, sugar is dissolved in boiling water, to which sour milk 
and tartaric acid are added ; rotten cheese is then thrown in as a ferment, and a quan- 
tity of chalk to combine with the acid as soon as formed. The whole is exposed to a 
temperature from 86° F. to 95° F. for ten days, and the lactic acid afterward separated 
by treatment with sulphuric acid. 
Free lactic acid normally exists in the muscular tissues-enough, it is said, to neu- 
tralize the entire alkalinity of the blood ; what is its source ? Lactic acid exists in the 
chyme as a normal constituent, according to some observers, being due to a conversion 
of glucose formed from starch by the saliva. If not over-abundant, it is neutralized by 
the alkaline secretions poured into the intestine below the pyloric orifice, like the acid 
phosphates of the gastric juice, and absorbed as a lactate. The lactates, like the malates, 
citrates, tartrates and acetates, are easily converted into carbonates by oxidation in the 
blood ; lactic acid, consequently, cannot exist as such in that fluid, at least in the normal 
state and while the oxidizing power of the corpuscles is undiminished. It has never 
been demonstrated in the liquor sanguinis. " All attempts to detect lactic acid in the 
blood have signally failed," says Lehmann. Nevertheless, I am inclined to agree with 
Ziemssen, when discussing the relations of lactic acid to polyarthritis acuta, that we may 
■readily conceive that lactic acid may effect certain changes in the tissue before it is 
oxidized. With this admission, a momentary presence of lactic acid in the circulation 
may be imaginable, although it would be more reasonable to suppose that through 
faulty hepatic action, which indubitably exists in rheumatism, the glycogen of the liver 
is abnormally converted, giving rise to lactic acid to some extent only as a pathological 
product. This will be presently considered more carefully. 
It does not, therefore, seem at all probable that the lactic acid of the muscle juice 
can be derived from the stomach or intestinal canal. 
A small proportion of hepatic glucose is now admitted to be present even in cen- 
tripetal venous blood. This quantity is notably increased during digestion, and it 
might be affirmed that the muscular lactic acid is derived from the glucose. It must 
not be forgotten, however, that the muscles contain a small quantity of sugar more 
nearly allied to lactose than to glucose or hepatic sugar. Inosite does not ferment into 
alcohol and carbonic acid, nor does it reduce the salts of copper. Glucose exists in the 302 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cephalo-rachidian fluid, but we do not find that it exhibits any tendency toward a 
conversion into lactic acid. 
Although the hypothesis of the lactic acid fermentation of glucose in the blood has 
generally prevailed, apparently in deference to the views of Bernard, I have been quite 
unable to discover any experimental or pathological foundation for it. Cantani's treat- 
ment of diabetes was based upon this hypothesis, and its temporary success would 
appear to substantiate it. Cantani assumed that by supplying lactic acid to the econo- 
my as an oxidizable substance, for purposes of calorifaction, in quantity sufficient for 
its needs, the progressive emaciation due to the incessant consumption of fats and 
albuminates might be arrested, and the characteristic subnormal temperature of diabetes 
elevated to its normal standard. He therefore proposed to administer lactic acid in 
quantities sufficient to accomplish these objects, but found himself limited, by the intol- 
erance of the stomach and system to this remedy, to from 77 to 154 grains per diem. 
This was all that could be taken, a quantity wholly inadequate to accomplish the results 
arrived at, representing not more than five per cent, of what is normally assimilated in 
the form of carbohydrates, and quite insignificant as a calorifacient addition to the food. 
Cantani, however, simultaneously administered small quantities of pure alcohol, and 
rigidly excluded starchy and saccharine food, allowing his patients only an exclusive 
meat diet, a mode of treatment long ago established as fundamental, and, with the 
alcohol allowed, quite adequate to account for the improvement of his patients. The 
skim-milk treatment was also based upon the same theory, and, like all systems of 
treatment where starch and sugar are withheld, has been of decided though usually 
only of temporary benefit. In the hands of Balthazar Foster a trial of this lactic acid 
treatment, after Cantani's method, produced in two patients most sharply defined 
attacks of acute rheumatism, in one of them so constantly ensuing upon repeated 
administrations of the acid, and so constantly disappearing after its suspension, that it 
was impossible to ignore so plain an etiological sequence. The patient was able to take 
only two drachms of the acid daily after persistent attempts, a quantity utterly unworthy 
of notice as a pabulum for the systemic heating processes. Indeed, Foster remarks that 
the facts developed in these two cases had dispelled the " last lingering doubts " in his 
mind as to the truth of the lactic acid theory of rheumatism. 
Ziemssen, in commenting upon this hypothesis, alludes to Foster's cases, and states 
that ' ' Kiielz has quite recently observed the same phenomenon in a diabetic patient 
under treatment for diabetes with lactic acid. " Ziemssen satisfactorily invalidates the 
negative experiments of Richardson upon healthy rabbits, cats and dogs, as well as 
other objections to the causative influence of lactic acid in the development of acute 
rheumatism, by calling attention to the obvious necessity of the simultaneous existence 
in the economy of various predisposing influences, and strongly endorses this lactic 
acid hypothesis of rheumatism, as follows : " The above considerations appear to indi- 
cate that the theory of an accumulation of lactic acid in the system deserves more 
attention in relation to the pathology of rheumarthritis than has been hitherto accorded 
to it. It is well worthy of being tested further, both by experimentation and by clini- 
cal observation." 
The presence of products of the uric acid type in abnormal abundance in the system 
during rheumatic fever indicates that the functions of the liver are seriously perverted, 
and it becomes quite possible that the glycogenetic function may be simultaneously 
modified, so as to cause a deviation from the normal processes by which glycogen and 
glucose are transformed, so that a formation of lactic acid may become established as a 
pathological process, in concurrence with the acute lithæmia. The successful employ- 
ment of alkalies alone, and of these in conjunction with colchicum and the salicylates, 
points to the effective neutralization of acid substances in the blood, and to an abatement 
and modification of morbid trains of action occurring in the liver, for the salicylates SECTION VIII PHYSIOLOGY. 
303 
undoubtedly control the processes of heat formation which are known to occur in that 
organ, and must, therefore, affect the secretory acts of the liver, both qualitatively as 
well as quantitatively. 
It may be also remarked that there is no natural desire among animals or in man 
for lactic acid, and there exists, on the contrary, a very marked intolerance to it. 
Lactic acid is a very powerful acid, capable of decomposing the chlorides even with the 
aid of heat, and some chlorides at common temperatures. When injected into the 
blood, it acts like other acids, destroying life long before the alkalinity of the blood is 
overcome. (Bernard, " Leçons," p. 236.) While, therefore, physiological considerations 
fail to substantiate the occurrence of the lactic acid fermentation of glucose within the 
economy, pathological and therapeutical observations furnish us with good reasons for 
regarding this process as a morbid one, which may be set in motion by certain func- 
tional perversions of hepatic action. 
From a priori considerations, on the other hand, the possibility of the occurrence of 
the alcoholic fermentation of hepatic glucose is very reasonably admissible. As has 
been stated, Bernard emphatically rejected this hypothesis because "beer yeast, the 
proper ferment of sugar, must, necessarily, be absent from the economy. ' ' I have care- 
fully verified this statement, also observing that the animal may be saved from death by 
an almost instantaneous thrombosis of the vein into which the mixture of yeast with water 
is injected; sugar alone may be injected into the veins with impunity. Bernard is, 
however, in error in defining beer yeast as the proper ferment of sugar, as yeast ranks 
only as the most potent form of ferment yet discovered for the induction of the alco- 
holic fermentation. It is not employed in nature for this purpose, and we may observe 
numerous instances in which this fermentation is accomplished without it. " Muscular 
flesh," says Régnault, "urine, gelatine, white of eggs, cheese, gluten, legumin, 
extracts of meat and blood, left to themselves for some time, exposed to air and mois- 
ture, cause sugars to ferment and convert them into alcohol and carbonic acid." 
In distinct cells of the ripened grape are contained a saccharine fluid and an albumin- 
ous material, which are kept apart and exert no influence upon each other as long as the 
fruit is fresh and uninjured. When, however, the envelopes of these juices are broken, 
they become commingled, and enter into regular fermentation, sometimes within thirty 
minutes. If a bunch of ripe grapes be expressed, one by one, under a bell glass filled 
with mercury and reversed over it, the juice rising into the glass remains unchanged 
for any length of time, but if a globule of air be admitted, the liquid begins forthwith 
to ferment. Wine of all kinds, therefore, is produced by the fermentation of sugar 
without yeast. Indeed, the juice of any vegetable which contains sugar and an albu- 
minous matter will take on the alcoholic fermentation by simple repose at moderate 
temperatures. The chica mascada of South America is made by the action of the saliva 
upon partly masticated maize. When a certain quantity has been duly ground 
between the teeth of the natives, it is placed under ground, and by the agency of the 
albuminous matter of the grain, and some further change, probably of the salivary 
ptyalin, is converted into an intoxicating liquid. The juice of the agave furnishes 
the Mexican pulque ; that of the sugar cane the guarapo of the West Indian negro; of 
the spadix of the palm, the East Indian palm wine or toddy; of apples, cider, and of 
pears, perry, etc. In these and in other instances yeast is not required; yeast is 
employed in the arts because it is the most effective agent known for the induction of a 
prompt and complete alcoholic fermentation in saccharine fluids prepared by artificial 
processes, as malted infusions of grain or solutions of molasses or honey. Such liquids 
will, however, ferment spontaneously at a later period if left unyeasted. I have found 
that saccharine fluids made by boiling finely-ground grain with dilute acids ferment 
quite as well without yeast as with it, though at a later period. Thus, such a mixture 304 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
when yeasted will begin to ferment within five or six hours, at a temperature of 75° F., 
but only after from twenty-four to thirty-six hours if left without yeast. 
Yeast, therefore, is not necessary for the accomplishment of the alcoholic fermentation ; 
albuminoid ferments of various origin are capable of inducing this fermentation. The 
truth may be, perhaps, more exactly expressed by saying that many different albumin- 
oids seem to be able to assume a polar condition during a progressive molecular change 
tending toward putrefaction, by reason of which they become capable of exciting the 
alcoholic fermentation, which polar state is similar or the same in all of them. It may 
be said that this fermentation cannot occur without the presence of the wi icrococeus 
cerevisiæ ; to this may be answered that while the unfailing attendance of the 
micrococcus upon the alcoholic fermentation is indisputable, so far as the process has 
been observed in saccharine fluids out of the body or even in diabetic urine, the relation- 
ship of the microscopic plant is not yet established to the alcoholic fermentation. The 
question here touches upon the germinal doctrine, which I prefer to disregard in this 
connection, because, in the first place, it is very distinctly upon trial in the scientific 
world as to the facts supporting it; and secondly, because in this place the question is 
between the existence in the organism of one or the other of two modes of the fermenta- 
tion of sugar, one of which undoubtedly occurs, while both are supposed to be induced 
by germinal influences, by those who accept the germinal hypothesis, although no one 
has ventured to assert that a micrococcus of any kind is present or active in the alleged 
transformation of glucose into lactic acid in the general blood mass. As it is, therefore, 
out of the question to argue with respect to either of these hæmal fermentations from 
a germinal point of view, I have preferred to do so from a Liebigian standpoint, which 
I beg leave to say, to my mind, affords us incomparably broader and more scientific 
views of these intricate and little understood phenomena. We must bear in mind that 
there are several stages in the conversion of starchy matters either into lactic acid or 
into alcohol and carbonic acid. Any given ferment is competent to guide the amyla- 
ceous matter through more than one of these stages; so, likewise, are acids, which not 
only cause starch to pass into dextrine, but also convert the dextrine into sugar. There 
exist abundant reasons for believing that the ferments which change starchy matters into 
dextrine, and thence into sugar, may, likewise, perhaps progressively changed them- 
selves, cause a still further conversion of the saccharine matter formed either into lactic 
acid or into alcohol and carbonic acid, under conditions which we may note, but which 
we certainly do not comprehend. Such a progressive action of the hepatic or blood 
ferment must be invoked under the lactic acid hypothesis of saccharine conversion 
in the blood, and equally so under that of the alcoholic fermentation. 
If alcohol is a physiological constituent of the blood, why, it might be asked, do we 
not find it, like starch, the sugars and 'the vegetable acids, in fresh saps and living 
plants and seeds ? The reason is one, apparently, which underlies the relationship of 
the animal to the vegetable kingdom. Alcohol is the product of a metamorphotic 
change by which force, in the form of heat, is extricated. The liberation of force within 
the animal organism is fundamentally subservient to its functions ; it would, therefore, 
be a plain violation of natural harmony, if this force-giving process (fermentation) 
should occur before the matters used as food are taken into the animal body. It is 
desirable that this fermentation, with its attendant heat and the production of an easily 
oxidizable matter, capable of furnishing still further supplies of heat, should occur 
within the animal body, for the sustentation of its proper temperature. Consequently, 
the alcoholic fermentation does not occur in the vegetable world as a normal process, 
but only in such fruits and juices as are exposed to the air, or whose investing textures 
are broken. The unfermented ripe fruit or grain is sought by animals, invited, so to 
speak, by nature to partake of it, and so aid in the continuation of the plant species by SECTION VIII-PHYSIOLOGY. 
305 
distributing the seeds imbedded in saccharine pulp. The alcoholic fermentation is a 
process of destructive metamorphosis, of the conversion of colloids (starch and dextrine) 
into crystalloids (sugar, alcohol aud carbonic acid), and therefore belongs essentially 
to the animal kingdom, and should naturally occur in animal bodies. The functions of 
plant life, on the other hand, are constructive, crystalloids being compounded into 
colloids, and thereby strictly opposite and complemental to the processes of animal 
nutrition. While, therefore, the starch and sugar, and eventually even the nitrogenous 
matters of the food of animals are the source of glycogen and glucose, and of alcohol, 
in the destruction of this last-named body, alcohol itself is nowhere found in living 
plants. 
I have adverted to Bernard's studies of the glucose and lactic acid found in the 
lungs and muscles of fœtal calves. It would seem that the sugar formed from the 
glycogen of these structures is as distinctly prone, to say the least, toward the alcoholic 
fermentation as toward the lactic, especially if the temperature be somewhat high. We 
find in the "Leçons" the following important note upon this point: "The muscles 
and lungs of fœtal calves (not older than the fourth month of gestation) are washed and 
immersed in water enough to cover them. In order to prevent a rapid lactic fermenta- 
tion, so that the intermediate presence of sugar might be recognized, a fourth or a third 
of alcohol was added to the water. (Alcohol possesses the power of preventing the lactic 
acid fermentation, while it does not arrest the alcoholic.) By the next day the liquid 
becomes charged with sugar. We find then, upon collecting the air imprisoned in the 
flask, especially if the temperature be elevated, that a disappearance of oxygen and 
formation of carbonic acid has taken place. This gas cannot come from the lactic fer- 
mentation, which consists simply in the fixation of an equivalent of water by the sugar. 
Does it arise by the saccharine (glycosique) fermentation at the expense of the organic 
matter? We cannot determine this at the present time." (Loc. ci/., p. 382.) It is 
very plain that the carbonic acid in question must have been derived from the alcoholic 
fermentation, the oxygen having been absorbed in the process of acétification ensuing 
at the elevated temperature named. (I am now experimenting upon this point, and 
will report the results in this paper before its publication.) The lactic acid fermenta- 
tion coincided with the later stages of the alcoholic, and the acidity observed at the end 
was probably due both to acetic and to lactic acid. 
Bernard has shown that the lymph of the thoracic duct at its entrance into the sub- 
clavian vein is normally saccharine, in consequence of the addition of lymph containing 
sugar brought by the hepatic lymphatic vessels. The large lymphatics belonging to the 
deep set, which emerge from the transverse fissure of the liver to join the lacteals, 
always contain sugar in healthy animals, derived by direct absorption from the hepatic 
stroma. Cruveilhier observes, with regard to these vessels, 11 They are often filled with 
yellow lymph, and are sometimes found distended with gas in cases of commencing 
putrefaction." This gas can be no other than carbonic acid, and of course implies a 
previous alcoholic fermentation of the hepatic sugar under the influence of ferments 
present or originating in the body. I shall detail further on some experiments showing 
that the alcoholic fermentation arises spontaneously in the liver and fluids derived from 
it long before putrefaction begins. 
Finally, we must notice the extraordinary appetite for alcohol which exists in the 
animal kingdom when once a knowledge of this substance is acquired. Moreover, a 
most remarkable tolerance for alcohol naturally exists, and is easily acquired for very 
large quantities. Such large quantities, within certain limits, have been shown, by 
Binz, Anstie and Dupré, to entirely disappear in the organism. A remarkable appetite 
exists, likewise, for saccharine substances, which are especially craved and sought after 
by all classes of animals, the dissemination of seeds and fructification of flowers being 
dependent more or less upon this instinct for sweets. A similar craving for acetic 
Vol. Ill-20 306 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
acid, in man at least, is very widely diffused. Sugar in many forms and several 
varieties, alcohol in numerous combinations, and acid preparations containing vinegar 
are so commonly used as food that they form items in the diet allowed to soldiers by 
all civilized nations. It is evident that so marked an inclination and tolerance must 
be based upon the occurrence of intra-systemic processes in which these matters play 
some important part. 
On the other hand, lactic acid is badly borne by the stomach ; tolerance of it is 
difficult to acquire, except in small quantities, and wholly impossible in quantities 
adequate to administer to the processes of heat formation. Its presence in the stomach 
in notable quantity, as in acid dyspepsia, is followed by chronic inflammation of the 
organ, while great pain is experienced as long as the food remains in the stomach and 
often during the transit of the imperfectly neutralized mass through the small intestine. 
I have cited Bernard's experiments upon the disappearance of sugar in samples of 
blood submitted to the action of various gases, from which he concluded that sugar dis- 
appears in the blood by some kind of fermentative movement, at the same time 
rejecting all hypotheses of direct oxidation. I determined to review these experiments, 
and to extend them by ascertaining how sugar comports itself in blood and liver tissue 
maintained at the temperature of the animal body, whence it was derived. Experi- 
menting in this direction, I have obtained the following results :- 
Sugar gradually diminishes in quantity in samples of mixed thoracic ox blood, 
which always contains it at ordinary temperatures, though it may be recognizable after 
several days. 
The sugar disappears more rapidly as the temperature is more elevated. Thus, 
at a temperature of 53° sugar may not be destroyed after ninety-six hours, while, at 
a temperature of 55.5° it may totally disappear after ninety hours. In another sample 
sugar disappeared at 63° almost entirely, after forty-four hours. The disappearance of 
the sugar was seldom complete before signs of incipient putrefaction occurred, though 
by far the greater portion of it had disappeared. Thus, sugar may quite disappear at 
a mean temperature of 55°, while as yet, even after four days, no signs of putrefaction 
have become manifest. 
The disappearance of the sugar is due to influences which antedate putrefaction ; 
whether they are intrinsically similar or not it is not possible to affirm positively. 
Sugar progressively increases during twelve hours or more in liver tissue, at tempera- 
tures between 50° and 66° ; it is then destroyed by a slow fermentation, with the 
formation of a considerable quantity of acetic acid. At higher temperatures, from 80° 
to 90°, an unmistakable alcoholic fermentation sets in within the substance of the tissue 
when no water has been added to it, after a lapse of from twelve to fifteen hours. Sugar 
does not promptly disappear in liver tissue, even after putrefaction is fairly established ; 
the li ver first becomes highly acid, and contains a large amount of acetic acid. 
When we add enough water to cover a mass of liver tissue, at a temperature of about 
84°, the following changes are noted : After two or three hours the liver tissue changes 
color, becoming whitish, and bubbles begin to form upon its cut surfaces. These increase 
in number, the water becomes covered with froth, and after four or five hours a 
tumultuous alcoholic fermentation is established, which completes its course with extra- 
ordinary rapidity, in not more than three hours. The liquid soon becomes acid from 
the development of acetic acid. Alcohol can be recovered from it by distillation, in 
small quantity only, while the presence of much acetic acid is demonstrable. All these 
phenomena occur before the least development of putrescence takes place. The con- 
version of the original glycogen evidently continues, and the resulting sugar dissolved 
partly in the water covering the mass, and also remaining in the substance of the liver, 
passes rapidly into a most tumultuous alcoholic fermentation, and almost simultaneously 
into the so-called acetic fermentation of the alcohol formed. These phenomena seem to SECTION VIII PHYSIOLOGY. 
307 
occur in virtue of a special proclivity toward the alcoholic fermentation proper to the 
solids and juices of the liver. 
When sugar-bearing blood is maintained at its somatic temperature, sugar disappears 
in from three to five hours. Thus, in one case, at a temperature of 105°, it disappeared 
in about three hours ; in another at the same temperature, after four hours ; in a third 
at a temperature of 105.3°, within five hours ; in a fourth case, at temperatures between 
103° and 105°, after four hours ; in a fifth experiment, in which sulphureted hydrogen 
had been passed through the blood, the sugar disappeared in three hours and fifty min- 
utes. The disappearance of the sugar was in no obvious way hastened or retarded by 
the treatment with sulphureted hydrogen. 
I found, as Bernard had done, that the disappearance of the sugar was evidently due 
to a fermentative movement, unaffected by the oxidative qualities of the blood, occur- 
ring, therefore, without perceptible modifications, whether the blood was treated in 
closed vessels, with frequent agitation, in contact with oxygen, sulphureted hydro- 
gen, carbonic acid or air. The disappearance of the sugar at somatic temperatures 
I have invariably found complete before anything like putrefaction had begun ; in blood 
containing sugar so treated, the reaction of a clear extract, made after the disappear- 
ance of the sugar, is neutral or faintly acid. 
Proceeding to study the behavior of exsected liver tissue at its somatic temperature, 
I observed that the phenomena already noted as occurring when the tissue was immersed 
in water enough just to cover it, at an atmospheric temperature of 80° to 90°, became 
still more marked and set in earlier. As this is a typical experiment, I quote it entire. 
Object : To test the phenomena of the disappearance of sugar in liver-tissue, maintained, 
as soon as practicable after exsection, at its somatic temperature. 
February 28th, 1876, 2.20 P.M. Ox struck down ; a thermometer plunged into the 
centre of the liver at the moment of its extraction registered 106°. Temperature of the 
liver when received, forty minutes later, 80°. Sugar abundant. 
3 P.M. Eight ounces of this liver tissue was placed in a covered beaker with an 
equal quantity of distilled water, the whole being set in a water bath. The liver was 
in one piece. 
3.10 P.M. Temperature of the liver 106°. A portion tested is very rich in sugar. 
As 106° was the somatic temperature of this liver, it will be maintained at that tem- 
perature. 
3.45 P.M. The reaction of the liver is neutral ; it sinks in the water. 
5.15 P.M. Two hours after elevation to the somatic temperature have elapsed. The 
supeijacent liquid is already distinctly acid. 
6 P.M. Sugar is abundant in a morsel of tissue taken from the middle of the mass. 
The temperature is steadily maintained. 
9 P.M. Sugar is far more abundant. (These comparative estimates were reached 
by using equal portions of the solid or fluid matters, and comparing the color after boil- 
ing with Fehling's test and the depth of the sediment.) The supernatant liquid is still 
more acid. (The following remarkable phenomena were then there observed.) A fer- 
mentative movement is in full progress. The liver masses have swollen greatly. The 
circumnatant fluid, at first sanguinolent, though transparent and without flocculence, is 
now full of large flocculi, which are driven about by the commotion of the liquid. The 
surface of the liquid is covered with a whitish scum, like that seen on the surface of a 
brewer's vat. The bottom of the beaker is strewed with masses of coagulated matters 
and liver débris, some of which rise quickly to the surface, borne by entangled bubbles 
of gas, and fall again when this escapes. The masses of liver have quite changed color, 
being now whitish, and they yield a whitish froth when a cut surface is squeezed. The 
contents of the hepatic vessels are forced out spontaneously as a similar whitish foam, 
from the recesses of the tissue, by the pressure of the gas generated within it. Where 308 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
a cut surface lies iu contact with the wall of the beaker, it is seen through the glass to 
be covered with innumerable fine bubbles, evidently springing out of the liver tissue 
itself. The liver is plainly the seat of a tumultuous fermentation advancing in the 
recesses of its tissue. 
10.15 p.M. The fermentative commotion is still more marked. A lighted match 
put under the glass plate covering the beaker is suddenly extinguished. The liver is 
now quite acid to test-paper. It crepitates between the fingers, showing the presence 
of gas, and the advance of the fermentation in its interior. Sugar was not tested lor 
again. 
The liver masses and circumnatant fluid were placed in a distillatory apparatus 
over a bath of common salt and distilled. The first few drops of the primary distillate 
were strongly acid, and this acidity continued for some time as the distillation pro- 
gressed. Acetic acid was present in the distilland. The final distillate assumed a 
bright green tint when tested with chromic acid dissolved in sulphuric acid, but the 
alcohol was in very minute quantity, having evidently been lost by acétification. In a 
second experiment, a portion of liver which had been submitted to a temperature of 
61° on an average, for sixteen hours, was found to be still richer. At this time its reac- 
tion was neutral or faintly alkaline; it emitted no odor whatever, nor were there any 
bubbles or scum upon the liver itself or on the distilled water in which it was 
immersed. 
Feb. 29th, 1876, 10 A.M. Under these conditions about three ounces of this liver 
tissue, with most of the superjacent liquid, was placed in a beaker set in a water bath 
and maintained with great care at 106°, which was the somatic temperature to the 
liver. 
12.45 P.M. Froth begins to form on the edges of the liquid. 
1.10 P.M. Fermentation plainly commencing. 
2 P.M. Fermentation in full progress. 
4 p.M. Liver in full fermentation, which also advances in the circumnatant fluid 
quite as actively as if it had been an artificial solution of sugar to which yeast has 
been added. Reaction strongly acid. The temperature (106°) is steadily maintained. 
By a small pneumatic contrivance three-fourths of the capacity of a large test-tube of 
the gas evolved was collected. It instantly extinguished a blazing splinter of wood ; it was 
carbonic acid. 
5 P. M. The fermentation is over. 
8 P.M. Upon trial, sugar has entirely disappeared. A portion of the circumnatant 
fluid which had not been boiled was treated with freshly calcined animal charcoal; 
filtered; boiled in a test-tube firmly closed by the thumb; filtered anew through animal 
charcoal; came through perfectly clear; tested with the chromic acid alcohol test, the 
fluid became at once of a vivid emerald green without further heating than that attend- 
ant upon the addition of the test (which contains sulphuric acid) to the filtrate. Alco- 
hol was, therefore, present in considerable quantity. By distillation the acidity was 
shown to be due to a volatile acid coming over with the very first portion of distillate; 
it was consequently acetic acid. This distillation was not, however, pushed further. 
The fermentation observed in these experiments, and since in similar ones, was evi- 
dently the alcoholic; not to any appreciable extent the lactic, which evolves no gas, and 
is never accomplished with the tumultuous vigor noted in these cases, where the fer- 
mentative movement was almost explosive in violence. The gas evolved in such large 
quantities was carbonic acid. The presence of alcohol in the masses of liver and in the 
fluid around them was determined by the chromic acid test; but I must call particular 
attention to the fact that the quantity of alcohol was very small, greatly less than would 
have been recovered from a decoction made with an equal weight of the same liver 
tissue and fermented with yeast at a moderate temperature, e. g., about 65° to 70°. The SECTION VIII-PHYSIOLOGY. 
309 
diminution of the alcohol must have been owing to acétification at the high temperature 
maintained, the extent of the alcoholic fermentation itself having been shown by the 
very large amount of carbonic acid thrown off. 
The sugar did not disappear, as in saccharine blood, but became more and more 
abundant, in virtue of the conversion of glycogen into glucose, the latter substance, even 
in the midst of the liver, passing at once into the alcoholic fermentation. 
The presence of a ferment or of a fermentative disposition in the blood of the liver 
capable of converting glycogen into glucose at somatic temperatures, had been affirmed 
by Bernard ; he took no note, however, of the effects of temperature upon these pro- 
cesses. The experiments detailed, which I have frequently repeated, illustrate the 
great influence which temperature exerts upon them. They also show that the alco- 
holic fermentation in the liver ensues directly upon the saccharification of the glycogen; 
if the temperature is high enough, with tumultuous violence; but, as I shall presently 
show, without any specially marked phenomena, if the temperature be low; in both 
cases, however, with the formation of some acetic acid. At high temperatures the forma- 
tion of acetic acid is excessively rapid in these liver masses, and the change would 
appear to be induced by the same ferment which caused the conversion of the glycogen 
into glucose and this latter into alcohol and carbonic acid, in a more advanced and con- 
sequently modified stage of molecular change, and, consequently, of catalytic effi- 
ciency. 
It must be borne in mind, though not generally known except as a scientific fact, 
that the alcoholic fermentation will progress regularly and with extraordinary rapidity 
at temperatures even of 120° to 130°, high enough for the fermenting fluid to boil, when 
the pressure of the atmosphere is removed. Processes have been devised for removing 
alcohol from fermenting liquids by the air pump, as fast as it is formed, in order to 
avoid the influence of the alcohol itself in the fermenting liquid in arresting the con- 
version of the last portions of sugar. This plan has proved perfectly feasible, but can- 
not be conducted except in conjunction with the vacuum pump, which delivers the 
alcoholic vapors over to a condensing apparatus, because at the high temperature 
employed, if air were admitted, a concurrent acétification would destroy the alcohol as 
soon as formed. Whenever the alcoholic fermentation is accomplished at a temperature 
above 60° to 65°, there is a concurrent acétification, which becomes more marked as the 
temperature rises, and becomes most effective at 100° and upward. When we ferment 
large masses of wort made by boiling grain with dilute acids, the nitrogenous principles 
being thoroughly dissolved, and in some way rendered exceedingly oxidizable by the 
prolonged action of the dilute mineral acid, the process of fermentation, once kindled, 
runs a violent course, often in a few hours, if it is not restrained by cooling apparatus. 
I have often seen such masses rise in temperature from 60° to 80° or 90°, with the inevi- 
table loss by acétification of three-fourths of the alcohol. At lower temperatures the 
alcoholic fermentation proceeds more slowly and the sugar is more completely converted, 
while the oxidative process we term acétification is entirely checked below 60°. Even 
at high temperatures, this process of acétification is one which experience has shown to 
be very promptly affected by a slight decline in temperature, a fact always carefully 
considered in the conduct of processes for making vinegar. 
The accomplishment of the alcoholic fermentation with a concurrent acetifying pro- 
cess in perfectly fresh liver tissue, at the temperature of the animal body, determined 
in the foregoing experiments, affords us strong reasons for inferring that similar phe- 
nomena take place during life as normal manifestations, for we know that many fer- 
mentative movements occurring soon after death, as the action of the ferments of the 
intestinal canal, the post-mortem digestion of the stomach, etc., are really continuations 
of proper vital processes. In the liver this has been proved to be true beyond any sort 
of doubt, for the conversion of glycogen into glucose occurs in the most marked manner 310 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
after exsection of the liver, which hour by hour becomes more charged with sugar up 
to a certain point, the post-mortem conversion being plainly a continuation of that in 
continual progress during life. Hence, it appears safe to conclude, that inasmuch as 
soon after death and before decomposition begins the glucose is fermented and its pro- 
duct acetified within the substance of the liver, the same phenomena occur in the liver 
and in the blood, which bears away the hepatic glucose and is impregnated with the 
hepatic ferments or retains the fermentative proclivities imparted to it in the liver. 
I must still further direct attention to facts which I have long since ascertained, viz., 
that the tissue of the liver possesses remarkable powers in exciting the fermentation of 
saccharine solutions and in saccharifying starch. If to a mass of dough a small quan- 
tity of pulped, uncooked liver mixed with a little water be added, and the whole main- 
tained at about 80° F., after seven or eight hours the dough is filled with bubbles, 
becoming excellent yeast, capable of making porous and wholesome bread. When, 
again, a little pulped liver tissue is added to a solution of sugar, at the same tempera- 
ture, in about four hours the liver tissue is seen to undergo that intrinsic alcoholic 
fermentation which I have described. This passes by in a few hours more, but after the 
lapse of from twenty to thirty hours from the beginning of the experiment, the alco- 
holic fermentation sets in vigorously in the saccharine solution, and advances as regu- 
larly and as satisfactorily as if yeast had been added. Nothing of this kind occurs with 
the muscular tissue or with the tissue of the lungs. The following comparative experi- 
ment illustrates these remarkable properties of the tissue of the liver :- 
August 15th, 1887, temperature air, 88°, 2.15 P.M. 
No. 1. Into a solution of glucose (18° Baume) a cubic centimetre of fresh compressed 
yeast was placed, and mingled with it. 
No. 2. Into a similar solution of glucose two cc. of calf's liver pulped with a little 
water was placed. 
No. 3. Into a solution of sugar of milk a similar quantity of liver tissue was 
stirred. 
No. 4. Into a solution of sugar of milk a similar quantity of yeast was placed. 
No. 5. Into a solution of cane sugar two cc. of liver tissue was placed. 
No. 6. Into a solution of cane sugar two cc. of the same compressed yeast was 
placed. 
No. 7. lu an equal quantity of water two cc. of pulped liver tissue was placed, as 
for control. 
No. 8. In an equal quantity of water two cc. of the same compressed yeast was 
placed, as for control. 
No. 9. Four cc. of the same liver tissue was pulped with a little water (two tea- 
spoonfuls), and incorporated with a certain quantity of dough, enough to half fill a glass 
goblet. 
No. 10. Four cc. of the same yeast was mixed with the same quantity of water, and 
incorporated with another portion of the same dough in equal quantity. 
No. 11. A similar quantity of the same dough was set aside, as for control. 
No. 12. Into a solution of glucose (18 Baumé) two cc. of the muscular tissue of beef, 
first pulped, was placed. 
No. 13. Into a solution of glucose (18 Baumé) two cc. of ox-lung tissue, as well 
triturated as possible with two drachms of water, was placed. 
All of the fluids were in equal quantity and contained in tall champagne glasses of 
the same set. All the samples were placed together, side by side, upon a mantel-piece. 
The parcels of dough were placed in glass goblets, which they half filled. 
After forty minutes the yeasted dough had risen to the top of the glass goblet, and 
the experiment was discontinued. 
After one hour and a quarter the yeasted glucose solution was in full fermentation, I 
SECTION VIII-PHYSIOLOGY. 
311 
and soon afterward the yeasted cane-sugar solution, and both of these experiments were 
discontinued. 
After four hours, the temperature of the air having remained unchanged, the pulped 
liver masses lying at the bottom of the glasses containing (No. 2) the glucose solution, 
(No. 7) the water, (No. 5) the cane-sugar, and (No. 3) the sugar of milk, began what 
we may term their intrinsic fermentation. The liver masses changed color, developing 
numerous bubbles in their midst, and rising and falling through the liquids or floating 
for a time on the surface of the saccharine solutions. A very active fermentation of 
these masses, evidently not propagated to the solutions in which they lay, and plainly 
due to ferments originally present in the liver tissue, continued for two or three hours 
and then ceased entirely, the liver masses subsiding to the bottom of the glasses in all 
cases. 
Nothing more was observed until thirty hours had elapsed; the temperature had 
been meanwhile very constant, ranging between 86° and 90° F. The glucose solution 
now began to ferment in mass, with complete regularity, and ran its course in forty- 
eight hours, the liquid having become attenuated to density of 6° Baurné. During the 
fermentation the mycoderma cerevisiæ was found to be very abundant upon microscopic 
examination. 
The solution of cane-sugar treated with liver tissue began to ferment twelve hours 
after the glucose solution (No. 2), and pursuing its regular course, reached an attenua- 
tion of 8° Baumé. 
At the eightieth hour the glucose with beef muscle had not fermented at all, although 
it showed an attenuation to 16° Baumé, or two degrees of the saccharometer. 
The sugar of milk with yeast did not ferment, nor did the sugar of milk with liver 
tissue; nor was any change observable in the solution of glucose with lung tissue, or in 
the control experiment of the yeast placed in water. 
By 10 P. M. of the evening of the first day, i. e., after about eight hours, the dough 
to which the liver pulp had been added was observed to have become fluid, and was 
filled with frothy bubbles throughout its entire mass, possessing an agreeable odor of 
yeast. The other dough remained unchanged for three days, becoming acid and 
acquiring a disagreeable smell. 
We observe that the liver tissue behaved like a true yeast, acting in all respects like 
the beer yeast employed, exciting the saccharine fermentation in dough, and inducing 
the alcoholic fermentation in glucose and cane sugar. Like the yeast, it failed to evoke 
any trace of alcoholic fermentation in the sugar of milk. Neither the lung tissue nor 
the beef muscle appeared to possess any power whatever, even after the lapse of eighty 
hours, at a temperature of 86° to 90°, to excite the alcoholic fermentation in either 
glucose or a solution of cane sugar. 
The odor of the saccharine fluids fermenting under the influence of liver tissue is 
yeast-like and pleasant, while the saccharine fluids into which the portions of lung 
tissue and beef muscle were placed, refusing to ferment, soon acquired a disagreeable 
odor of putrefaction. Hence the liver is remarkable: 1st, for the singular develop- 
ment of its intrinsic fermentation as described, sooner manifested and completed, and 
accompanied with a more intense concurrent acétification of the alcohol produced, as 
the temperature is higher and approaches that of the animal body; and 2d, for the fact 
that its tissue is invested with an ability to excite the alcoholic fermentation com- 
parable to that of the best brewers' yeast in intensity and regularity, though by no means 
so promptly active. It is also evident that the ferment which produces the intrinsic 
alcoholic fermentation of the liver is a different one from that which eventually induces 
this fermentation in saccharine fluids in which the liver is immersed; for the first is 
accomplished and finished twenty or more hours before the second begins. If, there- 
fore, it should be affirmed that the micrococcus cerevisiæ was the cause of the later 312 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fermentation, i. e., of the mass of the saccharine solution, it could not have been the 
inducing agent of the intrinsic liver fermentation, else the first fermentation would 
have been continuous with the second, while in reality there was a distinct interval of 
repose of twenty hours between the two fermentations. 
Considerations like those I have detailed, led me long ago to believe that a fermenta- 
tion of hepatic glucose into alcohol and carbonic acid normally progresses in the 
animal body. It had been my privilege to attend the courses of lectures given by 
Claude Bernard in 1852 and 1853, and after my return to America I began to con- 
sider this question of the disappearance of sugar in the economy, which he had 
not fully analyzed. Such reasons as I have given led me to regard the lactic acid 
hypothesis as quite insufficient to explain the facts, and I soon determined to test 
the matter experimentally by submitting the blood and tissues of animals to careful 
concentrative distillation, hoping to procure alcohol in definite form thereby, if this 
substance is really present in the economy. The working hypothesis under which I 
proceeded, accordingly, to conduct the series of experiments involved, was the one 
already suggested in this paper, viz., that hepatic glucose is fermented in the blood 
into alcohol and carbonic acid; that the carbonic acid is exhaled by the lungs and 
skin, and that the alcohol is oxidized by a process akin to that occurring when the 
vapor of alcohol, mixed with air or oxygen, is acted upon by platinum black; the 
phenomena of oxidation being also similar to the one known in the arts as the " quick 
vinegar process," while beyond this point the oxidative sequence was probably the 
one chemically normal to alcohol destroyed by slow combustion, viz., the successive 
formation of formic acid, oxalic acid, and carbonic acid and water. 
Considering the normal high temperature of the body, the formation of alcohol and 
its acétification and further oxidation must be parallel processes, simultaneously active, 
the alcohol scarcely existing as such in the blood, or only in very minute quantity, being 
consumed by oxidation as fast as formed by fermentation. It would still, how- 
ever, be possible to imagine that the alcohol might exist in a recoverable form for a 
moment of time, during a portion of the blood transit, or possibly a round or two of 
the circulation, for, although sugar is destroyed in the blood, it may, nevertheless, be 
detected even in the venous blood derived from the systemic capillaries, as Bernard has 
demonstrated. Especially might it be possible to procure alcohol from the blood, if 
the unceasing oxidative process in which it was assumed to be destroyed could be arti- 
ficially abated or arrested; and as this occurs by the arrest of respiration accompanying 
the slaughtering of animals, and also by the mere fact of withdrawing the blood from 
its vessels, the function of the lungs being thereby pretermitted, I thought it not 
improbable that in the blood of the lungs remaining in those organs after death, as 
well as in masses of blood collected from the throats of slaughtered animals, I might 
reasonably expect to recover a certain small quantity of alcohol which had been formed 
by normal processes, but which had not been destroyed, as it normally should have 
been, in consequence of the arrest of the oxidative processes under the conditions 
designated. 
At the same time I became aware, from certain calculations, that even if oxidation 
were in complete abeyance the quantity of alcohol existing at any given moment of 
time in the blood must be very minute indeed, as the rapid motion of the blood must 
quickly disseminate whatever might be present throughout the system or through 
extensive networks of capillary vessels, and that this must be the case, although this 
minute quantity of alcohol really represented the entire quantity of these proximate 
elements of the food, which, as we know, are subservient to the glycogenetic function 
Moreover, as it is out of the question to test the fluids or solids of the animal body 
for alcohol within a few minutes or even seconds, as we may do for saline bodies or for 
sugar, and as the organs and blood must first be extracted carefully, and then, after SECTION VIII-PHYSIOLOGY. 
313 
some inevitable delay, brought to the boiling point, some time must elapse, during 
which the vital chemistry of the organs concerned may most reasonably be assumed to 
remain unchanged. This period of inevitable delay, therefore, would allow of the for- 
mation of a small quantity of alcohol under conditions adverse to the accomplishment of 
that elaborate process of oxidation to which we know that substances are subjected in 
the circulating blood stream. I might reasonably expect, therefore, to obtain by distilla- 
tion a certain quantity of alcohol formed after death and before exsanguination or exsec- 
tion of the organs, and also an additional quantity formed by a continuance of normal 
action during the period of time elapsing between extraction of the matters operated 
upon and their elevation to a temperature capable of arresting all fermentative move- 
ment. It is not to be supposed, however, that the quantity of alcohol can ever equal 
what is assumed to be normally formed in a given time, for the arrest of oxidation, in 
the form of acétification at least, cannot be supposed to be complete, as the blood remains 
charged with oxygen and retains its temperature for a considerable period after extrac- 
tion, as both the liver and lungs, in man, do likewise. 
But first, it is worth while to determine what this theoretical quantity of alcohol 
present in the blood at any given time may be, oxidation being supposed absent. 
"From the accurate determination of the quantity of carbon daily taken into 
the system in the food, as well as that proportion of it which passes out of it in 
the faeces and urine in some form in which it is not combined with oxygen," says 
Liebig, "it appears that an adult taking moderate exercise consumes 13.9 ozs. of carbon 
daily." The carbohydrates ingested pass directly into the forms of glycogen and 
glucose, but it must be recollected that the ingested albuminoids are to be conceived of 
as resolved by ultimate conversion after ministering to the nutrition of the tissues 
(mainly) into glycogen, urea and the elements of the bile. The quantity of carbon 
noted above may, within certain somewhat narrow limits, be regarded as derived 
from hepatic sugar destroyed in the blood, indicating therefore, according to the 
formula of hepatic sugar (C16H12O6), 35.30 ozs. (Troy) of this substance daily 
converted into its final products. Now, if this amount be fermented into alcohol 
and carbonic acid, it would correspond to no less than 18 ozs. (Troy) of alcohol, 
equal to 8640 grains. 
Liebig estimates the carbon consumed by each prisoner in the House of Arrest at 
Giessen at nine ozs. Hessian (one oz. Hessian = 482 grains Troy). This amount of 
carbon would be contained in 22.5 ozs. of hepatic sugar, which would represent a daily 
consumption of 11.5 ozs., equal to 5520 grains of alcohol. As all of this must be sup- 
posed to pass through the heart, there would be present during one minute in the 
pulmonary blood the 1440th part of it, or exactly six grains by the last estimate, and 
3.83 grains by the present one. According to Miiller, ten pounds of blood = 76,800 
grains, traverse the lungs in the same time. The pulmonary blood, therefore, cannot 
contain more than to grains of alcohol during any given minute, equal to 
"0.4857 to 0.7812 of a grain of alcohol to 10,000 grains of blood. 
We may denominate these calculations by ' ' ingested carbon. ' ' Let us compare 
them with a similar one based upon the "expired carbon." 
Scharling estimates the carbon given off from the lungs of a man in twenty-four hours 
at 325.30 grammes. Supposing that all of this carbon (which is not strictly true) results 
from the destruction of hydrocarbon, and that this hydrocarbon is hepatic sugar, 813.26 
grains of sugar would be converted, with a production of 415.65 grammes of alcohol, 
equal to 6415 grains. As this quantity represents the daily consumption or supply of 
alcohol, = 4.45 grains of alcohol would pass through the lungs in one minute, and 
by Miiller's estimate of the velocity of the blood through the lungs, we would have 
Af2_== 0.5794 of a grain of alcohol present in the pulmonary blood during any given 314 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
minute. The mean of these three calculations is 0.6154 of a part of alcohol to 10,000 
parts of pulmonary blood. 
While, therefore, no less than 13.77 ozs. of alcohol is poured into the circulation within 
twenty-four hours-a quantity which represents all the carbonous constituents of the food 
capable of combining directly with oxygen, and which is evidently capable of sub- 
serving phenomena of primary importance, it would be impossible that more than .6 of 
a grain could exist in 10,000 parts of the blood passing through the lungs at any given 
time. This calculation assumes that the conversion of glycogen into glucose and the 
fermentation of this latter body are uniform ; but this is not strictly true, glycogenesis 
being stimulated by digestion and modified by various other conditions. Nor would it 
be reasonable to assume that either the haemal fermentation of sugar or the oxidation 
of alcohol is uniformly active. What I desire to illustrate, however, by the foregoing 
calculations is, that whatever the importance of the glycogenic function may be, and 
although as much as 13| ounces of alcohol may be consumed in the blood in twenty-four 
hours, it cannot be possible to obtain by distillation more alcohol, upon an average, than 
this small quantity, viz. : .6 of a grain to 10,000 of blood, and this even under the sup- 
position that oxidation is in complete abeyance, and that every atom of alcohol present 
is recovered. Consequently, all procedures addressed to this end must be surrounded 
with every possible safeguard, and large quantities only of organic material operated 
upon, if we desire to obtain measurable quantities of alcohol. 
The only available method of separating alcohol from aqueous organic fluids is dis- 
tillation. This is, moreover, the proper method for experimentation of this kind, on 
account of its prompt arrest by heat of fermentative changes going on in the material 
employed, and the completeness with which the alcohol is separated, this substance 
being entirely recoverable when one-half or a little more of the distilled liquid is brought 
over. I have distilled blood and the tissue of the lung, the liver, and the pancreas, 
under various conditions, but have always avoided any previous admixture of substances 
designed to separate or coagulate albumen, dissolve blood corpuscles, destroy sugar or 
arrest its fermentation. Tedious filtrations, unavoidable when anything of this kind 
is attempted, would occupy too much time, while the admixture of foreign substances 
would complicate the conditions of the experiment. I have regarded the greatest attain- 
able simplicity as most certain to furnish the best results, but I may remark, in passing, 
that in the distillation of blood it may be advisable to add an equal weight of sulphate 
of soda, which has the property of crisping the albumen and of preventing it from 
becoming so solidly coagulated by heat as to risk an imprisonment of the vapors. For 
these reasons, except in a few instances, I have invariably submitted the organic matters 
to the distillatory procedure without prior admixture, a bath of chloride of sodium 
being interposed between the vessel containing them and the source of heat. In some 
cases, where the main facts had been already established in a suite of experiments, I 
have placed the vessel containing the organic material directly over the source of heat. 
For the distillation of the organic matters, either copper balloons, holding from two 
to sixteen quarts, or cylindrical vessels horizontally placed, surmounted by a dome ter- 
minating in a copper pipe leading by a ground joint to a metallic worm, were employed. 
These vessels were set in larger ones containing the saline bath. None of these organic 
matters can be distilled in glass, for the vessel is infallibly broken by the generation of 
vapor between the wall of the vessel and the contained substance. The secondary dis- 
tillations were always conducted in glass balloons varying from one fluid drachm to 
four quarts. The connections were made with glass tubing and corks. Liebig con- 
densers, traversed by glass tubes of various sizes, were used, the tubes in all the later 
distillations reaching by a double bend, without joints, from the vessel submitted to 
heat to the centre of the receiving vessel, which was usually the balloon for the succeed- 
ing distillation. The sources of heat were charcoal and gas; no variety of coal oil was SECTION VIII-PHYSIOLOGY. 
315 
kept or used in the apartment. From six to ten successive distillations by halves are 
necessary for the proper concentration and purification of the final distillate. The 
quantity of material operated upon varied from a pound or less to twenty or more 
pounds, each experiment occupying several days. Before every operation all the 
metallic and glass vessels were carefully washed in pure water, rinsed repeatedly in 
distilled water which had been evaporated to half its bulk, and then thoroughly dried 
over a furnace, air being driven into them with a bellows through a metallic or glass 
tube attached to its nozzle until all vapor whatever was entirely expelled. The ves- 
sels were then corked and set aside. All tubes, corks and funnels and the tubes of the 
condensers were carefully washed, rinsed as described, and thoroughly dried over the 
furnace, after caref ully wiping with tissue paper and raw cotton. In no reported experi- 
ment whatsoever were any of these precautions neglected; the preparation of all necessary 
pieces of apparatus being made immediately before the institution of an experiment. 
For washing precipitates nothing but distilled water evaporated to half its bulk and 
freshly cooled was used. Chemically pure reagents only and different samples of these 
in successive operations were used. Solutions of salts were made with evaporated dis- 
tilled water, and the solutions themselves were afterward filtered and boiled so as to 
drive off any volatile substance accidentally present. With such precautions I believe 
it was impossible that any alcohol or other volatile matters from without could by 
chance have become mixed with the distilled fluids or with the substances operated 
upon. All distillates not directly under manipulation were closely corked and locked 
up. Whenever a distillation was commenced it was invariably completed at the ear- 
liest possible period. If fluid or froth (under the conditions of these experiments pos- 
sibly containing sugar) escaped from the balloon into the tubes or receiver, as occasion- 
ally happens when the balloon or cylinder is too full, the experiment was at once 
abandoned; and so, likewise, for accidental admixture of any sort whatsoever, e. g., 
as when a few drops of the water used for cooling in the condensers accidentally fell 
into the distillate. If vapor escaped through a joint or passed uncondensed through the 
tubes, thereby involving perhaps a loss of alcohol, the experiment was abandoned. 
Transference of distillates from vessel to vessel was avoided as much as possible, and 
when filtrations were required the funnels were covered and the receivers, narrow- 
mouthed flasks, if possible, the ones to which heat was to be applied in the ensuing 
distillation. The balance was of the best German make, with knife edges resting on 
cornelian, and platinum weights, according to the metrical system. It turned readily 
with the ten thousandth part of a gramme when lightly loaded. The thermometers 
employed were carefully corrected by comparison with a standard one. 
The final distillate seldom exceeding thirty grains in weight, and great accuracy for 
quantitative determinations being desirable, a special method, though similar in prin- 
ciple to that of the specific gravity, was employed as follows:- 
A common thermometer with a small tube but medium bore, and a bulb about a 
quarter of an inch in diameter, was selected and cut off two and a half or three inches 
above the bulb, and the end ground and polished. The mercury having been expelled 
the weight of the bulb and tube was ascertained to four places of decimals. The bulb 
was then rinsed out two or three times with boiled distilled water, and, finally, when 
filled with distilled water by the procedure described below, brought very carefully to 
a temperature of 60° F., and its weight again determined. To take the specific gravity 
of a final distillate, the liquid in the bulb tube was entirely driven out by boiling, 
and its extremity immersed in the final distillate. After it had again filled itself by 
aspiration, its contents were a second time returned into the final distillate by heating 
the bulb, and it was allowed to fill itself again. This manœuvre was practiced three 
times successively in order to secure a uniform density in the fluid contained in the 
bulb tube and the bulk of the final distillate. Care was taken to expel all the bubbles 316 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of air which are apt to linger in the bulb tube, and after their complete expulsion, the 
point of the tube was immersed in the distillate while the contents of the bulb tube 
w ere expanding ; the tube was then allowed to cool and fill itself completely at the 
temperature of the air. A jar of water being provided with a thermometer suspended 
in it, the temperature of the water in the jar was brought to 62° F. if the air was 
below 60°, and to 58°, if the air was above 60°, the specific gravity being always taken 
for this latter temperature. The bulb tube completely filled with final distillate was 
now attached to a thread long enough to allow its bulb to rest in the same horizontal 
stratum of water as that in which the bulb of the standard thermometer was situated, 
when immersed in the water of the jar for the entire length of its stem except about a 
quarter of an inch. The thread being tied around the tube near its extremity, j ust 
before its final immersion in the jar, the bulb was quickly passed over a flame so that 
its contents might expand sufficiently to cause a minute globule of the liquid it con- 
tained to appear by expansion upon the surface of its polished end; to this, a small 
drop of the final distillate was added from the tip of a glass rod, and the bulb tube at 
once lowered to the proper depth in the jar of water. It was allowed to attain the 
temperature of 60°, as shown by the standard thermometer, a small quantity of 
distillate being again added to the globule on its tip if this appeared in danger of 
entire aspiration into the tube by contraction, as would be apt to happen when the air 
was above 60° and the water in the jar, in consequence, cooling through two degrees aa 
explained. When the standard thermometer showed exactly 60°, the tube was quickly 
raised out of the water, the drop of distillate upon its extremity suddenly wiped off 
with a single application of a linen cloth, the tube itself carefully and quickly wiped, 
and immediately weighed. In this way the following w'eights were obtained : 1st, 
The weight of the empty tube; 2d, The weight of the tube filled with distilled water 
at 60° ; 3d, The weight of the volume of distilled water contained in the bulb tube at 
60° ; and 4th, The weight of the volume of final distillate contained in the tube at 
60°. These data enable us to determine the specific gravity of the final distillate by 
simple calculations. The weights of exactly equal bulks of very small quantities of 
liquid can be determined after this method with an accuracy equal to that of the spe- 
cific gravity bottle, without appreciable loss by evaporation, or gain in weight in warm 
weather by the deposition of dewy particles, if the air within the balance-case be kept 
dry by chloride of calcium, as it always was during these determinations. The table 
of drink water furnishes the percentage by weight of alcohol in any mixture of alcohol 
and water, corresponding to its specific gravity, up to ten per cent., a range amply suffi- 
cient for experiments of this nature. 
Organic matters should always be distilled over a bath of chloride of sodium ; a 
bath of simple wrater is not sufficient. When heat is applied blood becomes solid, and 
vapors being generated between the wall of the vessels and the coagulated mass, a 
spongy texture is induced which is very unfavorable for the conduction of heat to the 
contents of the vessel. The material should be spread out in a shallow layer not more 
than one or two inches thick, and when the cylinder is used, it must be provided with 
a revolving spiral rake turning in a hole at one end which does not penetrate the end 
of the cylinder, while at the other its shaft passes through a tight stuffing box and also 
traverses the end-wall of the vessel containing the saline solution. This rake must be 
frequently rotated back and forth during the distillation, whatever be the contents of 
the cylinder. In my earlier experiments, copper balloons with flatfish bottoms were 
employed, placed in larger copper vessels holding the solution of common salt. 
The organic matter having been prepared, weighed, and its physiological and phy- 
sical conditions noted, it is passed into the cylinder, to which the dome is carefully 
fastened. The bath is covered, and a hood adjusted reaching upward so as to enclose 
the dome and the bend of the eduction pipe. The steam of the boiling bath is thus SECTION VIII PHYSIOLOGY. 
317 
caused to ascend in contact with the dome and pipe, maintaining their temperature at 
a point which prevents premature condensation of the vapors arising from the substance 
distilled, which would otherwise trickle back, in the fluid form, into the mass of mate- 
rial. These first portions of vapor are always the richest in alcohol. Similar precau- 
tions must be observed, in all the succeeding distillations, against the premature conden- 
sation. The eduction tubes of glass should be heated with the flame of a Bunsen burner 
directed by a blow-pipe j ust before the distilland begins to boil, so that the first and 
most volatile portions may be separated from the distilled fluid at the earliest prac- 
ticable period. After they have passed over, and watery drops appear, the bend of the 
tube from the boiling vessels toward the condenser should be wrapped in cotton wick. 
The first distillate ought always to be equal in weight to one-half of the weight of 
the water contained in the matters distilled, and when fresh material is operated upon 
it comes over transparent or slightly cloudy, containing carbonate of ammonia and 
several volatile products. Its reaction is neutral or slightly alkaline. It must be dis- 
tilled down by halves, and the distilland must be kept slightly acid with hydrochloric 
acid. After two or three distillations the distillate is treated with freshly calcined 
animal charcoal, and this must be repeated as long as the first drops of fluid distilled 
are not absolutely transparent. At about the sixth distillation some crystals of nitrate 
of silver are thrown into the distillate and dissolved. A decomposition is thereby 
caused of certain volatile substances which come over before the alcohol, and which 
behaves in all respects like aldehyde-acetic ether, and acetal. The distillate is again 
passed through animal charcoal and well washed with distilled water evaporated to 
half its bulk. This takes away almost all the peculiar odor which the distillates of 
animal substances always possess, nor is the volatile substance above described again 
seen. 
When the organic matters have been allowed to remain for some days before distil- 
lation, inasmuch as putrefaction is beginning, carbonate of ammonia comes over in 
greater quantity and sulphureted hydrogen is found in the first distillate. In the 
process of rectification, therefore, acetate of lead must be added to decompose the sul- 
phides, and hydrochloric acid as usual, animal charcoal and the nitrate of silver being 
used as before, the treatment of the distillate with these substances being repeated until 
the volatile product ceases to play along the tubes before the alcohol itself comes over, 
as it does in greatest quantity soon after the distilland begins to boil. Care must be 
taken to bring over a quantity of distillate in every operation at least equal to one- 
half the fluid submitted to heat, even where, by washing filters, a considerable quantity 
of water has been unavoidably added to the liquid in process of concentration, and that 
the first portions condensed in the tubes be not allowed to trickle back. After suffi- 
ciently numerous distillations, eventually in a very small apparatus, where the quantity 
distilled is often not more than one or two drachms, a final distillate is procured. 
This final distillate should weigh from fifteen to thirty grains or more if alcohol is 
evidently very abundant, for its quantity can be approximately estimated by the eye as 
it plays along the tubes ; its reaction must be neutral, and it must possess little or no 
odor. A peculiar odor always attaches, however, to these products of the distillation 
of animal, substances, as Bernard has observed with regard to the alcohol obtained by 
distillation from decoctions of the liver of different animals. 
The tests upon which I have relied for the qualitative determination of alcohol are 
the following:- 
1. The optical appearance within the conducting tubes, during the final distillation, 
when the distilland began to boil. 
Alcohol comes over in greatest strength during the first moments of a distillation, 
and if present, may always be seen to play in a mobile manner just in advance of the 
less volatile and more sluggish watery drops, as both progress rapidly along the con- 318 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ducting tube when the distilland just begins to boil. To observe this peculiar play of 
the successively condensing and vaporizing alcohol, it is essential that the dewy drops 
of volatile matters given off from the liquid, as well as of humidity deposited from the 
air of the flask in the bend and first portions of the conducting tube, should have been 
dissipated by a gentle heat from the flame of a lamp directed by a blow-pipe with large 
orifice. The conducting tube must now be allowed to cool again before general ebulli- 
tion. This appearance is, of course, observable only between the balloon and the con- 
denser. It is a trustworthy indication of even very minute quantities of alcohol, and 
should be studied by the distillation of mixtures of a few drops of alcohol with a quart 
of distilled water. During the final distillations this appearance becomes more and 
more distinct, and if'not seen, alcohol is assuredly absent, at least in any determinable 
quantity. As I have said, in all these distillations some still more volatile'substances 
are present, whose "play'' in the tube precedes that of alcohol. Of these substances 
I believe aldehyde to be the most abundant, a body which ought to coexist with 
alcohol in organic fluids, as the result of the progressive oxidation of the alcohol. But 
after treatment of the later distillates with nitrate of silver, which decomposes aldehyde 
and acetal, the " play " due to these substances no longer occurs, while that proper to 
alcohol becomes more pronounced. 
2. Chromic Acid Dissolved in Sulphuric Acid.-By adding a quarter of a gramme of 
crystallized bichromate of potassium to 100 grammes of concentrated and chemically 
pure sulphuric acid (as Bernard recommends from Leconte), the bichromate is decom- 
posed, chromic acid liberated, and a rich, brownish-yellow liquid is obtained. When to 
any aqueous liquid containing the feeblest trace of alcohol an equal bulk of this reagent 
is added, much heat is evolved, the chromic acid is deoxidized by the alcohol and ses- 
quioxide of chrome set free, imparting to the fluid its brilliant emerald green color. 
This is an exceedingly delicate and most reliable test for alcohol; indeed, the very best 
we have for distilled fluids. Nothing similar occurs with other volatile fluids obtainable 
from animal matters. Sugar, dextrine, gum, uric acid, urea, albumen and gluten 
equally effect this reaction, but they must be absent in distilled fluids. I have found 
that the oils distilled from petroleum reduce the chromic acid in this test, but they 
must be absent from a final distillate, such as I have described, and were never kept 
or used in the apartment where these experiments were conducted. Empyreumatic mat- 
ters generated during the distillation of organic materials do not affect the test, even 
when strongest, as I have repeatedly and carefully determined. 
3. Inflammation of the Vapor of Alcohol in a Test tube upon Ebullition of the Final 
Distillate.-This most striking and satisfactory test I have found applicable when not 
less than two or three per cent, of alcohol exists in an aqueous fluid; below these per- 
centages the alcoholic vapor is too much diluted with steam to burn even at the first 
moments of ebullition. Some care is requisite in the use of this test. The quantity of 
the liquid should be about one-tenth of the capacity of the test tube ; the flame over 
which the tube is held should be very moderate and steady, and should give but little 
light ; the room should be darkened ; a wax taper ready lighted should be held just 
above the upper edge of the mouth of the tube ; the entire length of the tube should be 
heated before the liquid is made to boil, and the tube should be held in an oblique 
position and closely watched, as the least discomposure may prevent our observing the 
inflammation of the alcoholic vapor, which is sometimes a mere flash. When all is 
properly done, if alcohol is present in sufficient quantity, a flash of flame is seen to 
descend into the tube at the moment of ebullition, or a little after it, and if more 
abundant the alcoholic vapor continues, for a longer or shorter time, to bum continu- 
ously at the mouth of the test tube, with a characteristic flame, as the fluid in the tube 
is made to boil. 
No other substance met with in the distillation of animal matters is capable of SECTION VIII PHYSIOLOGY. 
319 
inflammation in this way. The primary distillate, and all successive ones, until the 
final one is reached, constantly refuse to burn as above described. Some organic acids, as 
formic and acetic, are inflammable in the state of vapor, but only when pure or nearly 
so. The greater part of the final distillate obtained by these processes is water, and 
acids are not present, as the fluid is neutral or must be made so by the rules which I 
have followed. 
Such, then, are the qualitative tests upon which I have relied. Whenever a final 
distillate, whose specific gravity is less than that of water, fulfills the requirements of 
these tests, alcohol unquestionably exists in it. By long experience in this kind of 
experimentation, during which I have had constantly recurring opportunities of observ- 
ing the behavior of alcohol either normally present in the organic matter acted upon, 
or designedly mingled with it and finally recovered in the distillate, and moreover, by 
the determination of the ratio of expansibility of some strong distillates, the reasonable 
skepticism I long endeavored to maintain has been entirely dissipated. 
The following considerations seem to me important in regard to the action of the 
tests employed, and better illustrate their cogency than a mere mention :- 
1st. In the fermentation of liver decoctions, after about twenty-four hours at mod- 
erate temperatures (65° to 75°), so much alcohol is obtainable that it may be concen- 
trated and purified, and recognized by its specific gravity and boiling point, etc., as 
well as by the taste and smell. When diluted with water the fluid burns in the test 
tube, in identically the same manner as the final distillates prepared from liver tissue, 
lung tissue, or blood set aside at ordinary temperatures for forty-eight hours or so, and 
also like those obtained from fresh organic matters. The vapor of all these fluids is 
inflammable and burns in a test tube at the first moments of ebullition, with a faint blue 
flame descending like a flash into the tube; they all contain the same substance which 
is known in the case of liver decoctions to be alcohol. 
2d. Liquids obtained by distillation from fluids in which sugar has disappeared, as 
by direct fermentation with yeast, and which are, therefore, known to contain alcohol, 
are inflammable in the test tube, and when purified, color the chromic acid test green ; 
liquids, therefore, obtained by distillation from fresh organic matters known (by direct 
testing) to contain sugar originally, and in which sugar has finally disappeared or 
diminished in quantity, and which are equally inflammable with the first named, and 
similarly decompose chromic acid, must likewise contain alcohol. 
3d. The vapor of empyreumatic substances does not become inflamed upon ebulli- 
tion of the fluid in which they may be present, in the test tubes, even when most 
abundant, as in the primary distillate, or after any degree of concentration. The dis- 
tillates become more inflammable as the purification is more complete, which would not 
be the case were their inflammability due to empyreumatic contaminations, for succes- 
sive digestions in the cold and with heat, with hydrochloric acid and animal charcoal, 
continually reduce any quantity of them originally present; and besides, when the 
saline bath is employed, no empyreuma is generated. 
4th. Final distillates from the same kind of material have been found to be more 
inflammable in proportion to the quantities of organic matter operated upon. This has 
been especially marked, as will be detailed, when the product of several successive 
and similar operations have been mingled and concentrated together; which shows that 
the substance obtained and certified by the tests to be alcohol existed originally in the 
matters treated by distillation, and that its presence was not due to any incompleteness 
in the methods followed or to any accidental contamination. 
5th. The specific gravity of the final distillates has always been found to be less 
than that of water, and the distillate is more inflammable in proportion to its lightness, 
and the depth of the tint produced with the chromic acid test, which should obviously 
be the case with alcohol. 320 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
6th. The quantity of the substance obtained has always been extremely small, 
which, on theoretical grounds, and from the calculations detailed, must necessarily be 
the case for alcohol. 
7th. The expansibility of the final distillate is always greater than that of water, 
and is universally proportional to its specific gravity. In view, therefore, of these facts, 
and by the direct authority of the tests enumerated, of which the chromic acid test is 
obviously the only one of perfect scientific rigor, the presence of alcohol in the fluids 
obtained by distillation has been affirmed. For ultimate analysis in the combustion 
tubes enough alcohol might be obtained from liver tissue allowed to remain for forty 
to sixty hours at moderate temperatures, but what we wish to determine is the existence 
of alcohol in the fluids or solids within an hour or two after death, and before their 
normal temperature has appreciably declined. The quantity of alcohol existing in 
fresh liver tissue is so exceedingly small-only one part in 400,000 of liver tissue- 
that it is hopeless as the source of a sufficient quantity of this substance for the above 
purpose. The same may be affirmed of the lung tissue, but from the blood it might 
be possible to obtain an adequate quantity, especially as the material can be obtained 
in great abundance. 
Having now described the methods followed in the distillation of organic matter, 
and the modes of determination employed, I proceed to devote a more particular atten- 
tion to the experiments themselves. In some preliminary studies, I determined- 
1st. That it is possible to distill such matters as liver tissue, blood and lung tissue, 
and to separate from the distillates obtained all substances foreign to the aim of the 
experimentation, so as to obtain a reasonably pure mixture of alcohol and water, the 
alcohol having been designedly added to the organic material. 
2d. In a quantitative sense, that a few drops of alcohol thrown into a quart of dis- 
tilled water could be entirely recovered, burning in the test tube, and reducing chromic 
acid. 
3d. That when one part, by weight, of alcohol is poured into three or four thousand 
of fresh ox blood it can be likewise recovered. 
4th. That in blood set aside for three or four days, to which alcohol is added in the 
same proportion, the substance is not destroyed, but can be almost wholly recovered 
from it by distillation. 
Fortified with these results, I determined, in the first place, to investigate the con- 
ditions of Bernard's experiments upon the disappearance of sugar in newly drawn 
blood. Undoubtedly, if the disappearance was due to the transformation of the sugar 
into lactic acid, no alcohol could be recoverable. But, if the sugar had disappeared in 
consequence of its conversion by the alcoholic fermentation, inasmuch as in cool 
weather (53° to 65°) rectification advances but slowly, the alcohol, if formed, would 
remain, at least in part, unconverted into acetic acid, and should be recoverable by 
distillation. 
I determined, therefore, to employ the mixed thoracic blood of the ox, which 
always contains sugar (from 0.00195 to 0.0074 parts to 1000 parts of blood, according 
to Carl Schmidt, quoted by Bernard), setting it aside after determining the presence of 
sugar at the temperature of the air until sugar had nearly or wholly disappeared. 
Upon such a basis the following experiments were conducted :- 
No. 1.-622 grammes (1.37 1b, avoir.) of ox blood containing sugar by Fehling's 
test, as it does invariably, was agitated with air in a large flask, and set aside at a mean 
temperature of 62° F. for forty hours. At the expiration of this period sugar had 
almost entirely disappeared. The blood was distilled over the salt bath. The final dis- 
tillate did not burn in the test tube, but struck a bright green tint with the chromic 
acid test. The quantity of alcohol present was 0.0162 gramme. SECTION VIII-PHYSIOLOGY. 
321 
No. 2.-622 grammes (1.37 lb. avoir.) of similar blood, abundantly charged with 
sugar, was set aside as before, at a mean temperature of 60°F., for 90 hours. The blood 
was occasionally agitated with the air in the flask, which was renewed from time to 
time with a bellows. Although sugar was still traceable at the expiration of the above 
period of time, the blood was distilled over the salt bath. The final distillate weighed 
1.2940 gramme. It struck a bright green with the chromic acid test but did not burn 
in the test tube. The quantity of alcohol was 0.0155 gramme. 
No. 3 -930 grammes (2.05 lbs. avoir.) of similar blood was introduced into a large 
glass-stoppered flagon. The blood contained sugar, upon examination. The vacant 
two-thirds-of the flagon was filled with carbonic acid, the blood well agitated with it 
becoming almost black. The flagon being securely stoppered, was carefully sealed with 
wax, and the blood set aside at a mean temperature of 66° F. for 42 hours. Though 
sugar was still traceable, it was distilled over the bath of common salt. The final dis- 
tillate weighed 1.6173 gramme; alcohol burned in a lively manner in the test tube, and 
struck an emerald green hue with the chromic acid test. The quantity was 0.0647 
gramme. 
No. 4.-1120 grammes (2.46 lbs. avoir.) of similar blood, containing sugar by exami- 
nation, was introduced as before with a large stoppered flagon, securely shut off from 
the air, and set aside at a mean temperature of 60° F. for 72 hours. The blood was 
well shaken with the air in the flagon from time to time, but no fresh air was allowed 
to enter. After the above lapse of time, the blood was distilled over the bath of common 
salt. The final distillate weighed 1.4880 gramme. The vapor of alcohol burned in a 
lively manner in the test tube, and the fluid reduced the chromic acid test as before. 
The quantity of alcohol was 0.0446 gramme. 
No. 5.-930 grammes (2.05 lbs. avoir.) of similar blood, containing sugar by 
examination, was well agitated with air and set aside at a mean temperature of 58° F. 
for six hours. It was then distilled over the bath of common salt. The final distillate 
weighed 1.0352 gramme. The vapor of alcohol burned in a lively manner in the test 
tube, and the chromic acid test was reduced as before. The quantity of alcohol was 
0.0414 gramme. 
In these experiments the blood was distilled before the establishment of putrefac- 
tion, only a faint odor being emitted; it changed in color from red to deep black within 
two days. The mean quantity of blood operated upon was 845 grammes; the mean 
temperature was 61° F. ; the mean duration of the experiments was 62 hours; and the 
mean quantity of alcohol obtained was 0.0365 gramme. Alcohol was obtained in every 
case, although the quantities of blood employed were comparatively small ; they were, 
however, on an average, thirty-five times as great as those experimented upon by Ber- 
nard (24 grammes). 
In blood left to itself, therefore, sugar is not destroyed, at a mean temperature of 
61° F., by transformation into lactic acid, but by the alcoholic fermentation, and more- 
over, for the occurrence of this fermentation under the conditions named, yeast of beer 
is not indispensable. 
Having determined these points, I proceeded to inquire whether the hepatic glucose, 
so abundant in exsected liver tissue, is similarly decomposed by the alcoholic fermenta- 
tion, at ordinary temperatures. I therefore experimented as follows :- 
No. 6.-750 grammes (1.65 lb. avoir.) of fresh ox liver was comminuted in a meat 
mincer (used only for these purposes, well washed and dried at a high heat over the 
furnace) and set aside at a mean temperature of 75° F. for 90 hours. At the end of this 
period sugar was no longer discoverable, and putrefaction was fairly established. While 
making a decoction of a portion of the tissue in testing for sugar, acid vapors were given 
off, the mass itself being strongly acid and effervescing vigorously with bicarbonate of 
soda. This free acid, canable of nassine off as vanor during the first moments of ebul- 
vol. ni-2i 322 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lition, and strongly reddening litmus paper, was undoubtedly acetic acid. The mass 
of liver was now distilled over the salt bath and yielded 0.3235 gramme of alcohol. The 
vapors of alcohol burned continuously at the mouth of the test tube upon ebullition of 
the final distillate, which struck a vivid emerald green tint with the chromic hcid test. 
Much of the alcohol, indeed nearly all of it, must have been lost by acétification, on 
account of the high temperature at which the liver tissue was set aside. 
No. 7.-190 grammes (0.42 lb. avoir.) of fresh ox-liver tissue was laid aside, sugar 
being present by examination, without comminution, at a mean temperature of 60°, for 
120 hours. When distilled over the bath of common salt, it yielded a large quantity 
of alcohol, the ultimate distillate, when boiled in a test tube, giving off vapors which 
burned continuously at the mouth of the tube as long as heat was applied, but little of 
the alcohol formed having been lost by acétification. 
The sugar, therefore, of liver tissue is largely converted into alcohol by the main- 
tenance of a morsel of liver at a temperature of 60° to 70°. At the lower temperature 
decomposition is longer postponed and acétification less active, so that larger propor- 
tional quantities of alcohol are recoverable. I have already shown with what tumultu- 
ous violence hepatic glucose is fermented in a mass of liver submitted to its somatic 
temperature. The alcoholic fermentation advances, however, at temperatures even as 
low as 45° F., but a rise of temperature very rapidly exalts the inherent tendency of 
the alcohol formed toward oxidation, especially in the presence of a ferment, so that at 
the somatic temperature, as I have proved by direct experiment, the alcohol is acetified 
nearly as fast as it is formed. 
I proceeded next to inquire whether the lung tissue might not ferment alcohol when 
left to itself at moderate temperatures. As the blood contained in the pulmonary capil- 
laries is derived from the saccharine blood of the right ventricle, sugar being borne con- 
stantly from the liver through the heart into the lungs, it must necessarily exist in the 
lung capillaries. Bernard formerly affirmed that sugar disappeared totally in the lungs 
in the fasting state, and in greater part during the digestive overflow ; nevertheless, he 
emphatically denied that the lungs contain sugar. "Weboil," says he, "and treat 
with the test liquids, decoctions of the spleen, kidney, pancreas, lung, muscular tissue 
and brain, derived, like the portions of liver already found to be so rich in sugar, from 
the ox. Not one of these decoctions reduces the test liquid ; not one of them ferments 
with yeast. We may, therefore, boldly declare that no organ of the body, except the 
liver, contains sugar in the physiological state" (Loe. cit., p. 53). I have already noted 
that in his later researches Bernard modified this statement, admitting that a certain 
small portion of sugar is normally present even in the systemic venous blood. But his 
original declaration was inherently contradictory to his own hypothesis, for if it be 
affirmed that sugar is destroyed in the lungs, it must of necessity exist there, although 
the lungs be the site, mainly, of the processes in virtue of which it disappears before 
reaching the left side of the heart. Sugar, therefore, or its representative, alcohol, must 
exist in the lung capillaries, at least transiently. I therefore determined to submit ox- 
lung tissue to the same conditions of time and temperature under which the blood and 
liver tissue had been examined. The following four experiments exhibit the result of 
this inquiry:- 
No. 8.-500 grammes (1.12 lb. avoir.) of fresh lung tissue from the ox was com- 
minuted to the size of an acorn, with scissors. The pleural portions of the tissue alone 
were used. All vessels and bronchial tubes, as well as fluid blood, were rejected. The 
lung tissue was set aside at a mean temperature of 66° for 72 hours. It was then dis- 
tilled over the bath of common salt. The vapor of alcohol burned in a lively manner 
upon ebullition of the final distillate in a test tube. The quantity of alcohol was 0.0323 
gramme. 
No. 9.-750 grammes (1.65 lb. avoir.) of fresh lung tissue from the ox, similarly SECTION VIII PHYSIOLOGY. 
323 
prepared, was set aside at a mean temperature of 66° F. for 96 hours. At the end of this 
period the odor exhaled was faintly disagreeable. It was then distilled over the salt 
bath. Alcohol was seen to pass over during the final distillation, and when the final 
distillate was boiled in a test tube, burned vigorously at its mouth. Its quantity was 
0.0485 gramme. 
No. 10.-2180 grammes (4.80 lbs. avoir.) of fresh ox-lung tissue was set aside at a 
mean temperature of 76°, for 17 hours. It was then distilled over the bath of common 
salt. Alcohol was seen to pass over during the later distillations. Its vapor burned in 
the test tube upon ebullition of the final distillate. 
No. 11.-5160 grammes (11.37 lbs. avoir.) of similar tissue was set aside at a mean 
temperature of 76° F. for 65 hours. At the end of this time it was distilled over the 
bath of common salt. The final distillate weighed 3.8820 grammes, and contained 
Ü.1640 gramme of alcohol. The vapor of alcohol burned continuously at the mouth of 
the test tube after removal of the taper, upon ebullition of the final distillate, which 
also struck a vivid green tint with the chromic acid solution. 
These results were in complete accord with those obtained by distillation of the 
blood and liver tissue; alcohol existed in lung tissue which had been submitted to 
ordinary temperatures during periods of time varying from 17 to 96 hours. It is certain 
that sugar had existed at some period antecedent to the distillatory process in the lung 
tissue employed, although this period may have been previous to the death of the ani- 
mal or have been extended somewhat afterward. From the fact that Bernard failed 
to find notable quantities of sugar in the lungs, and that by my own experiments alcohol 
can be obtained from these organs, as well as by considerations adduced further on, it 
is reasonable to conclude that the sugar conveyed to the lungs is promptly decomposed 
there by the alcoholic fermentation. In this way it becomes possible to reconcile Ber- 
nard's declaration that sugar does not exist inithe lungs, or, at least, cannot be demon- 
strated in the lung tissue of the ox, some time after death, with his inferential state- 
ment that this substance is mostly destroyed in the pulmonary transit. 
The conditions of the disappearance of sugar in the blood, the liver, and the lung 
tissue, at ordinary temperatures had now been determined, and it had been established 
that this disappearance was effected through the mechanism of the alcoholic fermentation, 
presumably with a concurrent acétification, which, however, could be actually observed 
only in the liver tissue, normally so much richer in sugar than the other matters oper- 
ated upon. While by no means denying the possibility of the occurrence of the lactic 
acid fermentation in these substances, I cannot believe that alcohol would have been 
recoverable from them, if the lactic acid fermentation had occurred as a continuation of 
the normal processes, while the converse of this might readily happen, as the alcoholic 
fermentation antedates the lactic, this latter fermentation being accompanied usually 
with changes initiatory of putrefaction. Thus in the preparation of bread, an alcoholic 
fermentation is first kindled in the dough by the yeasting, the carbonic acid evolved 
causing the dough to swell. If the temperature be too high, acétification of the alcohol 
very quickly supervenes, the acetic acid formed at the expense of the alcohol liquefying 
the gluten, so that the carbonic acid is allowed to escape, the dough falls and turns 
sour. As yet, however, there is no lactic acid formed ; this substance appears later, 
when the dough begins to putrefy, and is found to be associated with butyric acid. 
The foregoing experiments were instituted as the first stage of an inquiry as to the 
normal occurrence of the alcoholic fermentation within the economy of living animals. 
The physiological mind of the present day is fully prepared to admit that the fact of 
somatic death, as I have already hinted, does not necessarily arrest all nutritive trans- 
formations occurring in the several organs and fluids, some of which are independent of 
the circulation, of innervation and of respiration, although through certain mechanisms 
controlled by these functions. The converse of this proposition, properly guarded, 324 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ought likewise to be true, viz., that the chemico-vital processes observable within lim- 
ited periods after death, may, with prima facie reason be supposed continuous with 
those occurring during life. For, indeed, the moment of death is a very uncertain one, 
and the period at which the organs and fluids become unable to continue or to resume 
their normal trains of action varies greatly in the solids and liquids, as it does also in 
different animals and even individuals. It is reasonable, consequently, to infer that 
the modifications of sugar observed soon after death, or even before the establishment 
of putrefaction, are continuations of the modes of action normal to the organism, or at 
least chemically allied to them. We may conclude, in accordance with such an infer- 
ence, and with the satisfaction of knowing that it equips us with the best attainable 
working hypothesis, that the liver evinces its remarkable power of causing the sugar it 
contains to ferment into alcohol, in what I have termed its "intrinsic fermentation," 
because it possesses the same faculty during life; that sugar disappears in blood within 
a few hours after death by a change into alcohol, because it does so normally within 
the system, and that alcohol is obtainable from lung tissue not yet in process of putre- 
faction, because it naturally exists in the blood passing through the lungs. I engaged, 
therefore, as follows, in this important question, by submitting the above hypotheses to 
the test of direct experiment. 
No. 12.-750 grammes (1.65 lb. avoir.) of normal lung tissue was comminuted in a 
meat mincer and raised over the salt bath to 212° F., in 90 minutes after the animal was 
struck down. Alcohol was seen to pass over during the later distillations. The final 
distillate burned within the test tube upon boiling. The quantity of alcohol was 
0.0259 gramme. 
No. 13.-870 grammes (1.92 lb. avoir.) of ox-lung tissue, while still quite warm, was 
comminuted as above, and raised over the salt bath to 212° F. in 55 minutes after the 
animal was struck down. During the later distillations, alcohol was seen to pass 
over. The final distillate weighed 0.8411 gramme, and upon ebullition in a test 
tube the vapor of alcohol burned satisfactorily. The quantity of alcohol was 0.0168 
gramme. 
No. 14.-1240 grammes (2.75 lbs. avoir.) of ox lung tissue, comminuted to the size of 
a pigeon's egg, was raised over the salt bath to 212° F. in 75 minutes after the animal 
was struck down. During the final distillations alcohol was seen to pass over. The final 
distillate weighed 0.6470 gramme, and contained 0.0453 gramme of alcohol. It struck 
a vivid emerald green tint with the chromic acid test. It was not burned in the test 
tube, being reserved for demonstration before the Elliott Society of Natural History, of 
Charleston, South Carolina, on May 15th, 1858. 
The total quantity of lung tissue operated upon was 2860 grammes, or 6.32 pounds 
(avoir.). The total quantity of alcohol obtained was 0.0880 gramme. Alcohol can be 
recovered from fresh lung tissue, though only in exceedingly minute amount, if the 
weather is warm and the lung tissue allowed to retain the heat proper to the animal 
body. The lung tissue contains so much air that, in conjunction with heat, all the 
conditions are present necessary for the most rapid acétification. In warm weather, 
therefore, but little alcohol can be recovered from lung tissue, but if the air be cold, 
so that the lungs are rapidly lowered in temperature to the neighborhood of 50° or 60°, 
the amount of alcohol recoverable is proportionately larger. On account, however, of 
the volume of the lungs in proportion to their weight, they contain but little blood, 
and large masses must be distilled to obtain very moderate quantities of alcohol. Lung 
tissue is far easier to distill than blood, as it shrinks on heating to 212°, and when cut in 
strips from the peripheral portions of the organs, not more than half an inch thick, 
readily yields up its vapors. But on account of the great variability of the density 
of the lung tissue, and the small quantity of blood it contains, it is necessary to employ 
very large quantities, to obtain only minute quantities of alcohol, even in cold weather. SECTION VIII-PHYSIOLOGY. 
325 
However, as the fermentation process advances everywhere in the blood, and as this 
fluid represents several times its weight of lung tissue for the purposes of these experi- 
ments, in order to obtain alcohol in larger quantities I determined to submit the 
slaughter-house blood itself to distillation, procured with the least delay possible, and 
with every precaution against the admixture of foreign matters, except, as will be 
detailed, when designedly added. 
The mixed thoracic blood of the ox had been already employed for observing the 
disappearance of sugar at somatic and atmospheric temperatures. By distillation, 
alcohol was obtained from blood of this kind which had been set aside at ordinary tem- 
peratures for two or three days ; it remained to inquire whether it could be procured 
from perfectly fresh ox blood. This mixed blood can be obtained in large quantities, from 
ten to twenty pounds escaping from each slaughtered animal. In the process of slaugh- 
tering the animal is first struck upon the head, and soon after it has fallen the throat, 
just above the sternum, is longitudinally incised, and the large venous trunks opened 
with the point of the knife. By the Jewish method the animal is not struck down, 
but fastened to the floor by means of a windlass, and the throat transversely incised 
just behind the angle of the jaws. Bernard details the French method as follows : "In 
ox blood obtained from the slaughter houses, sugar is always present while the blood 
is fresh, and for the following reasons : In order to bleed (exsanguinate) the oxen just 
struck down, the butcher plunges the knife even into the right auricle ; the blood 
escaping is therefore partly derived from the hepatic veins ; and if we notice, moreover, 
that in order to evacuate the blood that the animal contains, the butcher applies his 
foot strongly to the region of the liver, so as to press as much as possible of it out of 
that organ, it can be understood how it happens that the blood issuing from the neck 
wound, thus commingled with that from the hepatic veins, contains notable quantities of 
sugar ; and whenever I have examined blood from the slaughter houses, I have deter- 
mined the presence of sugar in it. Besides, it must be observed, that the animals may be 
in digestion, a condition which augments the quantity of sugar in the organism, and 
that they struggle violently if the throat is cut without a previous blow upon the 
head." From extended observation, I can likewise affirm that sugar is always present 
in such blood, though in variable quantity, the variations being caused by different 
methods of slaughtering. When the internal jugular veins are both fully divided, and 
especially when the innominate venous trunks at the base of the neck are opened, which 
is the usual practice in this country, the maximum amount of sugar is present in the 
escaping blood. While conducting the subjoined experiments the slaughtering was 
frequently superintended in person, the blood being received into a flat cylindrical 
vessel of tinned iron, constructed for the purpose, twelve inches in diameter, and four 
and a half inches in altitude. In its upper side, an orifice four inches wide, with 
a low rim, and fitted with a cover, was placed as near the edge as possible. Handles 
were attached to the vessel, so that the wide mouth could be applied directly to the 
wound in the neck of the animal, as the butcher made the opening into the great veins. 
The blood was thus caused to pass directly from the animal into the receiver, no inter- 
mediate vessel being used. The receiver itself was washed with evaporated distilled 
water and dried over the furnace, all vapor being driven out of it with a bellows, while 
still hot, just before it was sent to the slaughter house. 
All the apparatus being prepared, as already stated, the temperature of the blood 
when received was noted, and it was passed out of the receiver through a wide-mouthed 
funnel into the distilling balloon or cylinder, and as soon as the conducting tube was 
securely adjusted the saline bath was poured on. 
The following ten experiments exhibit in detail the results obtained in the distilla- 
tion of blood fresh from the animal:- 
No. 15.-697 grammes (1.53 lb. avoir.) of ox blood was raised to 212° F. in 60 326 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
minutes after the animal was struck down. When received the blood was quite warm, 
coagulated and of a dark red color. Alcohol was seen to pass over during the final dis- 
tillations, and its vapor burned in the most satisfactory manner in the test tube. The 
final distillate assumed a bright emerald-green tint with the chromic acid test. The 
quantity of alcohol obtained was 0.0650 gramme. 
No. 16.-9734 grammes (21.46 lbs. avoir.) of ox blood was raised to 212° in 56 min- 
utes after the animals, two in number, were struck down. The temperature of the 
blood when received was 101°. During the final distillations alcohol was seen to pass 
over. The final distillate weighed 0.8416 grammes, and struck the usual green tint 
with the chromic acid test. The quantity of alcohol obtained was 0.0198 gramme. 
With the object of counteracting or abolishing post-mortem oxidation, and thus pre- 
venting a possible loss of alcohol by its transformation into aldehyde and acetic acid at 
the high temperature of the blood, it was determined to add a certain quantity of a 
solution of sulphurated hydrogen to the blood as it passed into the receiver. This 
solution was made by passing a stream of pure and dry sulphurated hydrogen through 
distilled water previously evaporated to half its bulk. 
No. 17.-9137 grammes (20.10 lbs. avoir.) of ox blood, from two animals, was raised 
to 212° in 70 minutes after the oxen were struck down. 250 grammes of a saturated 
solution of sulphurated hydrogen was added to the blood during its collection. The 
blood coagulated loosely and became very dark or even black. Notwithstanding the 
addition to the blood of so much liquid at about 70°, its temperature when received 
was 100.3°. Alcohol was seen to pass over during the later distillations. The final dis- 
tillate weighed 1.6218 gramme, and struck the usual green tint with chromic acid. 
The vapor of alcohol burned within the test tube and at its mouth when the final dis- 
tillate was boiled. The quantity of alcohol was 0.0605 gramme. 
No. 18.-9236 grammes (20.36 lbs. avoir.) of ox blood, from two animals, was raised 
to 212° in 77 minutes after the animals were struck down. During the collection 250 
grammes of a saturated solution of sulphurated hydrogen was added to it, as before. 
The blood coagulated loosely and was nearly black. Its temperature when received 
was 99.5°. Alcohol was seen to pass over during the later distillations. The final dis- 
tillate weighed 3.6130 grammes, and struck the usual tint with the chromic acid test; 
when boiled in a test tube the vapor of alcohol burned within it satisfactorily. The 
quantity of alcohol obtained was 0.0444 gramme. 
No. 19.-8988 grammes (19.81 lbs. avoir.) of ox blood, from two animals, was raised 
to 212° in 60 minutes after the animals were struck down. 250 grammes of the usual 
solution of sulphurated hydrogen was added, as before. The temperature of the blood 
when received was 99°. Alcohol was seen to pass over during the later distillations. 
The final distillate weighed 2.6092 grammes. The vapor of alcohol burned within the 
test tube in a most satisfactory manner upon ebullition of the final distillate, which 
gave the usual reaction of alcohol when the chromic acid test was added. The quan- 
tity of alcohol was 0.1357 gramme. 
No. 20.-8854 grammes (19.52 lbs. avoir.) of similar blood, from two animals, was 
raised to 212° F. in 60 minutes after the oxen were struck down. 255 grammes of the 
solution of sulphurated hydrogen was added, as before. The temperature of the blood 
when received was 98° F. Alcohol was seen to pass over in the later distillations. The 
final distillate weighed 1.7320 grammes, and gave the reaction of alcohol with the 
chromic acid test. The quantity of alcohol obtained was 0.0760 gramme. 
No. 21.-9423 grammes (20.77 lbs. avoir.) of similar blood, from two animals, was 
raised to 212° in 45 minutes after the oxen were struck down. No sulphurated hydro- 
gen was used in this experiment. The temperature of the blood when received was 
96°. Alcohol was seen to pass over. The final distillate weighed 1.8722 gramme, and 
gave the alcoholic reaction with the chromic acid test. Upon ebullition, the vapor of SECTION VIII PHYSIOLOGY. 
327 
alcohol burned within the test tube, and remained burning at its mouth for some 
seconds after the removal of the taper. The quantity of alcohol was 0.0708 gramme. 
No. 22.-9122 grammes (20.11 lbs. avoir.) of similar blood from two animals was 
raised to 212° in 61 minutes after the animals were struck down. The temperature of the 
blood when received was 98°. No sulphureted hydrogen was used in this experiment. 
Alcohol was seen to pass over during the later distillations. The weight of the final 
distillate was 0.9552 gramme. The chromic acid test gave the emerald-green reaction 
of alcohol. The vapor of alcohol burned satisfactorily in the test tube upon ebullition 
of the final distillate, remaining inflamed at the mouth of the tube after the removal 
of the taper, and being relighted several times, as the liquid in the tube was made 
repeatedly to boil. The quantity of alcohol obtained was 0.0350 gramme. 
In the preceding eight experiments, 1500 grammes of first distillate was brought 
over in each case from about 9000 grammes of blood. As a portion of alcohol might 
still remain in the organic material, all the alcohol of a spirituous liquid being driven 
over only by the evaporation of somewhat more than half its bulk, it was determined 
to bring over 4650 grammes of first distillate in a series of operations. To do this, about 
seven hours of distillation was necessary. 
No. 23.-27.330 grammes (60.25 lbs. avoir.) of ox blood was distilled in three opera- 
tions, in portions of about 9000 grammes each, the respective intervals between death 
and elevation to 212° being 50 minutes, 45 minutes and 50 minutes. About 4700 
grammes of first distillate in each case was brought over. The first was purified and 
concentrated to 120, 130 and 500 grammes. The three fluids were then mixed and 
treated as usual. The conjoint final distillate weighed 10.6883 grammes. It struck a 
bright green tint with the chromic acid test; when boiled in a test tube the vapor of 
alcohol burned satisfactorily, remaining lighted after the removal of the taper. Not 
more than a gramme was used ; the remainder was set aside. The quantity of alcohol 
was 0.2928 gramme. 
No. 24.-36.300 grammes (80.03 lbs. avoir.) of ox blood was distilled in portions of 
about 9000 grammes each. The interval between death and elevation of the blood to 212° 
F. was in each case 55 minutes, 56 minutes, 50 minutes and 45 minutes. 4900 grammes 
of first distillate was brought over in each operation. Each first distillate was purified 
and distilled down to about 120 grammes. The four resulting fluids were then mixed, 
as in the last experiment, and concentrated by distillation. The conjoint final distil- 
late weighed 14.0606 grammes, manifesting the characteristic reaction of alcohol with 
the chromic acid test; the vapor of alcohol burning, as before, in the test tube and at the 
mouth. The quantity of alcohol obtained was 0.5652 gramme. What remained of 
the final distillate of these two last experiments (Nos. 23 and 24) were mixed and set 
aside, a few crystals of nitrate of silver having been thrown in for the purpose of 
destroying any remaining traces of the volatile body supposed to be aldehyde, and kept 
in the dark for eleven months. At the end of this time the liquid contained a slight 
black precipitate, owing, doubtless, in part to reduction of some dissolved nitrate by 
diffused light, and upon concentration by two distillations to a specific gravity of 
0.986 (which is specific gravity favorable to the satisfactory application of the test), the 
vapor of alcohol burned at the mouth of the test-tube and within it, as before, though 
with far greater intensity. 
The mean quantity of alcohol obtained for 10,000 parts of blood when sulphureted 
hydrogen was not added at the moment of its collection, was, 0.0567 of one part ; and 
when sulphureted hydrogen was so used, 0.1028 of one part, or about twice as much. 
The assumption, therefore, that this body arrested or impaired the oxidative processes 
by which alcohol was destroyed in the blood operated upon after its escape from the 
vessels of the animals, appears to have been confirmed. Carbon protoxide should act 
in a similar manner, as, according to the investigations of Bernard, it renders the red NINTH INTERNATIONAL MEDICAL CONGRESS. 
328 
corpuscles of the blood incapable of absorbing or of parting with oxygen, but on 
account of the difficulty of using it at the slaughter house, due to its gaseous form and 
slight solubility in water, sulphureted hydrogen was preferred. In all the later experi • 
ments the solution of this latter substance was placed in the blood receiver, so that the 
blood was immediately subjected to its influence as it gushed from the incised veins. 
The mean quantity of alcohol obtained in these ten experiments was 0.0797 gramme 
to 10,000 grammes of blood. Alcohol is always present in this mixed blood. I have never 
failed to find it. Its quantity is necessarily variable; for, as I have explained, the blood 
cannot be supposed to be derived at all times from the same vessels, owing to variations in 
the process of slaughtering by which the quantity of sugar and its resultant alcohol must 
be notably affected. I have not found it practicable, so far, to surround the collection 
of this blood with any physiological conditions whatsoever ;it must be used as it pours 
from the neck of the animal. Practically, however, as the slaughtering is usually per- 
formed by experienced persons, in any one establishment, in the same way, so as to 
exsanguinate the animal as speedily and as completely as possible, considerable uni- 
formity ought to pertain to parcels of the blood collected at the same place. 
Having now determined the normal existence of alcohol both in the lung tissue and 
in the mixed blood of the slaughter house, I determined to search for it in the tissue 
of the liver. Here a new difficulty arose. The lungs, being exceedingly vascular, and 
collapsing by their proper elasticity after the thorax is opened, necessarily imprison a 
certain quantity of blood retained in their capillary vessels. It was from this capillary 
blood that the alcohol obtained by the distillation of the lung tissue must have been 
derived. The liver, however, is vastly less vascular than the lungs, and is very thor- 
oughly drained of its blood, not only by the practice of the French butchers, at least, 
of applying the foot to the hepatic region, but also because the larger trunks of the 
hepatic veins are not occluded by the weight of the organ when excised, their walls 
being directly continuous with the hepatic stroma; their channels, consequently, remain 
open for the escape of the blood upon exsection or slicing. It is from this blood of the 
hepatic veins, however, that we should expect to obtain alcohol, on account of the 
known presence of sugar in it. Nevertheless, as the smaller vessels of the hepatic 
venous system and their rootlets in the acini must retain some blood, and as this is 
normally saccharine, though far less so during life or immediately after death than 
Bernard originally believed, if the alcoholic fermentation is proper to the hepatic veins 
and begins to advance in their blood as soon as sugar is transuded into it by the cell 
action of the liver, it might be possible to obtain some trace of alcohol by distillation 
of the hepatic substance. Impressed with such considerations, I made the following 
experiments :- 
No. 25.-2985 grammes (6.58 lbs. avoir.) of ox-liver tissue was raised to 212° in 40 
minutes after the animal was struck down. 1400 grammes of first distillate was brought 
over. The final distillate weighed 1.1050 gramme; its specific gravity was 0.9989, 
corresponding to 0.0064 gramme of alcohol. This final distillate was too dilute for 
the inflammation of the vapor of so small a quantity of alcohol in the test tube, but it 
was colored a bright green by the chromic acid test. 
No. 26.-The entire liver of a dog, weighing 650 grammes (1.431b. avoir.), the 
animal having been killed by section of the rachidian bulb, was raised to 212° in 
seven minutes after the sacrifice of the animal. The final distillate weighed 0.860 
grammes and struck a bright emerald-green tint with the chromic acid test, but was 
too dilute for the inflammation of the vapor of the very small quantity of alcohol pres- 
ent in the test tube. This quantity of alcohol was 0.0024 gramme. 
These results determined me to employ masses of liver tissue many times greater 
than those distilled in these last two experiments, as follows:- SECTION VIII-PHYSIOLOGY. 
329 
No. 27.-18,200 grammes (40.12 lbs. avoir.) of fresh ox-liver tissue was distilled in 
three portions:- 
No. 1. -6000 grammes was raised to 212° in 35 minutes after the animal was struck 
down, 1550 grammes of first distillate being brought over. 
No. 2.-6000 grammes was raised to 212° in 40 minutes after the animal was struck 
down, a like quantity of first distillate being brought over. 
No. 3.-6000 grammes was raised to 212° in 45 minutes after the animal was struck 
down, an equal quantity of first distillate being brought over. 
These three distillates were mixed and concentrated. The final distillate weighed 
1.2304 gramme. It struck a vivid green tint with the chromic acid test. The vapor ot 
alcohol burned most satisfactorily and repeatedly, upon intermissions of the boiling, 
when the final distillate was tested. The quantity of alcohol obtained was 0.0324 
gramme. 
The ratio of the alcohol obtained in Expt. No. 25 to the liver tissue employed was 
one part to 466,406; in No. 26, one part of alcohol to 270,000, and in No. 27, one part 
to 555,555 of liver tissue. These results are so concordant that it is impossible to doubt 
their accuracy, and illustrate the extraordinary efficiency of distillation when con- 
ducted with the care taken in the experiments reported in the present paper. Indeed, 
my confidence in the quantitative accuracy of the methods followed is such that all of 
the results may be numerically compared with each other. Even in the present con- 
nection I think that a comparatively greater quantity of alcohol was obtained in No. 
26, where the dog's liver was distilled, because the exsanguination of the ox liver had 
been more complete, the liver of the dog having been rapidly cut up into several pieces 
and cast into the copper balloon, while the ox liver had been previously drained of its 
blood much more perfectly. 
Alcohol, therefore, undoubtedly exists in the stroma of the liver, even in animals 
slaughtered by hemorrhage, and within as short a period of time as it is practicable to 
bring the substance to the boiling point, the shortest of these intervals having been 
only seven minutes. It must then be conceded that the alcoholic fermentation pro- 
gresses in the liver during life. 
By comparing the results of distillation of liver tissue with that of the lung tissue 
an interesting fact is brought into view. The ratio of the alcohol recovered in Expts. 
No. 25, No. 26 and No. 27, as a mean, to 10,000 parts of the liver tissue operated upon, 
was 0.0188 of a part to 10,000 of the liver tissue, and in Expts. No. 12, No. 13 and 
No. 14 I have found that the ratio of the alcohol obtained to tbe weight of lung tissue 
operated upon was 0.3084 of a part to 10,000 parts of this latter tissue employed. 
Fresh lung tissue, consequently, contains somewhat more than sixteen times as much 
alcohol as liver tissue. As in both cases the alcohol can only exist in the capillary 
blood left in the organs after exsection and drainage, the lung tissue must retain a far 
greater quantity of such blood than the liver, owing to its vascularity, and especially to 
its elasticity, whereby the blood at least is imprisoned. I judge this to be the case from 
observing that when we cut a piece of fresh lung tissue and observe the surface, 
although the cut seems dry when made, within a few seconds, or a minute, the cut sur- 
face is moist and bloody. I do not think, however, that a difference of vascularity 
alone adequately accounts for the great difference observed between the liver and the 
lungs as to the quantity of alcohol obtainable from them; but feel disposed to attribute 
the small quantity found in the liver substance to the probable inauguration of the 
alcoholic fermentation in the blood of the hepatic veins, which contains much sugar 
and but little alcohol, while the lungs contain much more alcohol comparatively, and 
according to Bernard, little or no sugar. 
The sugar of the liver is thus to be regarded as fermented into alcohol and. carbonic 
acid for the most part in the transit between the liver cells dnd lung capillaries, but as 330 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
alcohol must be the unfailing attendant of sugar in the blood, and as we know that 
sugar is disseminated throughout the system during the digestive overflow, and also, 
to some extent, at all times, as Bernard finally admitted, we should find small quanti- 
ties of alcohol in the systemic blood of animals in digestion. 
To determine this point I made the two following experiments :- 
No. 31.-1368 grammes (3.01 lbs. avoir.) of the pancreatic tissue of the ox was 
rapidly and carefully isolated. The animals from which it had been derived, being 
ruminants, were, of course, more or less in digestion at all times, access to fodder and a 
field of grass being allowed to them. The tissue was raised to 212° in 60 minutes after 
the animals were struck down. The final distillate weighed 1.0246 gramme and 
struck a vivid green tint with the chromic acid test. The quantity of alcohol was very 
small and was not estimated, nor did its vapor burn in the test tube. 
No. 32.-280 grammes (0.63 lb. avoir.) of blood was drawn from the cephalic 
extremity of the jugular vein of a small bitch, and raised to 212° in ten minutes 
after the vein was opened. The animal was in full digestion. The final distillate 
weighed 0.6000 gramme, and struck a bright green tint with the chromic acid solution. 
The quantity of alcohol was minute and could not be inflamed in the test tube, nor 
was it estimated, as its specific gravity was too low. 
Alcohol was thus found to exist in the capillary blood of the pancreas, and in the 
centripetal venous blood in very minute quantity, according to the theoretical provision 
which governed the experiments. We must conclude that whenever we find sugar in 
the fluids of living animals we must likewise find alcohol in proportionate quantity, 
the alcoholic fermentation progressing everywhere in the circulation, though most active 
between the liver cells and the left side of the heart. 
In accordance with the foregoing observations, direct experiment should confirm the 
hypothesis of a hæmal oxidation of alcohol. I will premise, however, by remarking 
that processes instituted by art, in imitation of natural ones, and especially of those 
taking place in the animal body, can be conducted under conditions only roughly 
similar to those imitated, even when fortunately planned and skillfully executed; 
numerous difficulties embarrass the inquirer and tend to complicate his results. The 
attempt to oxidize alcohol in blood out of its natural channels can, of course, merely 
illustrate the direction of the normal processes, as it is evident that for many reasons 
the oxidative powers of the blood must be very gravely impaired by removal from the 
vessels, and that no degree of agitation with atmospheric air can compare in efficiency 
with the marvelous exposure to oxygen realized by the pulmonary structure. Never- 
theless, the following experiments, being conducted with great care, may be found to 
possess a certain degree of cogency :- 
No. 28.-Into 1000 grammes (2.24 lbs. avoir.) of fresh defibrinated ox blood 0.3882 
gramme of absolute alcohol was dropped. The blood was placed in a glass flagon 
holding three quarts, and the flagon, with its contents, was maintained for two hours 
at a temperature of 98°, by a water bath, regulated by a thermometer. The flagon was 
frequently removed from the bath, and its contents thoroughly commingled by agita- 
tion with the superjacent air, this air being removed every five minutes by a bellows. 
The blood assumed and maintained a florid arterial hue. It was then distilled over the 
bath of common salt. The final distillate weighed 1.9733 gramme, reacting with the 
chromic acid solution as usual, and when boiled in a test tube giving off vapors which 
burned in the manner of alcohol. The quantity of alcohol recovered was 0.0258 
gramme. 
I had previously ascertained that when 0.26 gramme of absolute alcohol was 
dropped into 1000 grammes of blood already ninety hours old, at a period, therefore, 
when the corpuscles have entirely lost their functions by disorganization, and when this 
quantity of alcohol was allowed to remain in such blood for forty-eight hours longer, it SECTION VIII-PHYSIOLOGY. 
331 
could be almost entirely recovered by distillation, provided the temperature had not 
been above 60° F. ; the legitimate inference, therefore, deducible from the results of the 
above experiment was that 0.3623 gramme of alcohol had been destroyed by oxida- 
tion into acetic acid, or still further in the two hours during which the aeration was 
continued. 
No. 29.-Into 1000 grammes of fresh defibrinated ox blood contained, as before, in a 
glass flagon holding three quarts, 0.5823 gramme of absolute alcohol was dropped. 
The flagon was placed in a water bath and maintained at a temperature of 100° by a 
thermometer hung in the bath during two hours. Every two minutes the air of the 
flagon was removed by a bellows, and the flagon, closed by its stopper, for a moment 
withdrawn from the bath and vigorously agitated. Sugar was found to be present, by 
Fehling's test, both at the commencement and at the termination of this procedure. 
The blood was then distilled over the bath of common salt. The final distillate weighed 
1.2616 gramme, reacting, as before, with the chromic acid test, and burning upon ebul- 
lition in the test tube. The quantity of alcohol was 0.1877 gramme ; 0.3946 gramme 
had therefore disappeared. 
From these results it appears that more than two-thirds of a certain quantity of 
alcohol added to fresh blood is destroyed in it under conditions simulating the oxidative 
processes of the economy ; and by comparing the relative quantities added and obtained 
in the two cases it would seem that a certain limit exists in this respect, the quantities 
of alcohol which had disappeared being nearly the same in both experiments, viz. : 
0.3623 gramme and 0.3946. These results, moreover, illustrate the great accuracy of the 
distillatory procedures. 
That the oxidating process assumed was really efficient in the destruction of the alcohol 
lost in these two cases, would, however, be more positively affirmed in a control exper- 
iment, in which a converse effect was aimed at by the employment, instead of atmo- 
spheric air, of a substance known in the economy to be associated with hypo-oxygena- 
tion of the blood, viz. : carbonic acid. If under the use, in a similar way, of this gas 
alcohol was not destroyed, or was not destroyed in equal quantity, its destruction 
would be still more reasonably attributable to the assumed hæmal oxidation. The 
blood having been rendered quasi arterial in the last two experiments, it was determined 
to ascertain the effect of rendering it quasi venous by the use of carbonic acid instead of 
air. 
No. 30.-'Into 1000 grammes of fresh defibrinated ox blood, contained in the same 
glass flagon, 0.5176 gramme of absolute alcohol was dropped. The flagon was filled by 
displacement after the introduction of the blood, and before the addition of the alcohol, 
with pure carbonic acid gas. It was then closely stoppered, and maintained at 100° F., 
in a water bath regulated by a thermometer, during two hours. Carbonic acid was 
repeatedly added during the experiment, the blood being each time thoroughly agitated 
with it, with the production and maintenance of a very dark or even black hue. The 
blood was then distilled over the bath of common salt. The final distillate weighed 
4.8848 grammes, and reacted as usual with the chromic acid solution ; upon ebullition, 
likewise, in a test tube, giving off vapors which burned after the manner of alcohol. 
The quantity of alcohol recovered was 0.2931 gramme ; 0.2245 gramme of this sub- 
stance had disappeared. 
The mean ratio of the alcohol lost in the two experiments in which the blood had 
been arterialized was 80.5; in the last experiment, in which the blood had been venosed, 
it was 43.0; results distinctly confirmatory of the supposition acted upon. Whatever 
process had been facilitated in the first two experiments, had been retarded or impeded 
in the third of the series. Arterial blood seems therefore to consume alcohol with far 
more facility than venous blood. If my object had been to destroy the oxidizing power 
of the blood corpuscles, hydrosulphuric acid might have been used, as when it was 332 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
employed with a similar purpose in the distillations of fresh ox blood. I preferred, 
however, to simulate as nearly as possible the normal differences of function obtaining 
in arterial and venous blood, especially as the use of sulphureted hydrogen had already 
contributed to the establishment of this hypothesis of the haemal oxidation of alcohol, 
by increasing the quantities of alcohol recovered in the final distillates. 
Alcohol is undoubtedly oxidized in the blood very completely, no portion of it, what- 
ever, being recoverable from the urine, according to the experiments of Benz, Anstie, 
and Dupré, when moderate quantities of it are ingested, while by far the greater pro- 
portion of what is consumed is lost in the organism, even when excessive quantities 
are taken. 
The alcohol which is produced in the blood by the /ementafion of hepatic sugar, is 
doubtless intended or utilized in a hæmal combustion, which is one of the prime sources of animal 
heat. This alcohol must be regarded, moreover, as the hydrocarbonous element, long since 
divined to be destroyed by the oxidative powers of the economy, for the maintenance 
of the proper animal temperature. While muscular action generates heat, and all the 
chemical and functional actions of the body likewise extricate a certain amount of heat, 
I regard the two processes involved in the alcoholic fermentation of hepatic sugar in the 
economy as contributing by far the greater part of the heat dissipated by the skin and 
lungs, or lost in the fæces and urine and by radiation. The fermentation of hepatic 
sugar itself must originate a large share of heat, for the marked rise of temperature 
which occurs in fluids undergoing the alcoholic fermentation, is a matter of common 
observation, which must, moreover, be guarded against, at great expense, by all who 
manufacture fermented liquids, such as ale and beer. This source of heat, consequently, 
is the primary one, though, perhaps, not so great as that which is involved in the hæmal 
oxidation of the resulting alcohol. I have not, however, had opportunities to make 
comparative researches on these points, which, indeed, have not been studied carefully 
with the calorimeter. That alcohol should fulfill this function in the organism is cer- 
tainly most harmonious with all we know of its properties and the circumstances 
attendant upon its generation in the economy and the elimination of its products. It 
is distinguished, chemically, for its ready oxidation. Its vapor is so inflammable as to be 
explosive, and its combustion is remarkable, both for the great heat which it evolves and 
the simple nature of its products. When alcohol is consumed in the air, water and car- 
bonic acid alone result; substances evolved at all times in the air expired from the lungs. 
The existence of these matters in the expired air has been long known, and their rela- 
tive quantities closely studied; their presence has always been referred to the combus- 
tion of a body containing carbon and hydrogen. What substance so fit for such a 
combustion as alcohol ? A fluid miscible with water in all proportions, with the most 
marked affinity for oxygen; capable of destruction by direct inflammation, and by slow 
oxidation under the influence of albuminous matter in a state of change, by platinum 
black and platinum sponge, or even by the oxygen dissolved in aqueous fluids with 
which it may be mingled, provided the reaction of the fluid be alkaline ; producing, 
moreover, by its rapid or slow oxidation, a gas which exists in the blood, and a fluid 
which is the common menstruum of the body, tolerated in almost any quantity by the 
organism. Alcohol is especially adapted to the function of maintaining the anima] 
temperature. 
It is easy to comprehend how alcohol may be transformed within the body into car. 
bouic acid and water. "Aldehyde, acetic acid, formic acid, oxalic acid, and carbonic 
acid," says Liebig, "form a chain of products arising from the oxidation of alcohol; all 
these products appear to be formed simultaneously by the action of oxidizing agents." 
In virtue of its extreme division, of the ease with which it assumes a pronounced nega- 
tively electrical condition, and its remarkable power of condensing gases, and oxygen 
especially, of which it can condense and retain several hundred times its volume, pla- SECTION VIII-PHYSIOLOGY. 
333 
tinum Hack, or metallic platinum in a state of minute division, effects a ready oxidation 
of alcohol into aldehyde, basic acetate of ethyl, or acetal and acetic acid. When platinum 
black is fully charged with oxygen, " if a drop of absolute alcohol be thrown upon it, 
the whole substance becomes incandescent ; and if a capsule containing platinum black 
be placed under a bell-glass filled with air, the sides of which are moistened with alco- 
hol, the vapors of alcohol undergo a slow oxidation, which converts them into acetic 
acid." (Reynault, II, 341.) Platinum sponge and wire also possess similar qualities, 
heat being always evolved. 
A strong analogy exists between the particles of platinum black and the red cor- 
puscles of the blood. Like platinum black, the red corpuscles possess the remarkable 
and significant property of condensing large quantities of oxygen, and of parting with 
it again with facility to easily oxidizable substances ; their size is also extremely small, 
their number infinitely great, and their exposure to oxygen in the lungs wonderfully 
complete. The red corpuscle also acts like a minute reagent, whose sides are in states 
of opposite polarity, for we see it attracting its neighbor as soon as the movement of the 
blood stream is arrested. And if this be true, which is rendered still more probable 
from the fact that iron is a constituent of the blood corpuscles, we are prepared to witness 
the energy with which it attracts oxygen, for the same is known to take place out of the 
body, oxygen being the most strongly attracted by the magnet of all gases (De la Rive). 
The blood corpuscles, therefore, in virtue of their proper constitution, are evidently fitted 
to effect the facile oxidation of easily oxidizable matters. This property of easy oxi- 
dation, however, such as alcohol and other similar bodies possess, into whose constitution 
hydrogen largely enters, is greatly enhanced by the presence of albuminous matters in 
the condition of a ferment or undergoing change of the nature so closely studied by 
Liebig, provided a suitable temperature be maintained. The process of acétification is 
essentially based upon this ferment influence, and requires the coincidence of favorable 
temperature and ready access of oxygen. At temperature of 70° to 80° the process takes 
place slowly, but at about the temperature of the animal body and with the aid of a 
designedly extended exposure of the alcoholic fluid to the air, and the addition of some 
albuminous matters, the change of alcohol into vinegar is very rapid, and the amount 
of heat extricated considerable. The details of what is termed the ' 1 quick vinegar 
process, ' ' are worthy of study in this connection. Régnault describes it as follows : 
" In order that acétification may progress rapidly, the alcoholic liquor must be suffi- 
ciently diluted with water, and present a large surface to the oxidizing action of the 
air. These conditions are fulfilled on a large scale by using an alcoholic liquor con- 
taining one part of alcohol to eight or nine of water, and adding about one-thousandth 
of fermentable liquor, such as beet juice, potato juice, or small beer, when the liquor 
thus prepared is dropped into barrels filled with beech shavings. The lower part of the 
barrel is pierced with several holes, and the upper part with other holes, while a false 
bottom forms a vat, into which the alcoholic liquor is poured. The false bottom has a 
great number of holes, through which pass pieces of twine, having a knot on the end, 
to prevent them from slipping through. The alcoholic liquor flows along the twine, 
and dropping on the shavings, spreads into a thin layer, and presents a large surface to 
the oxidizing action of the air ; oxidation being effected by means of the ferment con- 
tained in the liquor, and the albuminous substances in the wood, while the temperature 
rises and produces a current of air which enters at the lower holes and escapes at the 
upper ones Oxidation is so rapid that when the liquid reaches the bottom af the barrel, it 
frequently no longer contains any alcohol; but if after one passage, the alcohol is not com- 
pletely converted into acetic acid, it is passed through a second time." (" Elements of 
Chemistry," II, 544.) During the process the temperature maintains itself at from 86° 
to 97° ; at the beginning, the alcoholic liquor must be first heated. 
This process, originally noted by Liebig, strikingly illustrates the primary step of 334 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the oxidation of alcohol in the animal body. This first stage must be through aldehyde 
into acetic acid ; no other oxidative progress is possible for alcohol under the conditions 
of the living body. The substance which comes over in the later distillations just in 
advance of alcohol must be aldehyde, or its compound with the ethyl base of the alco- 
hol, basic acetate of ethyl, so-called acetal. This latter body is one of the products of 
the slow oxidation of alcohol by platinum black, and may be regarded as a compound 
of aldehyde with oxide of ethyl. In contact with platinum black, this substance is 
oxidized in the air into acetic acid, says Löwig. Aldehyde itself is one of the most 
oxidizable bodies known ; it dissolves in all proportions in water, boils at 71.3° F., and 
is converted into acetic acid by all oxidizing agents. For this reason, I have found 
the use of nitrate of silver, in considerable quantity, effective in destroying this mobile 
substance in the later and final distillates. On mixing from five to ten per cent, of its 
weight of crystallized nitrate of silver, in powder, with the distillate, the liquid 
becomes densely milky, and after an hour or two shows a blackish-brown, flocculent 
precipitate, while the supernatant liquid is clear. In the next distillation they no 
longer pass over, having been completely destroyed, if the quantity of nitrate of silver 
employed was sufficient. As both acetal and aldehyde produce acetic acid by oxidation, 
as both these matters, together with acetic ether in small quantity, are formed by the 
action of platinum black upon alcohol, as they are both destroyed by the action of 
nitrate of silver with heat, as they must necessarily exist wherever alcohol is oxidized 
slowly, and as the two volatile substances seen in advance of the alcohol, as it comes 
over beyond the first bend of the eduction tube, coexist with the alcohol found, thus, 
indeed, rescued from the oxidative processes of the body, I must regard them as 
aldehyde and acetal. The boiling points of these liquids are as follows : aldehyde, 
71.3° F. ; acetic ether, 165° F. ; alcohol, 173° F. ; acetal, 203° F., and water, 212°. 
Necessarily existing, in very minute quantities, in the liquid submitted to distillation, 
these substances will come over just at the beginning of the ebullition, which will not 
occur until the mean of the liquid has attained a temperature of 212°. They will then 
come over in the order of their boiling points, viz. : aldehyde, acetic ether, alcohol, 
acetal, and will continue to do so until a certain quantity of the liquid is brought over. 
This |is what is observable during the final steps of every distillation of this kind, and 
as all these substances disappear under the oxidizing influence of nitrate of silver with 
heat, I must conclude that these bodies are really such as I have named, and conse- 
quently derivatives of the oxidation of alcohol and associated products in the acétifica- 
tion of alcohol. Hence, their presence I regard as very strong corroborative evidence 
of the actual oxidation of alcohol in the body by the stages named, viz. : aldehyde, 
acetic acid, formic acid, etc. The only test which I have been able to apply to these 
bodies is the nitrate of silver, which is immediately decomposed by them and destroys 
them in turn, metallic silver being left, while the alcohol is unaffected. 
The conditions under which alcohol is oxidized in the blood we thus find to be 
wholly parallel with those existing both when it is oxidized by platinum black and in 
the " quick vinegar process." The process as conducted in the blood seems a combina- 
tion of the peculiar features of both of these actions, while the theoretical demands, 
viz., minute dissemination of the oxygen, the presence of albuminoids in a state of 
change, a high and constant temperature, and the liberation of the oxygen in the form 
of ozone, are vastly better satisfied in the animal body than in the oxidative processes 
referred to. The great surface of the beech shavings is analogous to the great surface 
of platinum black, and to a great surface in the blood mass, effected by the smallness 
and number of the red corpuscles. It is not, therefore, the lung, as suggested by 
Liebig, but the blood itself, which is analogous to a barrel of beech shavings. Irre- 
spectively of the red corpuscles, the blood containing alcohol is similar to the " fer- 
mentable alcoholic liquor ' ' employed in the quick vinegar process, while the corpuscles SECTION VIII-PHYSIOLOGY. 
335 
are analogous to the minute particles of platinum in the "black " or "sponge," espe- 
cially in their power to condense large quantities of oxygen, and still further of liber- 
ating this oxygen to easily oxidizable bodies in the form of ozone. 
The transformation of starch and dextrine into alcohol and carbonic acid are quali- 
fied by the extrication of large stores of heat, due to the gradual approximation of the 
molecules, as the original colloid becomes transformed into crystalloidal matters. We 
know this to be so out of the body, for the brewer's vat becomes heated, while the sugar 
is converted into alcohol and carbonic acid. The vinegar maker's tubs, also, where alco- 
hol is transformed into acetic acid, become hot ; the heat in this case being accredited to 
a loss of gaseous form by the oxygen consumed, a continued liberation of heat being 
observable as long as the quantity of carbon and of hydrogen are in excess of the 
oxygen combined with them in the train of matters submitted to progressive oxidation ; 
all this is familiar enough to the chemist and physiologist. The existence of alcohol 
in the organism, as proved by the distillation of a variety of organic matters ; the exist- 
ence in the distilled fluids of substances significant of the progressive oxidation of alco- 
hol into water and carbonic acid ; the existence of glycogen in the liver, which, by a 
change into glucose, is plainly a part of the mechanism by which alcohol is set free for 
an instant in the blood, constitute a network of concordant facts whose dominant 
hypothesis is plainly the one maintained in this paper. 
Dr. T. C. Stell wagen, of Philadelphia, Pa., read a paper- 1/ 
ON THE TEETH AS INDICATORS OF THE NUTRITION, PAST AND 
PRESENT, OF THE PATIENT. 
SUR LES DENTS, COMME INDICES DE LA NUTRITION DU PATIENT, AUTREFOIS 
ET A PRÉSENT. 
ÜBER DIE ZÄHNE ALS ANZEIGER DER ERNÄHRUNG DES PATIENTEN IN DER VERGAN- 
GENHEIT UND GEGENWART. 
The importance of proper regimen for development of the animal hody has always 
been a favorite subject with physiologists; hence it is by no means a novelty to which 
your attention is invited in this paper; yet there are some features that would seem to 
bear closer investigation. There appears, at least among the laity, to be an increased 
interest in the study of diet, and an effort to discover that most proper for general nutri- 
tion. To judge from the elaborate and expensive advertising of different preparations 
of foods for infants and invalids, they at least seem to support many of the medical 
journals and furnish a very desirable pabulum for their publishers as well as some sort 
of pap for the babes. Without attempting to discuss the merits of the various and not 
nauseous mixtures that, under the pretext of feeding, are forced down the 
throats of almost starving children, let us examine more thoroughly and discover any 
defects that may exist in the nourishment of the new being during its entire embryonic 
existence. 
No one experienced in agriculture or pomology would think of taking seeds or graft- 
ings from a defective and poorly nourished plant or tree if others could be obtained, 
and the most abundant evidence exists, indeed the proposition seems undisputed, that 
by proper application of fertilizers to assist the moisture, and by the full amount of sun- 336 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
light and fresh air, the value of the crop both as to quantity and quality is greatly 
enhanced. The attempts at too close planting have long since had their erroneous and 
unprofitable results shown in the most practical ways. The agriculturist and arbori- 
culturist both attest, by their careful avoidance of overcrowding their land, that the 
most favorable conditions for crops are those which allow the sun force and the atmos- 
phere to have free access to the individual plants; indeed, in nearly all cases, both of 
these are absolutely essential. Likewise it must be a self-evident truth that the same 
conditions hold as regards the domestic animals, and although breeders of stock recog- 
nize and obey this same law, strangely enough human beings seem to have so long fol- 
lowed a reverse, or nearly opposite course with themselves and children as to be too often 
forgetful of or oblivious to its application to their own progeny. The seclusion of the 
child-bearing women, which has become essential in the blind obedience rendered to a 
fiat of society in many parts of our country, is productive of serious injury that may 
even prove fatal both to the mothers and their offspring. . The dimly-lighted and tightly- 
closed apartments of the fashionable house affect the mothers' spirits, rendering them 
morbid and unhappy, apprehensive of danger and death. From like causes enceinte 
women's appetites, which at best may be subject to strange caprices, are made more 
unnatural and erratic. Finally it is not sufficiently well understood that innutritions 
or indifferent food, even if sw allowed, cannot be properly digested or assimilated. Under 
these conditions the digestive, the nervous, the muscular and the circulatory systems 
are sluggish in their action. But one result may be anticipated as following the semi- 
invalid and inactive conditions of the patients. Hearty open air exercise is doubly 
imperative for the women about to become mothers, while under the ordinary states, 
ouly their own lives, happiness and health are at stake. Modern philanthropists have 
given much charitable attention to improvement in the ventilation and daylight illum- 
ination of the dwelling places of the poor or of those in very moderate circumstances in 
our large cities. While on the other hand, modern society, in obedience to fashionable 
whims, seems engrossed in the shutting out of these old time and hackneyed agencies, 
thus most seriously adding to inherited infirmities. With the rich this is accomplished 
by means of such devices as heavy, deeply set, narrow window sashes, with stained 
glass, often too costly to permit of their being opened for any purpose, lest a passing 
breeze might dash them to pieces. While, as if to further seal the doom of both mother 
and offspring, what little light or air may penetrate these barriers, is again obstructed 
by heavy hangings in the way of blinds, curtains, lambrequins, portierres and various 
forms of arras. This evil is so great, and upon the children of the thrifty its results are 
so monstrous, that it would seem to be an equally important benefit to mankind to 
rescue these worthies from the darkness of their abodes and the perils with which they 
are innocently, but no less direfully, threatened. 
Already the sufferers from diseases engendered by these modes of living are increas- 
ing with alarming rapidity, and the premature impairment or loss of most important 
organs, as the eyes and teeth, are compelling the employment of specialists by thousands. 
Fortunes are daily expended by our fashionable and wealthy people in the vain endeavor 
to hold fast to the decrees of their fickle goddess and yet maintain a moderate degree 
of health for themselves and their still more unfortunate families. The injury to the 
respiratory apparatus by fine dust, the fuzz of the carpetings, and various forms of 
fashionable detritus, have been dwelt upon, but almost in vain, by the very practitioners 
whose honorable and praiseworthy motives are unapproachable, and in defiance of the 
fact that their entire livelihoods depend largely upon their reputation for skill in reliev- 
ing the discomforts and diseases directly traceable to these pernicious furbelows. Yet. 
while this sacrifice of self-interest may not have been in vain, still the evil is growing 
and advancing in greater proportion than the numbers of our population. 
The selection and use of the best materials for fertilizing and feeding is urged with SECTION VIII PHYSIOLOGY. 
337 
so much stress in the advertisements daily paraded before the public in agricultural and 
medical journals, that the more important matters of energy from the sunlight and 
the pure oxygen of the atmosphere seem to be overshadowed in the minds of the mem- 
bers of our clienteles. Children are begotten daily by parents who put at defiance the 
most imperative laws of life, and the innocent foetuses are compelled to run the gauntlet 
of a process of temporary deprivation or diminution of the most essential matters ami 
forces that sustain life. The newborn infants are coddled in darkness amid the bed 
hangings and coverings, which are costly both to the purses and the lives of the com- 
munity, and the mothers silently and secretly grieve over the deficient offspring, whose 
troubles were coexistent with their first moments of earthly being. Birth-marks among 
these unfortunates, who should be the best reared, are as plentiful as their monstrous 
deprivations, and have been brought about by a prodigality of money expenditures that 
is productive of a like prodigality of diseased conditions and surroundings. Dental 
histology has opened the books of the lives of the patients written by nature until their 
pages are filled with the ineradicable marks upon the successive layers of the teeth 
structures; writings as momentous, as infallible and truthful; records fraught with 
instruction to intelligent observers. Upon the microscopical tablets of dentine may be 
seen the impressions that plainly show the defects and omissions in nutrition of the 
former life, beginning as early as the fortieth day of the existence of the new being, 
who, like Noah, has been tempest-tossed in the amnion ocean, secure in the ark of its 
embryonic membranes. 
The deficiencies of the mothers resulting from false notions of the propriety of exer- 
cise, as above mentioned, and the evils of their depraved digestion, assimilation and 
circulation are oftentimes duplicated with increased injury to the foetuses or children 
that depend upon these mothers for their nourishment. Thus results the stunting of 
the development and impairment of the structural formations of the different organs 
that so universally beget disease. If the darkness of the abysses of the Mammoth 
Cave is responsible for the lack of development of the eyes of the fish that abound in 
the rivers of this wonderful cavern, why should not the eyes of unborn babes be sub- 
jected to like deleterious influences during intra-uterine life ? Certainly this is borne 
out by analogy with the teeth, which unerringly show the markings of the afflictions 
of their possessors, due to defective assimilation during general disease both of the 
children and the mothers. So plainly are these demonstrable as to put the causes in 
full view beyond the question of the necessity of any further search for them. Added 
to the inheritance, from the most trifling peculiarities to defects which may compel the 
unfortunates to submit to the premature extraction of the whole or a portion of a 
denture, there is further to be deplored the almost willful starvation and consequent 
defective nourishment of all the organs at the time when the most trivial causes and 
slightest events are proven to be prolific of the gravest after results. The direction of 
the developing bud is even more important to its after life than the proverbial bending 
of the twig is to the inclination of the tree. 
The conditions of the teeth are closely allied to those of the bones, and as the for- 
mer are much more easily subjected to examination as to density and histological 
structural changes, why should they be neglected in an examination for physiological, 
diagnostic, or prognostic purposes. The sympathetic changes in the mouth have long 
been known to be in close relation to the diseases of the alimentary canal, but they 
pass so swiftly as rarely to leave more than an evanescent history behind. Upon the con- 
trary, we find that the teeth preserve these same records for their entire life, nay more, 
the markings are rarely obliterated during their very existence. By carefully con- 
ducted microscopical examination of the deciduous teeth as they are shed, we may 
learn much of the children's past, as to their nutrition and assimilation, that will be 
of untold value. By means of regular periodical examinations as to the density and 
Vol. Ill-22 NINTH INTERNATIONAL MEDICAL CONGRESS. 
338 
general condition of these organs we may gather practical information as to the effects 
of changes of diet, water, and mode of life. The variations in the teeth of the mothers 
in like manner are worthy of more earnest and constant attention by the general prac- 
titioner, since they quickly indicate the lack of lime for hardening them and a similar 
impoverishment of thé foetal bones, mostly due to absence of this material from the 
food and rarely attributable to defect of assimilation. Temperament and disposition 
are so well shown by the shapes, shades and arrangement of the teeth, that we may, 
without much if any risk, presume that they are the underlying causes, the expressions 
or the effects of these upon the general nutrition, and with which these organs thus 
harmonize. The transverse axes of the human teeth in their natural positions form 
the parabolic curves of the jaws, which arrangements are affected in like manner by 
certain diseases, as has been shown by Mr. John Tomes in his studies of the develop- 
ment of these organs. The lateral pressure exerted by the cheeks upon the teeth dur- 
ing the labored breathing of children suffering from chronic swellings of the tonsils, 
tends to make flattened sides, lateral compression, and gothic arching of the roof of 
the mouth or palatal plates of the superior maxillary bones and pushing forward of 
the vomer, causing aquiline or prominent noses. This may be a natural explanation 
of the peculiarities of visage presented in different races. Thus the Roman climate 
and pontine marshes may have, by natural causes, produced the Roman nose. 
Facial expression enters largely into the elements of which a diagnosis is made up, 
and it depends much upon the formation of the maxillary bones. It requires but little 
clinical observation to see that the maxillæ vary according to the arrangement of the 
teeth, which corresponds in its perfection with the use of these organs in mastication, 
and the efforts made to comminute the food. Thus we may see how, without fully 
understanding the subject, a practical diagnostician is forming opinions of patients 
from the effects of their diet and past life. SECTION VIII-PHYSIOLOGY. 
339 
FIFTH DAY. 
Dr. 0. Everts, of Cincinnati, Ohio, read a paper- 
ON THE CEREBRAL FUNCTION-TRANSMUTATION OF ORGANIC 
OR LIFE FORCE INTO PSYCHIC FORCE-THE PHENOMENA 
OF CONSCIOUSNESS, SEQUENTIAL, ETC., ETC. 
DE LA FONCTION CEREBRALE-TRANSMUTATION DE FORCE ORGANIQUE OU 
VITALE EN FORCE PSYCHIQUE-LES PHENOMENES DE LA 
CONSCIENCE EN SUITE, ETC., ETC. 
UBER CEREBRALE FUNKTION-UMWANDLUNG ORGANISCHER ODER LEBENSKRAFT IN 
PSYCHISCHE KRAFT-DIE ERSCHEINUNGEN DES BEWUSSTSEINS IN FOLGE, ETC., ETC. 
The propositions of this paper, expressed or understood, include the following:- 
Matter, restless and eternal, is everything. Force, undergoing transmutations cor- 
responding to material changes, is a manifestation of an inherent quality of matter. 
Psychic force, although apparently peculiar, as a manifestation, to living mechanisms, is 
correlatable with all other forms of force. Brain mechanisms alone supply the neces- 
sary conditions for the manifestation of a transmutation of energy of other character- 
istics into mental energy. All phenomena, however familiar or strange, are manifesta- 
tions of conditions of matter by which apparent transmutations of force are effected ; 
hence natural, "inevitable sequences " of such " antecedent conditions." 
The importance of the brain as an organ essential to life has always been recognized. 
Vague ideas of a mysterious relation between brain and mind, and of certain inex- 
plicable powers exercised by the brain in the economy of animal existence, were enter- 
tained by the older physiologists. Its real capabilities and offices, however, were but 
dimly foreshadowed by instructors in physiology before the beginning of the present 
scientific era-or the present century. The gross anatomy of the brain, cord, and 
nerves had been accurately described; Charles Bell and Marshall Hall added greatly to 
our knowledge of the capabilities and functions of the brain and its appendages as 
related to respiration, circulation, nutrition and locomotion ; and Dr. Gall had made 
memorable dissections, observations, and suggestions, leading in the direction of 
scientific truth; but it was reserved for the present generation of physiologists to dem- 
onstrate the more intricate mechanisms of brain structure, and ascribe to them 
supreme functions, of which they alone are capable. 
It is by reason of the profound researches of modern physiologists, aided by the 
light of a general illumination of the universe effected by modern science, that we are 
now brought face to face with, and stand more or less hesitantly in the presence of, 
certain final questions in physiology. 
Is consciousness an inherent quality of matter, when reduced to its lowest term, 
responsiveness; or a condition of matter incidental to changes essential to the appar- 
ent transmutation of vital into psychical energy ? 340 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Are the phenomena of mind, or manifestations of consciousness, however simple or 
complex, natural and inevitable sequences of material movements, effected and affected 
by material conditions and capabilities? In other words: Is matter, under any com- 
bination of circumstances, capable of feeling? and do brains think, unaided by 
supernatural entities, of which no scientific knowledge is obtainable? 
Why should physiologists, or others, emancipated from the ancient thralldom of the 
" supernatural " in other respects, hesitate in the presence of these final questions in 
physiology ? Is it because of the lack of testimony ? Is it not rather because of a 
natural, perhaps commendable, reluctance to destroy the last ship that might serve in 
the days of our weakness, and weariness of adventure, to bear us back to the haven of 
our ancestors in the land of myths and the realms of the supernatural ? 
What is the testimony respecting these things ? 
(A) As all our knowledge is based upon information derived from material objects 
through the senses, and all imaginations are combinations, simple or complex, of 
memories of sensuous things, we have no knowledge, and cannot have any, of immate- 
rial objects-any attempt to think of which necessarily resulting in confusion of 
ideas. 
(B) Self-consciousness, the source from which supernaturalists presume to derive 
their information respecting mental phenomena, is, after all, consciousness of matter, 
as all efforts to construct mental concepts of anything without form or substance end 
in confusion or the substitution of images of material objects of which we have 
already become conscious through sensuous perceptions. 
(C) Matter, under all known or presumable circumstances, manifests capabilities so 
nearly resembling consciousness as to suggest the inherency of such capableness, how- 
ever latent under ordinary circumstances. Unorganized matter manifests elective 
affinities. The lowest recognizable living mechanisms exhibit responsiveness to excita- 
tions corresponding to their necessities as living beings. As more complex structures 
are evolved by natural processes of selection and adaptation, in accordance with a 
trustworthy uniformity of conduct characteristic of matter, equivalent to a reign of 
law, greater capabilities of responsiveness, corresponding to increased necessities of the 
being evolved, are invariably manifested, until we see in succession the selective 
responsiveness of unorganized matter-the irritability and contractility of vegetable 
structures, and the lower forms of animal mechanisms-instinct, perception, memory, 
imagination, reason, etc., manifested by the highest and most complex beings; the 
chain of beings, and the chain of manifested capabilities running in parallel lines, 
inseparably and harmoniously. 
Is not the testimony conclusive ? If valid and convincing as to the inherent capa- 
bilities of a plant, a worm, a fish, a snake, a bird, a beast, of any description, it is 
valid, and should be convincing, respecting the cerebral capabilities of a man. If the 
inherent capabilities of a molecule of living matter do not require, for the performance 
of its functions, and is not inhabited by, a dominating supernatural entity, having no 
other relation to matter than that of temporary association, it is irrational and unsci- 
entific to assume that a man requires the services of and is inhabited by such a hypo- 
thetical being, in contempt of logic and appearances. 
The occult phenomena of modern spiritism, even-such of them as may be genuine 
-do not require the presence, or imply the existence, of such beings ; inasmuch as 
such phenomena are always associated with material, living beings, the full psychical 
capabilities of whose brain mechanisms even science is not competent to limit, or 
explain. 
The occultness of a phenomenon should not remand modern observers, necessarily, 
to the supernatural for au explanation that, inasmuch as being purely hypothetical 
and outside of human knowledge and capability of knowing, does not explain, but SECTION VIII-PHYSIOLOGY. 
341 
still further mystifies. Do brains think ? Is an aggregation of living mechanisms 
constituting a man capable of thinking ? Why not ? 
Are our ideas of matter so gross and unsympathetic-so limited and dogmatic-that 
we cannot entertain such affirmations ? What warrant have we for supposing that 
immaterial beings, if the existence of such beings were possibly supposable, are more 
capable than material beings whose performances are as palpable and unmistakable as 
our capabilities, whether material or spiritual, are qualified to appreciate. Is it not our 
' ' familiarity ' ' with matter that ' ' breeds contempt " of it ? Is it our total ignorance 
of supposititious spiritual beings that justifies an exaltation of their imaginary capabili- 
ties to any degree necessary to meet the exigencies of our ignorance ? 
Some modern physiologists, having rejected the ancient theory of supernatural inter- 
ference in the performance of the functions peculiar to cerebral mechanisms, substitute 
spiritual entities by the introduction of "force," which, although attributed to "ner- 
vous action ' ' as the cause of its being, instead of a miraculous and supernatural parent- 
age, is treated of as an entity in association with material mechanisms, with cooperative, 
if not independent, capabilities, under the general designation "mind." Having thus 
substituted a hypothetical entity, "spirit," with an entity equally hypothetical called 
" the mind," one modern author of distinction goes so far as to accommodate his new 
theory of cerebral physiology to ancient metaphysical notions respecting ' ' the mind ' ' 
by asserting: " The mind, like some other forces, is compound-that is, is made up of 
several sub-forces. These are: perception, intellect, emotions and will. Either one 
may be exercised independently of the other, ' ' etc. This theory is without scientific 
justification or support. It is not true physiologically nor psychologically, if the two 
branches of knowledge are really distinguishable. Force is not an entity capable of 
subdivision and the performance of function. It does not bear the same relation to 
structures manifesting it, or relations to the brain similar ' ' to those existing between any 
other viscus and the product of its action. ' ' Force is phenomenal, not material. Bile 
and all other products of glandular action, for example, are substantial-as material as 
the viscera that organize or eliminate them. 
Neither the brain nor any other organ or material mechanism ' ' exercises ' ' force or 
is exercised by force as an entity. As well might one say that a steam whistle exercises 
sound, or that a cannon ball exercises momentum, or that the clouds exercise lightning 
-the phenomena of sound, motion and lightning being manifestations of conditions of 
matter undergoing change or transmutations and interchanges of relation between par- 
ticles effected by inherent qualities, responsive at all times and under all circumstances 
to necessities implied by such changes. It may be convenient to call these manifesta- 
tions "forces," and speak of matter as "producing" them, as if they were material 
offspring. But when steam is generated by heat manifested during the combustion of 
coal, or a tree is shattered by lightning, or a cannon ball crashes through the timbers 
of a ship, what has really occurred ? The material conditions of coal and water, of 
clouds and tree, of cannon ball and ship's timber, have all been changed in consequence 
of their relation to, and changes taking place in, other material mechanisms, each 
change, with its manifestations, being an ' ' inevitable sequence of antecedent conditions ' ' 
of matter implicated, as is indicated by the great similarity, if not absolute uniformity, 
of such occurrences under similar circumstances. Surely nothing has been added to or 
taken from matter as an aggregate. 
Much of apparent error in the assertions of advanced thinkers may be attributable 
to the "despotism of words." The terms that they are compelled to use in their 
endeavors to communicate new ideas to the less apt or forward renders the process 
difficult and the result sometimes doubtful. If it were practicable to use the term 
"spirit" or "spiritual" in speaking of the inherent qualities and capabilities of mat- 
ter, even to the extent of recognizing many of the so-called " spiritual phenomena " of 342 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
all ages as genuine, but natural-without conjuring in imagination the presence of a 
troop of ghostly spectres from an imaginary world, and ascribing such phenomena to 
supernatural, personal entities-scientific truths might be communicated thereby, and 
dissension of opinion and beliefs correspondingly avoided. 
But fortunately for science, it is never impatient nor in haste. It believes in and 
waits for growth, and that a time will come when such terms can be used intelli- 
gently ; when it will be seen by many, if not by all, that matter, uncreated and eternal, 
is everything ; that "force," "intelligence," "spirituality," and all of the facts and 
phenomena that have so dazed mankind in his infancy, and still overawe with porten- 
tous shadows multitudes of truth-seeking beholders, will be recognized as manifes- 
tations of inherent capabilities and qualities of matter, and the supernatural will dis- 
appear forever from this world's horizon. 
The following paper was read by title, the author being absent :- 
DIE LEHRE VON DER REFLEKTORISCHEN SPEICHELSEKRETION. 
THE DOCTRINE OF REFLEX SALIVARY SECRETION. 
LA DOCTRINE DE LA SÉCRÉTION RÉFLEXE DE LA SALIVE. 
VON DR. C. ECKHARD, 
Giessen, Deutschland. 
Die in der physiologischen Literatur über diesen Gegenstand vorhandenen Angaben 
stimmen theils mehrfach nicht mit einander überein, theils sind sie aus Versuchen 
abgeleitet, welche der Wiederholung bedürfen ; theils sind die Folgerungen, welche 
man aus denselben gezogen hat, nicht sämmtlich der Art, dass man ihnen so ohne 
Weiteres beistimmen kann. Dies hat mich veranlasst, die fragliche Lehre in meinem 
Laboratorium einer Prüfung unterziehen zu lassen. Ich gebe hier eine kurze Dar- 
stellung der hauptsächlichsten Ergebnisse derselben. 
Sämmtliche Untersuchungen beziehen sich ausschliesslich auf die reflektorische 
Sekretion in der Submaxillardrüse. Die in den anderen Speicheldrüsen sind vorerst 
bei Seite gestellt und einer weiteren Untersuchung vorbehalten worden. Als 
Versuchsthiere dienten Hunde. Zunächst wurden die Reflexe von den Schleim- 
häuten aus vorgenommen und vorzugsweise die von der Magenschleimhaut und der 
Conjunctiva aus in besondere Betrachtung gezogen. Beiläufig sind einige Erfah- 
rungen über die Erfolge der Reizung der Nasen- und Trachealschleimhaut gewonnen, 
jedoch nicht weiter ins Einzelne verfolgt worden. Ueber letztere sei kurz Folgendes 
bemerkt. Jede Einleitung der Chloroformnarkose, gleichgiltig, ob man sie von der Nasen- 
höhle oder von einer Trachealfistel aus vornimmt, erzeugt im Anfang eine starke 
Sekretion in beiden Submaxillardrüsen, die eine gewisse Zeit anhält und dann bis zum 
Verschwinden nachlässt, wenn man die Einathmungen aussetzt. Erneute Einleitung 
des Gases hat denselben, wenn auch dem Grade nach oft schwächeren, Erfolg. Da SECTION VIII-PHYSIOLOGY. 
343 
diese Sekretionen nicht weiter verfolgt worden sind, so kann über ihre Entstehung keine 
nähere Auskunft gegeben werden. Da sich die Versuchsthiere den Einathmungen 
widersetzen, dabei sehr unruhig werden und widerstrebende Bewegungen machen, ich 
aber bei diesen und allen folgenden Versuchen die Wahrnehmung gemacht habe, dass 
mit diesen Umständen meist sehr ausgiebige Speichelsekretionen combinirt sind, so 
kann möglicherweise dies die alleinige oder in den Vordergrund tretende Ursache der 
fraglichen Sekretionen sein. Möglich scheint allerdings auch, dass die Reizungen der 
Schleimhaut des Respirationstraktus an und für sich, sowie auch die in das Blut einge- 
tretenen Gasantheile erregend auf die cerebralen Ursprünge der Speichelnerven wirken. 
Ueber diese Möglichkeiten ist aber erst noch durch besonders eingerichtete Versuche 
zu entscheiden, indem wir darüber keine Erfahrungen gesammelt haben. 
Von besonderer Wichtigkeit war es, die Frage zu entscheiden, ob die Reizung der 
Magenschleimhaut, ähnlich der der Mundhöhlenschleimhaut fähig sei, reflektorisch die 
Speichelsekretion hervorzurufen, weil die bisher über diesen Punkt gemachten Angaben 
auseinandergehen. Die bezüglichen Versuche wurden folgendermaassen angestellt. 
Nachdem die Wharton'schen Gänge mit Kanülen versehen worden waren, wurde die 
Bauchhöhle eröffnet und durch die vordere Magenwand neben einander zwei stärkere 
Fäden gezogen, so dass zwischen beiden ein Raum blieb, gross genug, um daselbst eine 
Oeffnung anzubringen, welche zur Injection der reizenden Flüssigkeiten dienen sollte. 
Von den erwähnten Fäden wurde jeder an ein Stäbchen gebunden und dies über die 
Ränder der Bauchwunde gebrückt. Nunmehr wurde zugewartet, bis eine durch die 
erwähnten Manipulationen etwa angeregte Speichelsekretion vollständig zur Ruhe 
gekommen war. Ich muss hier einschalten, dass man dann und wann auf Thiere 
trifft, bei welchen, nachdem man Kanülen in die Wharton'schen Gänge gebunden, aus 
diesen ohne äusserlich wahrnehmbare Ursache fortwährend Speichel ausfliesst. Besänf- 
tigt sich die Sekretion nicht bald, so ist ein solches Thier zu keinem Versuch über 
reflektorische Speichelsekretion zu gebrauchen. Wurde nun an einem so vorgerichteten 
Thiere, wie es eben beschrieben worden ist, keine Speichelsekretion beobachtet, so 
machte man demselben zwischen den Fäden einen Schnitt in die Magenwand und, 
nachdem man sich von der auch jetzt noch bestehenden Ruhe der Drüsen überzeugt 
hatte, injicirte man verschiedene Mengen reizender Substanzen, wie Essigsäure, ver- 
dünnte Kochsalzlösungen etc., in den Magen. Unter diesen Umständen wurde aber 
niemals eine Sekretion in den Speicheldrüsen hervorgerufen. Es ist darauf zu achten, 
dass die Versuchsthiere auch während dieser Inj ectionen völlig ruhig bleiben, widrigen- 
falls eine mit der Unruhe des Thieres möglicherweise einhergehende Sekretion, als eine 
durch den Reiz der Magenschleimhaut entstandene, vorgetäuscht werden kann. Die 
Versuche verlaufen in völlig gleicher Weise an narkotisirten, wie nicht narkotisirten 
Thieren. Schon vor einer Reihe von Jahren liess ich bei einer anderen Gelegenheit 
Versuche über denselben Gegenstand ausführen. Damals bedienten wir uns mit 
Magenfisteln versehener Hunde, von denen bekannt ist, wie sie im Allgemeinen bei 
den verschiedenen Manipulationen, die man an ihren Fisteln vornimmt, sich sehr 
geduldig benehmen. Auch bei dieser Gelegenheit konnten wir durch keine Reizung 
der Magenschleimhaut irgend welcher Art eine reflektorische Speichelsekretion hervor- 
rufen. Es wäre nicht darauf zurückzukommen gewesen, wenn nicht das Gegentheil 
von den hier mitgetheilten Ergebnissen in die neueren Hand- und Lehrbücher über- 
gegangen wäre. Dies rührt offenbar daher, dass die Verfasser dieser sich auf einige 
Versuche, welche positive Ergebnisse von den Reizungen der Magenschleimhaut berich- 
ten, mehr zu stützen für berechtigt halten, als auf die mit negativen Ergebnissen. 
Wer aber solche Versuche mit der von uns angegebenen Vorsicht wiederholt, wird 
unsere Angabe für die richtige erkennen und sich dabei überzeugen, wie höchst wahr- 
scheinlich die gegentheilige Versicherung dadurch zu Stande gekommen ist, dass die 
Thiere, an denen man die Versuche ausführte, während dieser sich nicht absolut ruhig 344 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
verhalten haben. Eine Speichelsekretion in Folge der gereizten Magenschleimhaut 
würde auch den Zwecken der Magenverdauung wenig dienen. Welchen Sinn sollte es 
haben, durch die fortwährende mechanische etc. Reizung der Magenschleimhaut mittels 
der aufgenommenen Nahrung fortwährend Speichel absondern zu lassen und dadurch 
den Magen mit einer Flüssigkeit zu belasten, die durch ihre alkalische Reaktion die 
Pepsinverdauung beschränken muss ! 
Zur Verständigung muss noch Folgendes hinzugefügt werden. Wir haben mehrmals 
beobachtet, wie das Hervorziehen der Magenwand oder die Quetschung derselben, wie 
sie namentlich bei der Einbindung einer Kanüle in eine kleine Oeffnung der Magen- 
wand stattfindet, bei dem dadurch beunruhigten Thiere mehr oder minder deutlich 
Speichelsekretiou hervorrief. Es ist deshalb in Zukunft sich dahin auszudrücken, 
dass solche Einwirkungen auf den Magen, welche über das eigentliche Bereich der 
Schleimhaut hinausgehen und die übrigen Häute des Magens anätzen oder sonstwie 
verletzen, Veranlassung zur Submaxillardrüsensekretion geben können. Doch wird 
sich zu hüten sein, solche Sekretionen als rein reflektorische aufzufassen. Da sie 
bisher nur bei gleichzeitig eintretender Unruhe des Thieres beobachtet wurden, so 
sieht man sie wohl besser vorerst als damit combinirte Erscheinungen an und stellt sie 
in eine Kategorie mit den hernach zu besprechenden, bei Reizung sensibler Nerven- 
stämme auftretenden Erscheinungen. Nach diesen negativen Ergebnissen an der 
Magenschleimhaut lag keine Veranlassung vor, noch andere Abschnitte des Tractus 
intestinalis zu prüfen. 
Die physiologische Literatur berichtet auch von reflektorischen Speichelsekretionen 
in Folge von Reizungen der Conjunctiva des Auges. Dieselben sollen schon auf ver- 
hältnissmässig geringfügige Reize, wie z. B. auf Einträufelungen sehr verdünnter 
Atropinlösungen, eintreten. Dabei soll letzteren durchaus keine specifische Wirkung 
zukommen, sondern dieselben sollen ähnlich anderen Reizen wirken. Die Versuche, 
welche in meinem Laboratorium angestellt worden sind, beziehen sich nur auf die 
Submaxillardrüse des Hundes und haben ergeben, dass durch Reizungen der Conjunc- 
tiva mittels Atropin- oder verdünnter Kochsalzlösungen etc. die Speichelsekretion nur 
ausnahmsweise einleitbar sein muss. Wir sahen sie bei behutsamen Manipulationen 
am Auge des Hundes nie. In allen Fällen blieben dabei unsere Thiere vollkommen 
ruhig. Es mag aber sein, dass gelegentlich, namentlich wenn man noch andere Thiere, 
etwa Katzen, zur Prüfung verwendet, auch einmal Sekretionen eintreten können; auf 
alle Fälle handelt es sich aber um keine sehr einfache Beziehung zwischen Conjunc- 
tival- und Speichelnerven, ähnlich der, wie sie zwischen den letzteren und den Zungen- 
nerven besteht. 
Besonders zahlreich sind die Versuche, welche über die Wirkung gereizter sensibler 
Nervensto'mme, äusser den sensiblen Zungennerven, auf die Speichelsekretion berichtet 
werden. Die Berichte unterscheiden zwischen die Speichelsekretion erregenden und 
hemmenden Einwirkungen. Die ersteren werden gemeldet als Folge der Erregung sehr 
verschiedener, gemischter oder sensiblèr Nervenstämme, so dass es scheint, als ob fast 
jeder sensible Nervenstamm unter gewissen Erregungsverhältnissen zur Speichelsekre- 
tion führen kann. Wirklich beobachtet ist diese zur Zeit bei Reizung des Ischiadicus, 
Ulnaris, Musculo-cutaneus, Medianus, Auricularis und Vagus. In Bezug auf die Sub- 
maxillardrüse des Hundes schliessen sich die hier angestellten Versuche diesen Berichten 
im Allgemeinen an. Es sind aber dabei die folgenden Bemerkungen zu machen. Das 
Thatsächliche anlangend, so trat bei den Versuchen die Eigenthümlichkeit hervor, dass 
bei Weitem in der Mehrzahl der Fälle die Speichelsekretion in Folge der Reizung 
gemischter Nervenstämme (N. isch. oder n. ulnaris) sich nur dann einstellte, wenn jene 
einen solchen Grad erreichte, dass dadurch die Thiere in merkliche Unruhe geriethen 
und diese durch mancherlei widerstrebende Bewegungen ausdrückten, wobei man noch 
den Eindruck empfing, als ob die letzteren ein besonders günstiges Moment bildeten. 345 
SECTION VIII-PHYSIOLOGY. 
Auf alle Fälle kommen die auf Reizungen gemischter Nervenstämme erfolgenden 
Sekretionen in der Submaxillardrüse ohne die erwähnten Begleitungserscheinungen ver- 
hältnissmässig selten zur Beobachtung. Man wird in diesem Glauben noch besonders 
durch die Beobachtung bestärkt, dass man nicht selten bei Untersuchungen in der 
Chloroform- oder Chloralnarkose bemerkt, wie Reize geringeren Grades, die in nicht 
narkotisirtem Zustande Sekretion hervorrufen, merklich verstärkt werden müssen, 
bevor sie in der Narkose denselben Erfolg geben, und bei welchen dann die Thiere 
gewöhnlich aus ihrer Narkose erwachen. Es soll damit nicht gesagt werden, dass die 
in der Narkose in der Regel erst bei stärkeren Reizgraden auftretende Sekretion allein 
in der geringeren Empfindlichkeit der Thiere ihren Grund habe. Äusser dieser können 
noch andere Momente mitwirken, die zur Zeit nicht mit Precision anzugeben sind. 
Nur bei den höheren Graden der Curaravergiftung tritt es ein, dass die Reizungen der 
gemischten Nervenstämme Submaxillardrüsensekretion ohne Aufregung der Thiere 
und ohne besondere Bewegungen derselben geben, was bei der bekannten Wirkungs- 
weise des Curara wohl selbstverständlich ist. Vergl. hierzu weiter unten. 
Ueber die Art, wie man sich die auf Reizung sensibler oder gemischter Nerven- 
stämme entstehende Speichelsekretion zu denken habe, gehen die Meinungen der 
Physiologen auseinander. Einige stellen sich vor, dass die fraglichen Reizungen eine 
allgemeine Erhöhung des Blutdruckes bewirken und davon die entstehende Speichel- 
sekretion eine Folge sei. Dagegen ist mit Recht eingewendet worden, dass die Speichel- 
sekretion in keinem besonderen causalen Zusammenhänge mit dem Blutdrucke stehe, 
wie sich unter Anderem daraus deutlich ergiebt, dass bei atropinisirten Thieren die 
Reizung des Ischiadicus zwar den Blutdruck erhöht, aber keine Speichelsekretion 
bewirkt. 
Weiter hat man die Hypothese aufgestellt, dass durch Reizung der sensiblen Haut- 
nerven Gefässverengerung in den nervösen Centralorganen bewirkt werde und dadurch 
eine venöse Hyperämie entstehe, die eine Erregung der Speichelnervencentren hervor- 
rufe. Folgende Combination von Erscheinungen hat zu dieser Meinung geführt. Man 
beobachtet bisweilen, dass die beiden grösseren Speicheldrüsen ohne besondere äussere 
Veranlassung secerniren. Es ist geglaubt worden, dies komme nur bei lebhaft in der 
Verdauung begriffenen Thieren vor und sei auf die grössere Kohlensäurebildung zu 
dieser Zeit zu beziehen, indem man daran erinnert, dass bei der Asphyxie sich zu einer 
gewissen Zeit Speichelsekretion einstellt. Man ging dann weiter und sagte, dass die 
Reizung der sensiblen Nervenstämme, indem sie eine Zusammenziehung der Hirnge- 
fässe und venöse Hyperämie erzeuge, einen ähnlichen Erfolg wie die Asphyxie bewirke. 
Diese Deutung der Entstehung der Speichelabsonderung in Folge der Reizung sensibler 
Nervenstämme ist aber gleichfalls unhaltbar. Die erwähnten spontanen Speichelungen 
stehen mit der Verdauung in keinem Zusammenhänge und besteht keinerlei Recht, 
von einem Verdauungsspeichel im erwähnten Sinne zu sprechen. Sie kommen bei 
nüchternen Thieren ebensogut vor, als bei solchen, die eben Nahrung zu sich genommen 
haben, und können ebenso bei beiden fehlen. Ueber ihre wahren Ursachen will ich 
mich hier nicht verbreiten. Ferner stellt sich die in der Asphyxie vorkommende 
Speichelsekretion erfahrungsgemäss erst bei so hohen Ueberladungen des Blutes mit 
Kohlensäure ein, wie sie durch die reichlichere Kohlensäurebildung in der Verdauungs- 
periode nicht vorkommen können ; es müssten sich ja sonst auch in dieser die Zeichen 
der Asphyxie einstellen. Endlich geben die Reizungen sensibler Nervenstämme, wenn 
sie ihrer Stärke nach überhaupt geeignet sind, Speichelsekretion hervorzurufen, diese 
in so kurzer Zeit, innerhalb derer eine vollkommene Schliessung der Trachea sie niemals 
hervorzurufen vermag. 
Mir will es scheinen, als würde man zur Zeit am correctesten verfahren, wenn man 
die auf Reizung sensibler Nervenstämme erfolgende Speichelsekretion nur als eine 346 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
solche bezeichnet, die sich mit dem aufgeregten Zustande combinire, in welchen man 
die Thiere durch jene Reizungen versetzt, wobei man freilich darauf Verzicht leisten 
muss, anzugeben, wie sich diese Combination im Einzelnen vollziehe. Ich mache diesen 
Vorschlag aus folgenden Gründen. Erstens ist eine Anzahl physiologischer Erschei- 
nungen bekannt, mit denen sich eine Absonderung des Speichels ohne weitere Zuthat 
von aussen sehr leicht vergesellschaftet, und an diese kann die auf Reizung sensibler 
Nerven erfolgende als ein weiteres Beispiel bequem angeschlossen werden. Wenn man 
ein beliebiges motorisches Rindenfeld, es muss dies nicht nothwendig das des Facialis 
sein, intensiv oder längere Zeit reizt, so entstehen bekanntlich leicht Krämpfe, die 
auch noch nach Entfernung der Reize eine gewisse Zeit fortbestehen. Mit diesen 
Krämpfen ist fast ausnahmslos Speichelsekretion verbunden, wie denn auch nicht selten 
eine solche bei durch anderweitige Ursachen hervorgerufenen Krämpfen ein tritt. 
Weiter erzeugt der Anblick begehrlicher Speisen bei manchen Personen Speichelabson- 
derung, so dass auch bei gewissen Vorstellungen die Speicheldrüsen in Thätigkeit 
gerathen. Wir haben endlich, wie weiter unten nachzusehen ist, bei gewissen Graden 
der Curaravergiftung die Beobachtung gemacht, dass in Zeiten, wo noch keine vollkom- 
mene Lähmung aller motorischen Körpernerven eingetreten ist, die Thiere von mehr 
oder weniger ausgedehnten Muskelzuckungen ergriffen werden, und dass damit parallel 
eine vermehrte Speichelsekretion einhergeht, gleichfalls ohne dass ein äusserer Reiz 
einwirkt. Zweitens ist gegen den Ausdruck ' ' reflektorische ' ' Speichelsekretion, 
der für unsere Erscheinungen empfohlen worden ist, Mancherlei einzuwenden. Bei 
allen denjenigen reflektorischen Erscheinungen, die nur einmal, höchstens doppelt, 
am Körper vorkommen, wie Pupillarbewegung, Husten, Niesen, Augenblinzeln, 
sind die sensitiven Nervenbahnen, welche jene auslösen, ganz ausserordentlich be- 
schränkt, während in unserem Falle, der gleichfalls zu dieser Gruppe sozusagen 
beschränkter oder localer Reflexe gehört, wohl von fast allen sensiblen Nervenstämmen 
aus unter gewissen Umständen Speichelsekretion hervorgerufen werden kann. Mit 
Rücksicht auf diese Bemerkung erscheint es angemessener, nur insofern von reflek- 
torischer Speichelsekretion zu sprechen, als dabei die Geschmacksnerven, oder vielleicht 
Mundhöhlennerven überhaupt, als incitirende Nerven in Betracht kommen, und für 
diejenigen Speichelsekretionen, die auf die Reizung fast aller sensiblen Nervenstämme 
sich einstellen, den Ausdruck " combinirte " Speichelsekretion einzuführen. Ausser- 
dem machen sich auch erfahrungsgemäss die Sekretionen auf Reizungen sensibler 
Nervenstämme der Art, dass nicht bloss jene, sondern mannigfache andere, in verschie- 
denartigen Sphären auftretende Thätigkeiten erscheinen, wie : Schmerzensäusserungen, 
veränderte Athembewregungen, sehr complicirte und nicht gesetzmässige Körperbewe- 
gungen etc. Es ist auch behauptet worden, dass man durch gewisse Grade der Reizung 
sensibler Nervenstämme eine aus irgend welchen Gründen bereits bestehende Speichel- 
sekretion hemmen könne. Die Versuche, welche wir hier über diesen Punkt angestellt 
haben, ergaben keine überzeugenden Resultate. Sie scheiterten daran, dass die Sekre- 
tionen, die wir zu hemmen beabsichtigten, in ihrem Verlauf zu variabel waren, mochte 
man die durch Reizung der Mundhöhlenschleimhaut ausgelöste oder die spontan bei 
der Curaravergiftung auftretende zu dem beabsichtigten Zwecke auswählen. Bei dieser 
Gelegenheit machten wir die bereits oben angedeutete Wahrnehmung, dass in solchen 
Fällen der Curaravergiftung, wo noch nicht absolute Lähmung aller motorischen 
Körpernerven eingetreten ist, die Thiere in unregelmässigen Intervallen von mehr oder 
weniger ausgedehnten Zuckungen befallen wurden und jedesmal, wenn sich diese ein- 
stellten, der Speichelfluss, welcher vorher in Folge der Vergiftung bestand, auffallend 
beschleunigt erschien. In einem Beispiele war diese Coincidenz so scharf ausge- 
sprochen, dass man mit der grössten Sicherheit aus dem Eintritt der einen Erscheinung 
den der anderen ankündigen konnte. Aber auch noch nach dem Verschwinden der SECTION VIII-PHYSIOLOGY. 
347 
erwähnten Zuckungen floss der Speichel nie für längere Zeit in gleicher Stärke aus. 
Wir versuchten zwar, einmal mit dem erwähnten Umstande bekannt, verschieden- 
gradige Reize auf den Ischiadicus während verschiedener Phasen der Curaravergiftung 
einwirken zu lassen, aber mit Bestimmtheit haben wir niemals etwas Anderes als 
Beschleunigung der Sekretion gesehen. Wir kennen zwar einige Erfahrungen, auf 
welche hin man immerhin geneigt sein kann, an eine reflektorische Hemmungswirkung 
sensibler Nervenstämme bezüglich der Speichelsekretion zu glauben, aber es ist uns 
bis jetzt nicht gelungen, ein nie versagendes Experiment in dieser Beziehung vorzu- 
legen. So wird beispielsweise von anderen Forschern erwähnt, dass in Fällen spontaner 
Speichelung, die vorher nicht zutreffend Verdauungsspeichelung genannt wurde, bei 
dem Hervorziehen von Darmschlingen aus einer Bauchwunde die Sekretion gestockt 
habe, und wir selbst haben mehremal eine ohne Anregung durch äussere Ursachen 
entstandene Sekretion auf hören sehen, als wir gewisser Zwecke halber eine Tracheal- 
fistel anlegen wollten. In einem Falle war die spontane Speichelung sehr erheblich, 
aber als die Einbindung der Kanüle in die Trachealfistel vollendet war, existirte keine 
Spur mehr von jener. Wir glaubten, die Erscheinung auf eine Zerrung des Vagus bei 
der fraglichen Operation beziehen zu sollen, da uns die Angaben über eine Hemmungs- 
funktion dieses Nerven bezüglich der Speichelsekretion bekannt waren. Als wir aber 
in drei bis vier anderen Fällen, in denen gleichfalls spontane Sekretion in beiden 
Submaxillardrüsen bestand, bei der Herstellung der Trachealfistel eine Zerrung des 
Vagus absichtlich vermieden, bemerkten wir ein gleiches Stocken der Sekretion, ja in 
einem Falle sahen wir den Stillstand schon eintreten, als wir kaum die ersten Schnitte 
durch die die Trachea deckende Haut angelegt hatten. Derartige Erscheinungen ent- 
ziehen sich zur Zeit einer näheren Zergliederung, fordern aber zu weiteren Unter- 
suchungen auf. 
Wir haben dann zum Schluss noch beim Hunde eine Anzahl von Reizungen des 
oberen Stumpfes des durchschnittenen Vago-Sympathicusstammes, mit und ohne voran- 
gegangene Trennung des Sympathicus, bevor er sich mit dem Vagus mischt, in Fällen 
nicht bestehender Submaxillardrüsensekretion vorgenommen. Unsere Erfahrungen 
über diesen Punkt können wir dahin zusammenfassen, indem wir sagen, dass sich unter 
diesen Umständen Sekretion wie bei Reizung sensibler Nerven einstellen kann, wie 
dies auch schon vor uns von einem Beobachter gesehen worden ist. Manchmal haben 
wir kein gutes positives Resultat bekommen. Dieser Theil der Untersuchung befindet 
sich also noch in einem unfertigen Zustande und soll demnächst hier in ausführliche 
Arbeit genommen werden. 
Zum Schluss noch ein paar Worte über die mehrfach erwähnten spontanen Sekre- 
tionen der Submaxillardrüse. Weshalb wir dieselben als nicht mit der vermehrten 
Kohlensäurebildung nach der Nahrungsaufnahme im Zusammenhang stehend ansehen 
können, ist oben bereits angegeben worden. Eine Zeit lang hegten wir den Verdacht, 
dass sie dadurch zu Stande kämen, dass man bei den Operationen, welche zum Einlegen 
der Kanülen in die Wharton'schen Gänge nothwendig sind, den Chordafasern zu nahe 
komme und diese gewisse Reizungen erfahren möchten. Aber als wir sahen, dass man 
auch dann noch auf Fälle spontaner Sekretion stösst, wenn man die Einbindung der 
Kanülen möglich weit vorn vornimmt und somit den erwähnten Nervenfasern ferr 
bleibt, konnte an den erwähnten Umstand nicht mehr gedacht werden. In manchen 
Fällen mögen die Stricke, deren man sich zur Fesselung der Thiere bedient, reizend 
auf die Mundschleimhaut wirken und die fragliche Sekretion hervorrufen. Doch kanr 
auch dies in vielen Fällen nicht die wahre Ursache sein; denn mehrmals haben wir bei 
spontaner Sekretion die durch das Maul ziehenden Fesseln entfernt und die Sekretion 
bestand noch so lange fort, dass man endlich des Zuwartens müde wurde. Es bleibt 
somit kaum etwas Anderes als die Annahme übrig, dass sich mit den Aufregungen, in 348 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
welche die Thiere beim Fesseln gerathen, die Thätigkeit der cerebralen Speichelcentren 
verknüpft. In der That macht man auch im Allgemeinen die Wahrnehmung, dass je 
unbändiger sich die Thiere beim Auf binden benehmen und je langsamer sie sich nach 
der Fesselung besänftigen, desto wahrscheinlicher eine spontane Sekretion zu gewär- 
tigen ist.* 
* Eine vollständige Darstellung des besprochenen Gegenstandes, nebst den nothwendigen 
Literaturangaben, findet sich in der demnächst erscheinenden Inauguraldissertation meines 
Schülers, des Herrn R. Buff', "Revision der Lehre von der reflektorischen Speichelsekretion." 
Giessen, 1887. - Wird auch abgedruckt im 12. Bande meiner "Beiträge zur Anatomie und 
Physiologie." In Memoriam. 
Alonzo B. Palmer, m.d., ll.d. 
350 SECTION IX-PATHOLOGY. 
President: ALONZO B. PALMER, M.D., LL.D., Ann Arbor, Mich. 
Andrew Fleming, m. d., Pittsburgh, Pa.. 
Joseph Coats, m. d., f.f.p.s. Glasgow, Scotland. 
Charles Creighton, m. d., London, England. 
Julius Dreschfield, m. d., f. r. c. p. Lond., 
Manchester, England. 
James Frederick Goodhart, m. d., f. r. c. p. 
Lond., and m. r. l. s. Eng., London, Eng. 
VICE-PRESIDENTS. 
David James Hamilton, m. d., f. r. c. p. Edin., 
F. R. c. s. Edin., Aberdeen, Scotland. 
John B. Johnson, m. d., St. Louis, Mo. 
Henry F. Lyster, m. d., Detroit, Mich. 
John North, m. d., Keokuk, Iowa. 
Joseph Frank Payne, m.d. oxon., f.r.c.p. 
Lond., London, England. 
Edward 0. Shakespeare, m. d., Philadelphia, Pa. 
Herman M. Briggs, m.d., New York, N. Y. 
SECRETARIES. 
Isaac N. Himes, m. d., Cleveland, Ohio. 
Ezra P. Allen, m. d., Athens, Pa. 
Nathan Smith Davis, Jr., m.d., Chicago, Ill. 
Llewellyn Eliot, m. d., Washington, D. C. 
Thomas J. Gallaher, m. d., Pittsburgh, Pa. 
Daniel R. Hatrner. M. D.. Washincton. D. C. 
COUNCIL. 
Wm. J. Herdman, m.d., Ann Arbor, Mich. 
Chas. H. Hunter, m. d., Minneapolis, Minn. 
Sam'l Ruff Skillern, m.d., Philadelphia, Pa. 
E. M. Schaeffer, m. d., Washington, D. C. 
A. S. Von Mansfield, m. d., Ashland, Neb. 
A. F. Wheelan, m. d., Hillsdale, Mich. 
351 352 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
The Section met on Monday, September 5th, at 3 P. M., and was called to order 
by its President, Dr. Alonzo B. Palmer, who delivered the following- 
ADDRESS. 
Gentlemen:-In commencing the duties of assisting in the deliberations of the 
Section of Pathology of this International Medical Congress, to which I have the 
honor to have been called, you will permit me to invite your attention to some 
thoughts which suggest themselves as appropriate to this occasion. 
Those who are now present as members of this Section are supposed to be workers, 
or at least advanced students in Pathology, and I shall venture only upon suggestions, 
and not attempt instruction. This department of knowledge must be considered as 
embracing subjects among the most fundamental, the most intricate, and the most 
scientific which are included in the broad and daily widening field of medicine. 
You well know its importance, and how far from scientific, how exclusively 
empirical, how really inefficient or injurious, was much of the practice of medicine, 
even in the most enlightened hands, before pathology was cultivated in the light of 
modern science. You also know what wild and irrational speculations have been 
indulged, and what absurd systems have been constructed whenever, even up to the 
present time, the study of pathology as now understood, based upon anatomy, physi- 
ology, and chemistry, has been repudiated or neglected. 
You know that the author of the most absurd of exclusive modern systems of medi- 
cine not only neglected the proper study of pathology, but actually repudiated it, and 
ridiculed the " pottering with morbid specimens" as useless or leading astray. 
Taking into view chiefly methods of treatment, though the most modern methods, 
many men of intelligence and writers in popular periodicals deny to medicine the 
character of a science, not even allowing it to be what we must admit it is, an imper- 
fect science. In fact, all the natural sciences are more or less imperfect; pathology 
certainly not more so than some others; but the denial of all scientific qualities to 
medicine, from respectable sources, though so unjust, has had an effect, and has low- 
ered the dignity and general character of the profession in public estimation ; and 
worse, has encouraged every species of quackery and deception. 
We must look to the advancement of pathology and to a dissemination of some 
knowledge of its principles and methods of investigation among the people, to 
correct popular errors and prevent the adoption of absurd beliefs and practices. 
Though certain useful facts have been known, and empirical knowledge in Medi- 
cine has been accumulating, since the time of Hippocrates, yet if we go back a single 
century, or even less, we shall find many crude notions prevailing among the most 
learned and orthodox of the profession ; and a few centuries further back will bring 
us in contact with a very irrational jumble of medical statements, and with a marvel- 
ous array of inert and disgusting, if not injurious, agents then in general use. SECTION IX-PATHOLOGY. 
353 
The study of the intimate nature of disease-of accurate pathology-something 
beyond the mere observing of its external phenomena and the outer circumstances of 
its prevalence, was the first important step in strict medical science. 
In order to a proper view of the present state of pathology, dr of general medicine, 
we must not overlook the steps which have led up to its successful study and the aids 
which have been afforded by all the modern arts and sciences. 
Though there is much that is interesting in ancient modes of thought and expres- 
sion respecting nature, and in the mediaeval systems of speculative philosophy, they 
had little influence in establishing exact science, and it is not till since the time of 
Bacon, whom we should not forget (and whom we are not likely to forget while 
Englishmen have a voice), that scientific methods have been prevailing ; and it is 
especially to the present philosophical views of nature and her fixed laws-the general 
trend of modern science-that we are indebted for the present state of pathology and 
what we hope for it in the future. 
As to its special cultivation the Continent of Europe is most conspicuous for the 
earlier and more persistent labors in original experimental investigations; yet Great 
Britain has done much most excellent critical and cautious work, while America has 
been too much occupied in what are called ' ' practical matters, ' ' and with applying 
the scientific discoveries of facts and principles to useful purposes, to appear other- 
wise than as following at a respectful distance in the more elaborate investigation of 
pathological subjects ; but she is doing something at the present, as we may see 
before our meeting closes, and she has a hopeful future, if not so long and brilliant a 
past. 
At this meeting of the Congress, in consequence of the broad intervening Ocean, 
a very large proportion of its membership will be Americans, and there will doubtless 
be greater activity and a larger number of papers in the Sections of Practice of 
Medicine, of Surgery, of Obstetrics, and the Specialties, than in those of the founda- 
tion sciences, upon which the more showy superstructures, if substantial and abiding, 
must be based. 
But Pathology is steadily pushing its way to the front, even in America. Patho- 
logical laboratories are being established and furnished with apparatus and men, and 
experimental investigations are being pursued; and ere long, if not so much here and 
now, we hope to be heard from, joining (not over modestly, it may be presumed,) 
in the chorus, if not performing the solos, or wielding the baton. Some things 
American have already been done which are not mere imitations, and there will be 
more to come. 
With the increase of the number of men of leisure and scientific tastes, and with 
the endowments of professorships for the advancement, as well as the teaching of 
science, it will, we hope, be demonstrated to the scientific world, as it has been to 
the business and practical, that the American mind, an offshoot from the European, 
is not destitute of originality, ingenuity, and the power of persistent application, 
which are the main elements of scientific success. -In the meantime, for our consola- 
tion, we can repeat the aphorism, ' 'All that is not behind us is before us, ' ' and the 
desirable will be reached if with sufficient energy we move forward. 
But Pathology, wherever cultivated, is an offspring, or rather a part, of general 
science, is under the universal "reign of law," and has advanced and will continue 
to advance with the other sciences. A knowledge of every department of nature- 
of Matter and Force, of forms and properties, of the persistence and correlation of 
the forces, of sensible and molecular motion, of the particular chemical as well as 
physical properties of matter, of the great principles of heat, light and electricity, 
Vol. IH-23 354 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and especially a knowledge of that crowning department of nature where comes 
into action, the science of Biology, as is too well known to require me to say, has 
wonderfully developed in recent times; and it would have been strange if pathology, 
which is but a part of biology, had not partaken in the common movement. 
Since the conception has become common in the profession that the laws of nature 
are general and uniform-that pathological processes are but modifications of physio- 
logical-that disease is but a change of proper actions and conditions under unfavor- 
able influences, that its processes are moved by the same natural forces, governed by 
physiological laws, simply modified by injurious agencies, and that the results of 
wrong actions in perverted functions and structure have their likeness in normal 
actions-in the natural processes of growth, renewal, decay and death-since this, 
pathology has to a large extent lost its obscurity and mystery, and the whole science 
and art of medicine has become at once more simple, more intelligible, more rational 
and more successful. 
But I must not detain you longer by these general and trite remarks. I will, 
however, venture a few further suggestions upon some matters of detail which seem 
to me to justify a passing mention. 
Speaking from the standpoint of the great body of the profession-those engaged 
in distinguishing and treating diseases-in administering to the sick and injured-it 
may not be presuming to refer to some things that are needed by them from the 
working, laboratory pathologists, which it is possible in their special absorbing pur- 
suits, they may not always bear in mind. 
The practitioner needs, of course, to learn of the pathologist the structural and 
chemical changes which occur in disease. This knowledge he needs, the better to 
understand the living processes he witnesses, and to make a proper diagnosis of his 
cases. He also needs to know from the pathologist the causes of particular diseases, 
in order, if possible, to avoid or counteract them. 
And here we can but be reminded of the essential service which pathology has 
already rendered to preventive medicine, now, perhaps, the most practically useful 
department of the profession. During the long past, while diseases were completely 
enshrouded in mystery, or were regarded as produced by some supernatural cause- 
by some evil spirit, by the displeasure of the gods, or by a special dispensation of 
Providence-incantations, exorcisms, sacrifices and invocations were the preventive 
measures employed. The real causes being unknown, proper efforts were not made 
for their removal, and all forms of disease, especially devastating epidemics, prevailed. 
Since pathology has revealed the nature of diseases and so many of their causes, 
true preventive measures have followed, and the value of human life in all enlightened 
countries has largely increased. Even within a very few years the bills of mortality 
have wonderfully changed, as public sanitation has received popular attention and 
legislative action. In England, for instance, within the last thirty-five years the 
annual death rate from continued fevers has been reduced from about 1000 in 1,000,- 
000 of the living, to less than 300; and the proportion of deaths from all causes will 
be as wonderfully diminished when private and personal hygiene receives even as 
much attention as has been given to municipal health measures. 
When pathology is still better understood by the profession, and its leading prin- 
ciples reach the masses of the people, and the lessons it teaches are fully carried out 
in practice, the continuance and the enjoyments of life will be enlarged beyond all 
former conceptions. Pathology, then, is a subject in which humanity is deeply 
concerned. 
But to the physician it is quite as interesting, if not as necessary, to know how SECTION IX PATHOLOGY. 
355 
special causes produce their effects, and the particular actions which occur in their 
production. At the bedside and in the consulting room it is with the living phe- 
nomena of disease he chiefly has to deal. It is these morbid living processes that 
he desires to modify or remove ; and he can go about his work more rationally if he 
knows the particular character of the processes that are going on. For instance, it is 
interesting and important to know that a certain microbe or ptomaine is a factor in 
the production of a particular disease, but it is also interesting to know how the 
microbe produces such an effect, and the particular process that occurs in its produc- 
tion. I am aware of the obscurities which exist in these matters, and the great and 
often insurmountable difficulties of this part of the investigation ; but our patho- 
logical knowledge is not complete and our therapeutical measures are not all entirely 
rational until this is understood. It is not reasonable to insist upon impossibilities, 
but the investigating pathologist should have this part of his function prominently 
in view. 
"Pathology," as was recently said by one of our Vice-Presidents-Dr. Goodhart 
-" is something more than morbid anatomy; it is an attempt to interpret morbid 
changes ; an attempt to unravel, not so much the conditions themselves, as how they 
came about-the processes which produce them, and the successive steps by which 
the result is reached. ' ' 
Allow me to add, indeed it goes without saying, that pathology should deal with 
morbid functions as well as structural changes, and that it becomes the complement 
to physiology, as well as to normal chemistry and anatomy. Indeed, there are mor- 
bid functional processes which, with our present means of investigation, have no 
morbid anatomy or morbid chemistry to show. But the functional changes aside 
from structural, are too frequent and too important to be in any degree neglected. 
The nervous activities, their centres and connections, their control over secretions, 
■circulation and nutrition, over production and growth, over waste and decay, normal 
and abnormal, the sympathetic relations of different parts of the brain to each other, 
and of the different and distant parts of the body to other parts through the nervous 
system, and through blood and lymph supply (the latter modified by nervous action), 
all these, in their relation to the production of disease, constitute a subject at once 
vast in its extent, obscure in its nature, difficult to study ; and at the same time most 
important to be understood. 
A department of this subject which needs elucidation, and belongs equally to the 
physiologist and pathologist (and everywhere physiology and pathology are intimately 
interwoven), is that of the excitor and inhibitory functions of the nervous system, 
their actions upon each other and upon the various parts and functions of the body- 
and particularly the pathological relations of inhibition. 
I am aware that no little attention has been given to the general subject of inhibi- 
tion by very able observers, experimenters and writers, such as Lauder Brunton, 
Brown-Séquard, Rossback, Gaskell, Herrmann, Panum, and many others; but it 
has been treated chiefly as a physiological problem, though its great importance to 
pathology, etiology and therapeutics is acknowledged. Such questions as the follow- 
ing have been chiefly discussed. What is the essential nature of inhibition ? What 
is the mode of its action ? Are there special and exclusive inhibitory centres and 
nerves, or do the same centres and nerves produce either excitation or inhibition, 
according to the state, at the time, of the nervous matter, or the organs to be acted 
upon ? Is the inhibitory function exercised in some cases by nerves that have also 
excitor function, and in other cases by exclusively inhibition centres and nerves ? 
What is the influence of the excitation of cftie function upon the inhibition of other 356 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
functions ? What is the physiology of reflex action, and what are the laws of sympa- 
thy as connected with inhibition ? All these are important questions and have rela- 
tions to pathology; many of them are still undecided and require further investiga- 
tion. But, however they may be settled, or whether or not they must be left open 
questions, there are, somewhere or somehow, two forces existing in living parts, or 
two processes going on, perhaps in each cell or group of cells, one excitory and the 
other inhibitory, and by the proper balancing of these, normal functional activity 
throughout the system results. The unbalancing of them causes disease. 
The particular effects of morbid agencies on these balancing forces, especially on the 
inhibitory functions, in the production of particular forms of disease, have not been 
so fully investigated. Among these agencies are the poisons taken in from without, 
and those developed within the system-both the common and specific poisons-and, 
in fact, all varieties of morbid impressions, of whatever character, which are made 
upon these centres and nerves; and these influences and the manner of their opera- 
tion upon the exciter and inhibitory functions should particularly interest patholo- 
gists. 
It is not only scientifically interesting but practically important to know, when an 
impression is made upon the nervous system which results in disease, whether the 
derangement is produced by impressions upon the exciter or inhibitory functions. 
When an increased action results, it is important to know whether it is produced by 
paralyzing inhibition or by stimulating excitation. If by paralyzing inhibition, is the 
agent a stimulant in any proper sense, and will its effects in increasing action be per- 
manent, however constantly the agent is applied ? 
No organ has been so much studied in relation to excitation and inhibition as 
the heart. The vagus has generally been considered as exercising the inhibitory 
function, while the sympathetic acts as an excitor upon the organ. Compressing 
or otherwise arresting the action of this vagus nerve, it is well known, generally 
increases the frequency of the heart's action, though it may not its force, and 
thus its inhibitory function is declared. But exceptions have been observed to 
this effect, which have been explained by the alleged fact that two sets of fibres, 
inhibitory and excitor, are found in the vagus nerve. They, of course, come 
from different centres, and each centre and nerve has its own selective affinities 
for excitants and depressants. 
These and other facts show the complexity and difficulty, as well as the im- 
portance, of this subject ; but complexities and difficulties call for efforts at solutions, 
especially when important practical results depend upon such solutions. For illus- 
tration, it may be mentioned that at present we are not entirely in the light as to 
whether various poisons or therapeutical agents, such as the narcotics or the so-called 
narcotico-stimulants, produce those effects which appear to be stimulant by increasing 
excitor activities, or by paralyzing inhibitory functions. For example, the direct 
effects of the alcohols upon the tissues of the isolated heart were found, by Drs. 
Ringer and Sainsbury, to be clearly paralyzant and not excitant, in every stage and 
degree of their operation. {Practitioner, London, May, 1883.) The same was 
found by Dr. Martin, of Johns Hopkins University, in his experiments with common 
alcohol upon the heart of the dog. Yet, from certain sensations felt and other tem- 
porary effects observed, alcohol has been regarded as a cardiac stimulant ; and the 
statement to this effect, handed down from the darkness of the past, still holds its 
place in the common language of the profession and the people. The question cer- 
tainly fairly arises as to whether the apparent excitation, when it occurs, is not 
dependent upon the greater paralysis of the inhibitory, rather than the stimulation SECTION IX-PATHOLOGY. 
357 
of the excitor function ; and whether alcohol should not be called a heart depressor 
rather than a heart stimulant. 
Dr. Norman Kerr, of London, explains what is the matter with drunkards as 
follows : "There is an abnormal cerebral condition, a dynamical and psychical dis- 
turbance of the brain and nerve function, a real departure from sound health, which 
is itself a pathological state with, in all probability, its post-mortem equivalent in 
hyperplasma of the neuroglia. ' ' 
It may well be questioned whether any of the substances with distinctly narcotic 
properties-substances whose ordinary full effects are depressant-can be regarded as 
stimulants in any stage or degree of their action. A more exact knowledge of the 
physiology and pathology of this subject might lead to important modifications in 
therapeutics and hygiene. 
But this is only one of many instances which shows the necessity of greater 
knowledge of the influence of inhibition in deranging proper activities. These 
remarks are made as suggestive of the course of future investigations, rather than 
with the object of establishing any particular theories or practical views. 
But the properties, actions and relations of the most ultimate known particles of 
the body-the protoplasm and the cells, fixed and wandering-constitute another 
subject requiring further elucidation. The grosser and more perceptible actions 
of organs in health and disease have been properly designated as the "outer court " 
of the science of life. This outer court, it is true, must be traversed, its passages 
understood, but the inner court, within the incasement of the more perceptible 
physical and chemical conditions, is the more fundamental part of physiology and 
pathology. When we fully penetrate to this central part and understand its nature 
and all the laws which govern it, our physiological and pathological knowledge may 
then, but certainly not till then, become complete. ' ' Pathology, as distinguished from 
physiology, is some deeper strata of phenomena brought to the surface by the up- 
heaval of some catastrophe"-phenomena produced by some injury or perverting 
influence acting upon the ultimate elements. A new phase is then presented, new 
combinations occur, but the same vital laws are present, requiring to be studied in 
the same general way. 
It is at this central point that injurious influences produce their effects, and here 
the relations of poisons, organic or inorganic, living or chemical, bacteria, ptomaines, 
leucomaines, retained excretions, or what not, are to be studied. The contests 
between bacteria and the cells, alleged to have been seen by Mecknikoff, the destruc- 
tion of some tissue cells by other tissue cells, and the attacks of the living cells, both 
the more fixed and mobile, upon various intruding irritants-these contests, followed 
often by the disturbing effects of a battle-are matters that require further investiga- 
tion. Here, it seems to me, is the great field of future achievements in pathology. 
Upon this field some of the papers awaiting our consideration will enter. 
Of the recent achievements in pathological science, those of Koch and Pasteur, 
and their colaborers, are most conspicuous. Whatever may be thought of some of 
their conclusions, it cannot be denied that they have rendered very important services 
to pathology. The discovery of the tubercular bacillus, which is now so generally 
regarded as having an intimate, if not a necessary, causative relation to tubercular 
phthisis, at present seems to be a permanent addition to our pathological knowledge ; 
and the investigations respecting the comma microbe as the cause of cholera, though 
less conclusive, have instituted a method of inquiry which, it is hoped, will result in 
the establishment of positive truth as to the etiology of that disease. 
The labors of Pasteur in regard to the different infectious diseases of the lower 358 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
animals, and the means of their prevention, have opened up new fields of inquiry, 
developed new facts, and established some new principles ; and his more recent ex- 
periments with the poison of rabies have filled the whole world with some knowledge 
of this subject. Lister's name should be mentioned because of the practical results 
which have followed his investigations. But the success of these three distinguished 
men should not cause other laborers in similar fields to be overlooked. It might, 
however, seem invidious to name others without naming all who have contributed to 
the present stock of knowledge on the subject of infections. 
The inoculation experiments for destroying susceptibility to certain infectious 
diseases, in which, in the matter of rabies, Pasteur has been the central figure, have 
broadened a field not new, which may be followed by consequences to humanity 
greater even than we have heretofore thought. 
The inoculation with the virus of smallpox, for the purpose of modifying and 
rendering milder that disease while destroying susceptibility to future attacks, was 
introduced into Europe and this country, from the East, a century ago. The reason 
for the milder effects of the poison when introduced by local inoculation instead of 
the natural way by the lungs, may not be clear ; but its more speedy operation, 
affording less time for its multiplication in the system, and possibly its introduction 
in smaller quantity, may account for it. Its practical benefits were decided, and it 
doubtless would have continued in use had not the discovery of Jenner been made. 
But this inoculation of smallpox was the first grand illustration of a principle and a 
practice which are widening before us. 
Vaccination was the next example, the glorious results of which are the standing 
boast of our profession. This involves the same principle as the smallpox inoculation, 
as essentially the same virus is used, modified, however, and rendered milder, by 
passing through the system of the cow. It is introduced in a similar manner, and 
requires a shorter period for the development of its effects. A much milder form 
of disease is induced, but it has the power, as a rule, of preventing another attack 
of this non-recurrent affection. 
Inoculation with the diluted virus of syphilis was at one time practiced, it was 
said successfully, for the purpose of destroying the susceptibility to that disease. 
Then followed the experiments upon the lower animals with which Pasteur's name 
is particularly connected, until, according to the recent report of the British com- 
mission sent out to investigate the subject, the demonstration comes that animals 
may be made insusceptible to the poison of rabies by a series of inoculations with the 
diluted and weakened virus. 
Whether human beings bitten by rabid animals have been prevented from having 
the disease or not, the fact that, commencing with weak and modified preparations 
of the poison and going on to the introduction of stronger, destroys the susceptibility 
to the strongest, is of the greatest interest ; and the additional fact, which is just 
coming to the light, and is to be reported here, that similar inoculations with the 
virus of the rattlesnake cause a similar insusceptibility to its effects, shows that the 
principle is a more general one than was before known. 
The questions here suggest themselves : Can it be made applicable to other 
infectious diseases? to scarlatina, measles, diphtheria, cerebro-spinal fever? to 
typhoid and typhus? to cholera? and, above all in importance, to phthisis? Will 
the principle explain the facts of acclimation ? 
So far this principle has only been proved to apply where the poisons artificially 
introduced are identical with those naturally taken. Will it apply to poisons that 
are similar but not the same ? and to what extent will it apply to poisons that do not SECTION IX PATHOLOGY 
359 
multiply themselves in the system ? To show that the principle has some degree 
of application to non-multiplying poisons, I need but mention opium, tobacco, 
arsenic and alcohol, as illustrating the modifying effect which the repetition of doses 
and the establishment of habits have upon the action of these agents. The com- 
parative insusceptibility produced by habitual use and the modification of actions, 
especially upon the sensations, should be taken into the account in judging of the 
effects and determining the avoidance or the use of these articles. 
The widespread indulgence in narcotics, especially in tobacco, alcohol and opium, 
and the threatened introduction of cocaine, should lead the pathologist to inquire 
into the physical and mental conditions of those who become habitués in the use 
of these substances. Whether there is any substantial good in their moderate use 
(except as therapeutical agents), or in their habitual or even occasional use as matters 
of luxury, to compensate for their evils or not, it is certain that the amount of injury 
which the narcotic habits are inflicting throughout the world is enormous and incal- 
culable. Can the habitual use of these articles, however moderate, be physiological 
and well, when their abuse is acknowledged to be so frequent, and their general and 
ordinary effects are so pathological and in every way so injurious? This constitutes 
one of the most urgent practical questions of our time, and the medical profession- 
physiological and pathological science-must be looked to for the proper answer. 
In the general subject of the production of disease by poisons, there is a field for 
further investigation which, in its extent and importance, is certainly second to none 
other. The interests of science, no less than the calls of humanity, demand its 
thorough exploration, and he who penetrates it furthest will stand high among the 
distinguished pathologists of the future. 
But all diseases are not specific and infectious, and all wrong actions of the system 
are not produced by material and recognized poisons acting upon the individual 
system. Various diseases and a great amount of suffering arise from constitutional 
peculiarities-from a want of proper balance in the different functions, leading to 
deficient, excessive and irregular actions and their results. Circulation, secretions, 
growth, wasting and renewal-explosions of nervous and muscular force-become 
deranged, producing various morbid consequences ; and all these must depend upon 
wrong actions of the ultimate cells and tissues. These may be disturbed, temporarily, 
periodically, or more permanently, by a variety of causes, external and internal, even 
by immaterial influences-by mental impressions, by emotions and thoughts. Some 
of the wrong tendencies are congenital and hereditary, and some are acquired. The 
exhaustion of fatigue and the over-indulgence of passions ; the changes of age, 
physiological or premature, and, indeed, every influence disturbing the most healthy 
actions, are matters demanding the attention of the pathologist. His work extends 
in every direction, to the very boundaries of human imperfection and suffering, 
and, with the rest of the profession, he should ever bear in mind that the great aim 
of his calling is not merely to learn the morbid conditions which affect humanity, but 
to find means for relieving them ; that the chief object in studying diseases is to 
prevent, alleviate and cure them. 
In pursuing investigations, the mind should not be too narrowly fixed on the 
special alterations that characterize distinctive nosological affections. The patient's 
general surroundings, his habits, ancestral and personal, and everything that can 
influence him, should be considered. These, at least, modify results. 
A man is greater than his diseases, and, in administering to him, we should 
remember that we have a person to care for and not simply a disease to contend with 
and subdue. In subduing the disease the patient might not be spared. 360 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A division of labor in our profession, as in every other complicated occupation, 
is necessary for the greatest efficiency : but that devotion to these pursuits which 
makes one a great pathologist need not, indeed cannot, make him a small man. The 
subject is great enough to elevate the man, and from an elevated position other 
things can be seen. The benevolent, the humanitarian, the Christ-like character 
of our profession should never be lost sight of, and it never is by those who labor 
with warm sympathetic hearts and with a consciousness of their great responsibility. 
If, as a poet* has recently said, the doctor is "the flower of our civilization ; and 
when the present stage of man [or of that civilization] is done with, and only remem- 
bered to be marveled at in history, he will be thought to have shared as little as any 
in the defects of the period, and most notably exhibited the virtues of the race " - 
we must not only pursue our science and art for humanity's sake, but must cultivate 
and exhibit those personal qualities which all appreciate and approve. 
* Robert Louis Stevenson. 
PLATE I. 
TAYLOR ON THE CRYSTALLOGRAPHY OF FATS. 
Descriptive List. 
Fig. 1.-Crystals of Boiled Butter. (Shorthorn Durham.) 
Fig. 2.-Crystals of Boiled Dog Fat. Coach Dog. 
Fig. 3.-Crystals of Boiled Lard. 
Fig. 4.-Crystals of Boiled Monkey Fat. 
Fig. 5.-Crystals of Boiled Butter. (Jersey.) 
Fig. 6.-Crystals of Boiled Beef Fat. 
Fig. 7.-Crystals of Boiled Human Fat. Man, Kidney. (Inebriate.) 
Figs. 8, 9,10,12.-Crystals of Boiled Human Fat. Kidney. (Dementia., 
Fig. 11.-Crystals of Boiled Duck Fat. Erismatura Rubida. 
Fig. 13.-Crystals of Boiled Seal Fat. 
Fig. 14.-Crystals of Boiled Cat Fat. (Domestic.) 
Fig. 15.-Crystals of Boiled Cotton-Seed Fat. Plate I. 
CRYSTALLOGRAPHY OF FATS. 
MOSS ENG. CO., N. Y. 
W. I. GASCOYNE, PHOTOG. 
CRYSTALS PREPARED BY 
THOMAS TAYLOR, M, D, SECTION IX PATHOLOGY. 
361 
THE CRYSTALLOGRAPHY OF FATS AND THEIR COMPOSITION, 
CONSIDERED IN RELATION TO HEALTH AND DISEASE. 
[Abstract.] 
LA CRYSTALLOGRAPHIE DES GRAISSES ET LEUR COMPOSITION, CONSIDÉRÉES 
PAR RAPPORT. À LA SANTÉ ET A LA MALADIE. 
DIE CRYSTALLOGRAPHIE DER FETTE UND IHRE ZUSAMMENSETZUNG, MIT RÜCKSICHT 
AUF GESUNDHEIT UND KRANKHEIT BETRACHTET. 
BY THOMAS TAYLOR, M.D., 
Washington, D. C. 
Mr. President, and Members of the Section :-I have, for several years past,, 
devoted much of my time to the study of the crystalline forms of animal fats in gem 
eral, having in view their ultimate classification. 
In crystallizing fresh butter fat, I subject it, as nearly as possible, to a uniform 
treatment, as follows : About two ounces of the butter is placed in a porcelain capsule, 
in a water bath at a temperature of 212° F. (100° C.) until its water is evaporated. It 
is then strained through a clean cloth, to separate the casein, brought to the boiling point 
(212°F., 100° C.) for a moment, over a spirit lamp, and then slowly cooled for a period 
of twelve hours, at a temperature of about 60° F. ( 15.56° C. ), when it will appear granu- 
lar to the naked eye, and if viewed under suitable powers of thè microscope, with 
polarized light, the field in view will present numerous crystals, the forms in some cases 
varying within certain limits. 
I have, in the course of these investigations, through the courteous cooperation of 
breeders and owners of valuable herds of cattle, obtained samples of the butter of regis- 
tered milch cows of different breeds, in various parts of the United States, in order to 
ascertain whether butter crystals are modified in form, color, etc., by breed, or by 
marked changes of food, climate, or other conditions. Although these investigations, 
thus far, are comparatively limited, the practical results have a substantial value, as 
shown by my present exhibit of photographs of their crystallized fats. In two instances I 
have found marked modifications of the butter crystal, produced, it would seem, by giving 
the cows a peck of cotton-seed meal each day in addition to other food. The cows were 
of the Jersey and Ayrshire breeds, respectively. The butter was of a lardy consistency, 
its secondary crystals very large, resembling, in some respects, crystals of beef fat rather 
than those of butter. The butter crystals of the Shorthorn breed are generally very 
smooth as compared with other types, but seem to have a tendency, under certain con- 
ditions, to assume the broken outlines characteristic of butter crystals of other breeds. 
Animal fats other than butter should be rendered at a temperature of about 300° 
F. (148.89 C.) in order to separate the fat from the tissues, and should be strained and 
cooled, as in the case of butter. If a fat is firm to the touch when congealed, it should 
be brought to the consistency of butter by remelting it with a small quantity of cotton- 
seed oil, at a temperature not exceeding 212° F. (100° C.) This treatment is necessary, 
as normal crystals do not form in hard fats. 
Certain foods, it is well known, affect the quality and quantity of milk and butter, 
and necessarily of the fats deposited in the tissues. This results from the food contain- 
ing, in varying proportions, glycerides of the fatty acids which enter into the composi- 
tion of these substances, or yielding them in varying proportions under the action of 
animal ferments and of the organs of secretion. It is to the varied proportions of the 
fatty compounds that I attribute the differentiation of their crystals. I have observed 
that the fat of several aquatic animals boils like butter, owing to the large amount of 
water contained. Milch cows and swine on the same class of feed, secrete a fat which 
varies materially, owing to some functional differences in the organs of secretion ; the 
one is a soft lard, the other a hard tallow. 362 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I find that the fats of animals generally differ very much in health and disease, as to 
consistency, color, odor, drying qualities, etc. ' ' Loon ' ' fat has the odor of fish oil and 
when boiled becomes a drying oil. In some fishes an almost pure olein prevails in 
certain tissues, while in other tissues of the same fish solid fats abound. 
In the prosecution of this inquiry, I have observed, incidentally, that the fat of 
several monkeys, victims of consumption, when rendered, strained and cooled at a tem- 
perature of about 70° F., according to my usual method of treating fats in order to 
crystallize them, exhibited but a trace of the solid fats ; the mass consisted principally 
of olein. From this fact my attention was directed to the consideration of the fat of 
human beings, subjects of emaciating diseases from whatever cause. I have tested the 
fat of three consumptives, each of whom was greatly emaciated. The fats were crys- 
tallized in the usual manner ; boiled, strained and cooled at 70° F., and when exam- 
ined, were found to be nearly destitute of solid fats, olein largely predominating. 
While the cases cited are insufficient data for determining what may be the invari- 
able condition of the fats of emaciation, I deem the facts thus far observed worthy of 
attention, and I propose to continue these researches in order to ascertain whether the 
conditions I have stated are constant. If in the animal economy it can be shown that 
there is a greater tendency to oxidize the solid fats than the oil, in cases of high tem- 
peratures, valuable information will be gained. 
With regard to the composition of fats in general, they consist of three distinct 
fats, viz : olein, palmitin and stearin. These are known as the glycerides of the fatty 
acids, oleic, palmitic and stearic. Early chemists applied the term margarine to a 
substance which they believed to be a simple fat, but modern chemistry has demon- 
strated that this substance is merely a combination of palmitin and stearin. It has 
been demonstrated that the fat of milk and butter contains but a trace of stearin, and 
that it is composed mostly of palmitin and olein, and it is stated on high authority, 
that the fat of man is of similar composition. 
In my investigations relating to the forms of animal fats, I have observed that the 
crystals of human fat have a marked resemblance to the crystals of milk butter, sug 
gesting the importance of its use as the proper form of fat for man, as superior to fats 
which consist largely of stearin, such as some oleomargarines I have tested. According 
to modern chemistry, stearin requires a temperature of 144° F., to melt it, and each suc- 
ceeding melting requires a still higher temperature. For this reason, the fats in com- 
mon use cannot be as well adapted for the sick as butter, which melts at blood heat; 
therefore, I think it might be well to use pure butter as a substitute for the various 
forms of olein now in use, in cases of emaciation. For this purpose, I would suggest 
that the butter used should be boiled and strained, to remove its casein, the casein of 
milk butter frequently proving very indigestible and unbearable to a weak stomach. 
Milk, the natural food of man, contains all the essential proximate principles neces- 
sary to build up a perfectly healthy human being; but the butter fat of milk contains 
but a small proportion of nitrogenous matter as compared with the milk from which 
it is made ; therefore, butter of itself would not sustain life, but for a brief period. 
It being desirable to make sure that the diet contains a proper amount of nitrogen- 
ous matter in an acceptable form, the use of peptonized beef, in other words digested 
beef, in connection with butter so treated, would prove favorable to the sustenance of 
the vital tissues. 
In the oxidation of fats in the tissues, water and carbonic acid are formed, factors 
favorable to recovery, as by an increased elimination of these conveyers of heat, pro- 
ducts of fat oxidation, the abnormal temperature of the patient may be reduced to a 
condition approaching the normal, and this in a higher degree theoretically than would 
take place in the use of alcohol for the same purpose, since a pound of alcohol contains 
but 52.17 per cent, of carbon, while the solid fats contain about 57 per cent, of carbon. SECTION IX-PATHOLOGY. 
363 
PRESSURE PARALYSIS OF POTT'S DISEASE, TOGETHER WITH 
THE REPORT OF A CASE AND PRESENTATION OF SPECIMEN 
SHOWING PRESSURE OF THE CAUDA EQUINA, ACCOMPANIED 
BY SECONDARY ASCENDING DEGENERATION OF THE POS- 
TERIOR COLUMNS OF THE SPINAL CORD. 
PRESSION ET PARALYSIE DE LA MALADIE DE POTT, AVEC LE RAPPORT D'UN 
CAS ET JjA PRÉSENTATION D'UN SPECIMEN DEMONTRANT LA PRESSION 
DE LA QUEUE DE LA MOELLE EPINIERE, SUIVIE D'UNE DEGENERATION 
ASCENDANTE SECONDAIRE DES COLONNES POSTÉRIEURES DE LA CORDE 
RACHIDIENNE. 
DRUCKPARALYSE DES POTT'SCHEN ÜBELS, NEBST BERICHT EINES FALLES UND DEMON- 
STRATION DES OBJECTS, WELCHES DRUCK AUF DIE CAUDA EQUINA UND AUFSTEI- 
GENDE DEGENERATION DER HINTERSTRÄNGE DES RÜCKENMARKS AUFWEIST. 
BY GEO. R. ELLIOTT, M.D., 
Instructor of Orthopedic Surgery, New York Post-Graduate Medical School and Hospital. 
The object of this paper is to determine the mechanism of the lesion or lesions 
which give rise to pressure paralysis, limited to that form of paralysis which complicates 
Pott's disease 
ANATOMICAL CONSIDERATIONS. 
It may not be out of place to call attention to the following anatomical points :- 
1. The spinal cord reaches only to the lower border of the first lumbar vertebra. 
2. The spinal cord only partially fills the spinal canal. 
3. The cord swings in the spinal canal, insulated by means of the arachnoid fluid 
which surrounds it. 
4. The cord is much nearer the anterior wall of the canal than the posterior, held in 
position by means of the anterior nerve roots. 
5. The tracts conducting motor impulses are, generally speaking, more superficially 
placed than those transmitting sensory impulses. 
It further may not be out of place to state that paralysis in Pott's disease bears no 
relation to deformity; a spinal column may be bent at nearly right angles without 
giving rise to any paralytic symptoms, while in another case where no deformity exists 
complete paraplegia may be present. 
PATHOLOGY. 
In order to arrive at an intelligent understanding of the pathology of the lesion, I 
cite briefly the history of the carious process which is the exciting etiological factor. 
It matters little whether we accept the tubercular theory or not. The process is one 
insidious in its onset and slow in its progress. Cornil and Ranvier, in comparatively 
recent investigations, show rather conclusively that the disease begins not as an inflam- 
matory process, but by " a fatty degeneration of the bone cells; the result a destruc- 
tion of same, and consequent inability on their part to perform their functions as agents 
of nutrition. The osseous trabeculae, killed by the death of their cell elements, form 
so many small, foreign bodies, which determine suppurative inflammation around 
themselves. The medulla becomes vascular and adipose cells disappear, and are 
replaced by embryonic cells, and suppuration is established. The bone cells which 
have escaped fatty degeneration become active, the osseous substance around them is 
dissolved, the necrosed trabeculæ becomes free, and granulations or fungosities are 
formed from embryonic medulla. Inlets of osseous tissue become necrosed oftentimes. 
These are dislodged by granulation and carried away by suppuration. In their place 
are left irregular cavities. ' ' 364 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Here, then, we have a suppurative process in progress which is usually confined to 
the anterior portion of the bodies of the vertebrae. These portions giving way permit 
the vertebrae to fall together. The disease creeps dorsal and destroys, to a greater or 
less extent, the posterior common ligament. The latter, dissociated, allows the pus to 
pass from the vertebrae. The dura mater and the peri-dural tissue are aroused to 
inflammatory activity. The external surface of the dura mater becomes covered with 
granulations of a fungoid character, and infiltrated with caseous pus. This condition 
passes under the name of pacchymeningitis externa caseosa. This inflammation shows no 
tendency to extend beyond the site of the vertebral disease. It is limited. In a cross 
section we can see how the diseased condition abruptly gives way to the healthy mem- 
brane. The membrane may be infiltrated throughout its entire thickness with 
embryonic cells, or simply on its surface. Comil and Ranvier* have found tubercular 
granulations in different stages of evolution in the thickened dura mater, even on the 
internal surface. 
Up to this point we can safely say the pathology stands undisputed. All patho- 
logical findings bear evidence of this. In the large majority of cases of spinal caries the 
pathological chapter closes here, the products of inflammation remaining imprisoned, 
ultimately to be absorbed and replaced by reparative material. Frequently paralytic 
symptoms manifest themselves, and here the pathology is by no means settled. 
Ollivierf was among the first to describe at all carefully the changes which take 
place in the cord as a result of slow compression. He cites numerous cases where the 
membranes were found thickened and the cord softened without evidence of further dis- 
organization. His findings were verified and described later by Louis. J 
These writers and many followers who have described Pott's disease, have dwelt 
upon the mechanical point as the cause of the paralysis. From time to time cases were 
reported where the cord seemed harder than natural, a condition not touched upon by 
these writers and, consequently, no explanation offered. That the cord should become 
injured, as a result of crumbling and broken vertebral bodies, which led to the develop- 
ment of marked angular curvature, was considered but a natural sequence. This idea 
became so thoroughly fixed that many books, even to this day, refer only to bone as the 
pressure cause of the paralysis. 
It was noticed, however, that very commonly no paralysis followed in cases where 
the deformity was marked. The spinal cord was even seen to be bent to a right angle 
and still no paralytic symptoms manifest themselves. That marked deformity can occur 
without the cord becoming compressed, is also observed in lateral curvature, where some- 
times the deformity assumes a frightful aspect. 
In the words of Fagge, $ " every pathological museum contains specimens which 
show that the spinal canal generally retains its full width, however much its direction 
may be altered. Further, paralysis was seen to complicate caries where careful exami- 
nation of the spinal column gave no evidence of deformity. These observations called 
for some explanation other than the current view. 
The middle of this century, which inaugurated an active interest in the physiology 
and pathology of the great nerve centres, produced men who sought a solution of the 
problem. Among others, Charcot and his pupils made investigations and published to 
the medical world their conclusions. To Michaud|| can be credited, I think, the pio- 
* " Manual of Pathological Histology," Second Edition, 1882, Vol. I, p. 607. 
f " Ueber das Rückenmark und seine Krankheiten." Uebersetzt von Dr. J. Radius, Leipzig, 
1824, p. 202. 
J " Mémoire sur l'état de la moelle dans la carie vertébrale." Paris, 1826. 
§ Fagge, Vol. i, p. 410. 
Il "Sur la Méningite et la Myélite dans le mal vertébral." Paris, 1871. 365 
neer article upon this form of paralysis. These authors and investigators contended, 
and apparently demonstrated, that the paralysis in these cases was not directly due 
to a mechanical lesion, but to a myelitis, the result of the mechanical lesion. Michaud 
held that myelitis is invariably the lesion, and even went so far as to claim its existence 
in cases giving no evidence of paralysis. 
This explanation of the cause of the form of paralysis first described by Michaud 
and Charcot,* and subsequently supported by Bouchardf andCorjon,j was accepted 
and verified by Leyden § in his microscopical examinations of compressed cords. 
NATURE OE THE PATHOLOGY OF MYELITIS. 
Great controversy has now long been in vogue regarding the exact nature of inflam- 
matory processes of the cord. So loosely has the term myelitis been used, that various 
affections of the cord have been called myelitis-polio-myelitis, ascending and descend- 
ing degeneration, various kinds of softening-all these have been described by observers 
under the head of inflammatory lesions. Recent pathologists have come to look upon 
the disease myelitis as one giving rise to certain unmistakable and ever present findings. 
Stricker, Leyden, Joffroy, Schultze, Strümpell and others, have found the following 
pathological conditions, which they consider pathognomonic of the inflammatory lesion. 
1. Increased size of nerve elements. Axis cylinders enlarged, or without the sheath 
of Schwann. 
2. Swelling of the interstitial tissue and increase of same, according to age of the 
process. 
3. Increased number of round cells in the connective tissue and around the blood 
vessels. 
4. Enlargement of Deiter's cells. 
The later stages characterized by hyperplasia of the connective tissue. 
Erb practically coincides with the view of these authors, and their observations 
have been verified by numerous competent and careful observers, both here and 
abroad. 
The progress of the lesion in cases of slow compression is, as a rule, insidious, and 
to reconcile the clinical symptoms with the lesion the interstial form of myelitis is 
believed to predominate. This is characterized by an increase of the neuroglia or con- 
nective tissue, similar to that occurring in other organs, the parenchyma becoming 
secondarily affected. The interstitial tissue becomes increased together with prolifera- 
tion of the nuclei, great thickening of the walls of the blood vessels and distinct 
atrophy of the nerve fibres. A later stage is characterized almost exclusively by the 
presence of connective tissue, among the fibres of which run isolated nerve fibres. 
In support of the inflammatory theory, are usually found post-mortem considera- 
tions, showing the cord at the site of compression converted largely into connective tissue 
with thickened blood vessels and sparsely distributed changed nerve fibres and granular 
bodies. 
Further, in one case examined by Michaud, || where the compression lesion had not 
as yet produced paralysis, but where sensory disturbances in the form of fulminating 
pains were complained of by the patient, the microscope revealed increase of connec- 
tive tissue in the posterior root zone. 
The inflammatory theory of compression paralysis, which was so ably treated of by 
SECTION IX PATHOLOGY. 
* " De la Compress, lente de la moelle ép., Leçons sur la mal. du syst. nerv., n Sér., ii fascic. 
1873. 
f Compress, lente de la moelle, Dictionn-ency., des se. Midie." il Sér., vol. viii, p. 664, 1874. 
J " Etude sur la Paraplégie dans le mal de Pott." 
$ " Klinik der Rückenmarks Krankheiten," n B, i Abth., § 149. || Michaud. Loc. cit. 366 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Michaud and Charcot, supplemented by the studies of Corjon and Echéverria,* became 
-as thoroughly implanted and accepted as had the explanation of Ollivier and Louis a 
quarter of a century before. 
Let us now proceed to a closer study of the subject in hand, and to that end we ask: 
-Can a mechanical lesion satisfy the demands of pathology and symptomatology ? Let us see. 
A mechanical cause is present. We have seen how as the bodies of the vertebrae 
become destroyed by the carious processes going on in the bone, leading to the forma- 
tion of an abscess cavity, the walls of which are largely composed of the thickened 
surrounding soft tissues, the anterior ligament and dura mater undergo changes 
characterized by the name of pacchymeningitis externa caseosa. This is not a simple 
abscess cavity, but in it are developed fungoid granulations and the abscess products 
tend to accumulate. Nature tends to fortify the walls as far as possible. It is not 
common for the pus to perforate the walls and escape into the surrounding tissue. The 
site of least resistance is toward the spinal cord, which swings insulated in the spinal 
canal. The membrane bulges into the spinal canal and the cord recedes. The canal 
offers escape for the cord up to a certain limit, when, if the bulging still goes on, the 
cord substance is destined to suffer. Here, then, is practically a fluid sac, its pressure 
force commensurate with its fluid tension-mechanically an elastic ball. 
Clinically, the appearance of a psoas or gluteal abscess in a case of paralysis is 
oftentimes followed by the disappearance of paralytic symptoms. No one who has seen 
many of these cases has failed to note this clinical symptom. It is unnecessary to dwell 
on the mechanism of this relief, further than the allusion to it. 
What does the gross lesion tend to show ? At the compressed site the spinal cord is 
often reduced in size to such an extent as to appear simply like a band of connective 
tissue. It is a striking fact, that the diseased dura mater is limited to the site of the 
diseased vertebræ-the change from ' ' pacchymeningite externe ' ' to normal dura mater 
is abrupt. This has been noted by numerous observers. Cornil and Kan vier f say, 
"inflammation of the dura mater is limited exactly to the parts of the vertebræ dis- 
eased." This change in the dura mater is invariably in the anterior part of the mem- 
brane, and only in grave cases of caries does it encircle more than one-half of the cord. 
Does not this limitation of the diseased dura to the exact site of vertebral disease argue 
the non-tendency of the inflammatory process to extend in the membrane beyond what 
is necessary to protect the cord from the abscess cavity itself, beyond nature's necessary 
protective area. 
The medullary surface of the dura mater is usually intact and perfectly normal in 
appearance, the inflammatory process seeming to have spent its force in the external 
layers. Frequent microscopical examination of the diseased membrane rarely shows 
even infiltration of the internal layers. Can we not draw a further inference from this, 
of the non-tendency of the process to extend. 
Here, then, is a slow form of inflammation, which does not seem active enough to 
extend beyond the limits of the diseased vertebræ, not active enough to involve, as a 
rule, the internal layers of the membrane in which it originates. Is it probable, then, 
a priori, that it -will extend to the cord ? The irritation force, then, is simply that of the 
pressure of a bland mechanical body. 
Is there anything in the pathological findings to militate against the lesion being a mechan- 
ical one ? Examination of compressed cords at the site of compression, in the recent state, 
show :- 
1. Granule cells, many or few, according to the mass of the destroyed nerve fibres. 
2. Débris of broken-down nerve tissue. 
* Gonzalés Echéverria. Sur la nature des affections dites tuberculeuses des vertèbres. Thèse 
Paris, 1860. f Ed. 1882, Vol. i, p. 606. SECTION IX PATHOLOGY. 
367 
3. Swollen axis cylinders, or absence of same. 
If examined at a later stage- 
1. Nothing indicative of changes in the blood vessels. 
2. No increase of cells about the vessels. 
3. Occasionally traumatic hemorrhage. 
4. Nerve fibres in course of destruction and others which have been destroyed. 
5. Swollen axis cylinders or empty spaces, the former site of nerve fibres. 
Then follows, as in all other analogous conditions, a secondary increase of the neu- 
roglia. 
Experimental Physiology.-It is a settled fact that pressure upon nerve trunks inter- 
feres with nerve conductivity. It has been demonstrated over and over again that a very 
moderate constrictive force about a nerve separates the myeline within the sheath,, and 
if severe enough leads to secondary degeneration accompanied by all its pathological 
results, rendering the nerve incapable of transmitting nerve impulses, e.g., the injury 
to the musculo-spinal nerve from pressure. Has it been demonstrated that the pressure 
in these cases invariably leads to a neuritis in the sense of an inflammatory lesion ? 
Vulpian has shown experimentally that paralysis follows the introduction of a 
wooden match so as to press upon the spinal cord of a guinea pig; the pressure kept 
up for a certain length of time, and the paralysis disappearing shortly after the pressure 
was removed. 
Attention is directed to what occurs after a nerve has been tied:- 
1. Segmentation of the myeline and disintegration of same. 
2. Disintegration of the axis cylinders. 
3. Complete absorption of the mass, leaving the nerve sheath empty, or containing 
only débris and nuclei. The nuclei of the perineurium and endoneurium aid in the 
transformation of the nerve into a band of connective tissue. 
Here, then, is a process the result of which is practically identical, up to a certain 
limit, with that following compression of the cord-changes degenerative in character, 
the result of the mechanical interference, followed by increase of the connective tissue 
elements. Pathological views characterizing degenerative changes as inflammatory are 
by no means established. 
In the endeavor to settle this point, Dr. O. Kahler* made certain experiments upon 
dogs. He injected beeswax about the spinal cord. Motor and sensory paralytic symp- 
toms followed in the lower extremities. At varying periods the cords were examined. 
After the compression had existed from six to thirteen hours, he found slight nodular 
foci located in the posterior and lateral columns. Microscopical examination of same 
revealed marked swelling of the axis cylinders, disappearance of the myeline sheath. 
No interstitial changes were found. 
Two to ten days. Microscopical examination showed greater swelling of the axis 
cylinders and destruction of same ; granular cells ; slight increase of Deiter's cells. 
Later, five weeks to six months. Examination showed nodules of sclerosis with 
marked thickening of the connective tissue. He claims to have found none of the char- 
acteristics considered by Leyden, Joffroy, Strickler, Schultze and Strümpell as pathog- 
nomonic of myelitis, and concluded that the results were purely those of a mechanical 
lesion. 
Kahler states, as in peripheral nerves, so in the spinal cord, a moderate pressure is 
enough to excite a break in conduction; a few fibres are destroyed in such cords, and we 
find lacunar changes, distributed in the form of nodules. 
Do the connective tissue growth changes which are usually found at the site of the com- 
pression lesion necessarily signify the inflammatory character of the lesion? It is not 
* Zeitschrift für Heilkunde, 1882, vol. in, p. 187. 368 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
denied that we usually find a sclerotic condition of the cord at the compressed site 
when paralysis has existed for any length of time. A glance at the tabulated result of 
post-mortem findings will make this conclusive. That such is the outcome of the pro- 
cess is beyond dispute. We contend, however, that the presence of sclerotic tissue in 
the cord is no proof that the initial lesion was necessarily inflammatory. 
We have seen, moreover, that this follows various processes. 
Ziegler says the increase of connective tissue is a result of every process of softening ; 
that connective tissue increase characterizes the later stage of every process of degenera- 
tion; that throughout the nerve centres destruction of nerve tissue by processes, degen- 
erative or otherwise, is invariably followed by increase of the neuroglia. 
The examination in the great majority of these cases is made long after the onset 
of the lesion. We then find only the result of the process which has produced destruction. 
Leyden,* who came to look upon the lesion as identical with transverse myelitis, drew his 
conclusions almost exclusively from old findings, and these as shown are identical with 
those following myelitis. Charcot's case, where the disease was cured after one year's 
duration, and where two years subsequently death occurred, the end at the compressed 
site being found smaller and presenting a sclerotic condition, does not seem to offer any 
great support to the theory that the original lesion was inflammatory. Michaud him- 
self offers but one case as the strong pillar of his argument, where the examination was 
made at an early stage, and this case had not as yet given evidence of paralysis. 
Erb t says the fact that in not a few cases of compression of the cord the microscope 
reveals in the softened mass no granule cells, no hyperplasia of the connective tissue, 
no proliferation of the nuclei, but only swollen and disintegrated nerve elements, speaks 
unmistakably in favor of the view that the process is sometimes one of simple soften- 
ing. 
Strümpell contends that in repeated examinations of cords compressed from spinal 
caries he has never found signs of inflammatory change. He refuses it upon pathological 
grounds, and believes that there is nothing found histologically that cannot be accounted 
for as a result of a mechanical lesion. He says: "We must maintain against the 
theory generally received at present, on the ground of many of our own investigations. 
We have not the slightest ground for referring the occurrence of paralysis in spondylitis 
to a secondary myelitis. Such a 'compression myelitis'-that is an inflammation 
of the spinal cord arising from the pressure as such-is to be rejected, from general 
pathological reasons, and the microscopical examination of the cord also shows nothing 
which points to an inflammation, or what may not be entirely the result of mechanical 
compression. If we make examinations of hardened sections we see under the micro- 
scope no signs of vascular changes, of hyperæmia, of accumulation of cells about the 
vessels, and only exceptionally a little traumatic hemorrhage ; but we do find, in addi- 
tion to many still preserved nerve fibres, other fibres, which are involved in the disinte- 
gration or are already destroyed. If the destruction of nerve tissue has advanced to a 
certain degree, then, as in the later stages of all similar processes, there is a secondary 
involvement of the connective tissue. Now follows an increase of this, and we find in 
place of nerve fibres, firm fibrous tissue." 
What inference can we draw from reported autopsies ? In examining the literature of the 
subject, I have found but twenty-five fairly well recorded cases of pressure paralysis due 
to spinal caries, among which are cases reported by Michaud, Mathieu, Kahler, Rollet, 
Ogle, Gibney and others. From a careful perusal of these cases, I find that in nearly 
all mechanical pressure upon the cord was present in the form of bone, abscess or exuda- 
«- « Klinik der Rückenmarks-Krankheiten," vol. n, part i, p. 149. 
f Ziemssen, vol. xin, p. 469. 
J " Lehrbuch der Sp. Path, und Therapie der inneren Krank.," vol. n, part i, p. 167. SECTION IX-PATHOLOGY. 
369 
tion into the peri-dural space. In all but three cases the condition known as pacchy- 
meningitis externa caseosa was marked. 
In eleven cases the spinal cord was converted into connective tissue at the site of the 
lesion. In four cases there was well marked evidence of inflammation, shown in direct 
involvement of the pia mater. In three of these four cases perforation of the dura 
mater had occurred. Simple softening of the cord is recorded in four cases, one of 
which, reported by Kahler, showed marked anæmia, together with softening. Michaud, 
in his memoir, reports but five cases where autopsies were made, three of which showed 
the sclerotic condition. Of the two remaining cases, his report of the autopsy of one 
refers to the lesion in no more definite terms than beginning myelitis-no attempt being 
made to enter into detail. The one remaining case showed beginning interstitial changes. 
In this case, prior to death, no paralytic symptoms had manifested themselves. 
By way of summary, then, we have shown- 
1. We have present a simple mechanical pressure, in the form of an abscess cavity, 
thickened dura or bone. 
2. The inflammatory process is invariably a limited one, the inflammation of the 
dura mater being limited exactly to the site of the diseased vertebrae, showing no ten- 
dency to extend in the membrane-nature's protection. 
3. The ventral or medullary surface of the dura at the site of the lesion is almost 
invariably normal. 
4. The pressure lesion is simply a mechanical one, manifesting no tendency to involve 
the spinal cord through any inherent specific characters of the carious process-a simple 
bland mechanical lesion, and the damage it does commensurate with the pressure 
exerted. 
5. Pathological examinations have, in the vast majority of cases, necessarily been 
limited to'old cases where the lesion had existed fora very considerable period, and 
such examinations usually reveal the cord largely converted into connective tissue at 
the site of the lesion. 
6. The presence of sclerotic tissue at the site of compression is no evidence that the 
original lesion was of an inflammatory nature, since it is a well-established pathological 
law that throughout the nerve centres destruction of nerve tissue by processes, degener- 
ative or otherwise, is invariably followed by increase of connective tissue. 
7. Experimental physiology gives no evidence of an inflammatory lesion following 
experimental compression of the spinal cord-microscopical examination of same show- 
ing a few granular cells, swollen axis cylinders, and evidence of destruction of same, 
together with foci of traumatic hemorrhage-changes identical with those observed by 
Kahler, Strümpell and others, at the site of recent compression of the human spinal 
cord. We do not find signs of vascular changes ; of accumulation of cells about the 
vessels and in the connective tissue ; in other words, no evidence of those pathological 
changes which are considered pathognomonic of inflammatory change. 
8. Finally, a careful revision of the pathological findings of carefully reported cases 
reveals to us, in the light of recent pathological knowledge, but a very few cases (4) 
where we have reason to believe the lesion to have been inflammatory. The suppura- 
tive carious process in these cases had been a very virulent one, and the pia mater had 
become involved. In three of the cases the dura mater had been perforated. 
Mechanical interference with the circulation of the spinal cord as a direct cause of certain 
forms of paralysis complicating spinal caries. Whatever claim there is to consider myelitis 
as the active lesion in the cases alluded to, there certainly is a large class which it is 
folly to classify as due to myelitis or to the more profound mechanical lesion already 
described. Those accustomed to see many cases of paralysis of Pott's disease will readily 
recall patients who recover the use of their paralyzed members with a rapidity out of 
all keeping with any pathological lesion which has produced inflammatory changes, 
Vol. Ill-24. 370 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
even though the latter have been of short duration; out of all keeping, too, with a 
destructive mechanical lesion, be it bone or abscess, or thickened dura. How frequently 
do we see immediately upon the institution of treatment in the form of thorough and 
efficient support, a paralysis begin to disappear. Frequently within twenty-four hours 
there is an increased muscular control which rapidly marches on to complete restora- 
tion of normal power. Tuesday, August 30th, I applied a support to a little patient 
who had been paralyzed in the lower extremities for ten days. There was complete 
motor paralysis; sensation but slightly affected. August 31st, the day following the 
application of the support, he was able to stand. Inflammatory lesions, destructive 
mechanical lesions, stand unable to satisfy the mind with any rational explanation. 
Nearly all writers upon the subject have recognized this large class, and also recog- 
nized the failure of the commonly accepted lesions to explain it. Some have assorted 
that they were due to circulatory disturbances, but dismissed the subject with but an 
allusion to it. That the paralytic symptoms in these cases are of the nature of reflex 
paralysis is by no means probable-this brought about by vasomotor ischaemia, Brown- 
Sequard's theory of reflex paralysis, is by no means probable. Many authorities are 
skeptical as to the existence even of reflex paralysis, and in the words of a well-known 
writer, here ' ' a Vigorous scientific imagination has contributed much more than obser- 
vation has supplied." To offer the theory of " reflex paralysis" as an explanation of 
the class of cases alluded to, in a lesion so grave as spinal caries, is, I think, as useless as 
it is unscientific. 
In direct interference with the circulation we believe, lies the solution of the 
problem. 
Experimental physiology teaches us that interference with the blood supply of the 
cord causes paralysis. When the aorta is compressed motor and sensory paralysis imme- 
diately occur. Gull, Romberg, Leyden, Tutsscheck and others have reported such 
cases. When the aorta is gradually compressed, the paralysis advances correspondingly 
slow. We anticipate the question, is not the paralysis in these cases due to shutting 
off the blood supply from the peripheral muscles and nerves ? That the paralysis is 
largely due to the shutting off the blood supply to the spinal cord, has been shown by 
Kussmaul and Tenner, and later by Schiffer. Ehrlich and Brieger* found that after 
temporary ligation of the aorta, by which the cord was deprived of blood for half an 
hour, the gray matter and anterior roots were markedly affected and decided paralytic 
symptoms were present. 
Erbf says it is plain that mechanical pressure upon the cord may produce ischaemia 
in a corresponding portion. How do disturbances of the circulation occur? Here it is 
important to direct attention to certain well-established anatomical points. The spinal 
cord is completely insulated by means of the surrounding spinal fluid. It hangs sus- 
pended in a canal of vastly greater diameter than the cord itself. It receives its blood 
supply from the vertebral arteries at the base of the brain, viz., the anterior and posterior 
spinal arteries, both of which run down the cord in rather a tortuous course. The 
anterior spinal artery is the larger. This artery is unusually long, and it is a well-estab- 
lished law that the blood pressure is diminished in proportion to the length of the vessel. 
I take the liberty of quoting here from Moxon,j whose observations have an important 
bearing on the subject. He says : "The supply of this important part (referring more 
especially to the lower part of the cord) becomes one of nature's difficulties. How does 
she meet it ? The difficulty is overcome by little reinforcing arteries which are sent in 
* Zeitsch f. Klin, Med., 1884, vol. vu, supplement, p. 155. 
f Ziemssen, Vol. xiii, p. 284. 
J "The Croonian Lectures on the Influence of the Circulation on the Nervous System." 
Lancet, April 2d, 188Ï. SECTION IX PATHOLOGY. 
371 
from the inferior thyroid, intercostals, lumbar, ilio-lumbar and lateral sacral arteries, 
through the intervertebral foramina. These little arteries course along the spinal nerve 
roots and reinforce the blood supply which comes down from the brain. The nerve roots 
of the upper part of the cord pass out at once through their respective foramina. In the 
middle and lower portions of the cord, the nerves run some distance along the surface 
before making their exit. The length of the little reinforcing vessels varies with the 
length of the corresponding nerves." 
We know, also, that the central part of the cord receives its blood supply from arteries 
passing from the main trunk through the anterior median fissure. What is true, also, 
of incompleteness of anastomosis in the brain is, also, in great measure, true of that in 
the cord. 
Further, it is a well-established fact that the lesion of the cord in pressure paralysis 
is usually superficial, and the arteries which supply the cord are necessarily placed at a 
great mechanical disadvantage by being placed on the surface of the cord and nerves. 
With these anatomical points in view, it is not difficult to see how pressure would 
interfere with the circulation. 
The intervertebral foramina are, as we know, usually at the site of the lesion, filled with 
inflammatory or exudative material. This is common even at an early stage of the carious dis- 
ease. We have thus the nerves, and consequently the arteries, subjected to this pressure. 
Again, as the arteries pass with the nerves through the dura mater, they are again 
subjected to the pressure of the inflammatory thickening of this membrane. 
Further, microscopical examination of the minute arteries show their walls thickened 
by the inflammatory process. Add to this the course of the vessel running on the sur- 
face of the cord, and the slight pressure from a thickened dura, or from the pressure of 
an abscess in a canal already narrowed by deformity, and an imperfect circulation is but 
a natural conclusion. 
Erb says if interference with the circulation of the cord reaches a certain degree of 
intensity and duration, ischæmic necrosis and softening are induced. On the other hand, 
if the outflow of blood is hindered by the compression, we have hemorrhage from venous 
engorgement. The white matter is the first to suffer-the gray matter persists, its blood 
supply being derived, not from the periphery, but from the vessels of the longitudinal 
fissures. 
We have thus demonstrated, in support of a circulatory cause being a common one, 
producing pressure paralysis, the following :- 
1. Loss of blood supply to the spinal cord produces motor and sensory paralysis. 
This is the result of experimental physiology to that end. 
2. Increasing interference with blood supply to the cord produces gradually increasing 
paralysis. 
3. The blood supply of the cord depends largely upon the reinforcing branches which 
pass through the intervertebral arteries. 
4. These arteries course over the surface of the cord. 
5. The symptoms of this form of paralysis arise from affection of the anterior rather 
than the posterior portion of the cord, of the superficial rather than the deep, and the 
pathological findings sustain the clinical picture. 
6. We have further shown that the result of interference with the blood supply may 
be in all degrees from partial impairment of function to complete ischæmic softening. 
7. This form of paralysis complicates a lesion when there are inflammatory products 
pressing upon the nerves and arteries coursing through the intervertebral canals. 
8. The clinical picture of the vast majority of these cases is satisfactorily explained 
by the variance of the vascular mechanism. 
Is it, I ask, too much to suppose that the lack of nutrition consequent upon the 
interference with the blood supply may be sufficient to interfere with nerve tissue per- 372 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
forming its function in originating and transmitting impulses without necessarily being 
sufficient to lead to its complete disorganization ? 
Finally, our researches have led us to the following conclusions :- 
1st. The lesion producing pressure paralysis is, in certain cases, of an inflammatory 
character, a true myelitis, manifest in either the parenchymatous or interstitial form. 
Clinically, there are cases which progress rather rapidly and manifest the active symp- 
toms of myelitis. The dura mater is frequently perforated, and in the intensity of the 
process the pia mater is apt to become involved. 
2d. The vast majority of cases, however, we believe are due to a mechanical lesion, 
of which the circulatory cause is but a variety, and that this in the future is to be made 
the basis of pathology, and will merit the place held by the inflammatory theory of 
to-day. This, I think, we have demonstrated from a pathological standpoint, supported 
it by experimental physiology and corroborated it by clinical manifestations. 
The following case, which came under our observation, is interesting, as showing well 
one of the varieties of this lesion : Male, æt. nine years; family history good; father and 
mother still living and well. No brothers or sisters; no hereditary phthisical or syphilitic 
evidence attainable. In November, 1881, at the age of three years, he fell, striking upon 
his back. Soon afterward he began to complain of pain in the back, localized over the 
lower lumbar region, worse after walking and exercise. The disability increased rapidly 
and he was removed to the Hospital for Ruptured and Cripples, December 10th, 1881. 
Upon admission examination showed slight fullness of lumbar region, rather large 
and somewhat tympanitic abdomen, inability to bend the spinal column, "stooping 
stiffly " to pick up objects from the floor. No paralysis of motion or sensation ; great 
pain upon motion, localized in the lumbar region. The diagnosis of lumbar caries 
was made, and a spinal support applied, which gave the patient great relief. Patient 
remained in the hospital one year, during which time a psoas abscess (left) formed, which 
was aspirated. At the end of one year patient was discharged improved. He was re- 
admitted June 17th, 1884, still showing no paralytic symptoms. A slight angular defor- 
mity was now distinctly noticeable in the lumbar region of the spinal column. Early 
in January, 1885, patient complained of pain about the region of the left knee joint, which 
continued while he remained in the hospital. About this time paresis of the lower 
extremities began to develop, and increased rather rapidly, and soon it became impossible 
for him to stand. At first constant trembling of the legs was present, which after a while 
subsided. He was discharged May 20th, 1886, with almost complete paraplegia. 
Soon after this he was admitted into Randall's Island Hospital. It is impossible to 
obtain here a history more complete than that the lower extremities were completely 
paralyzed, with marked atrophy of same until death, which occurred November 25th, 
1886; death apparently due to exhaustion (sepsis). 
Autopsy made twelve hours after death. Body markedly emaciated, most marked 
in the lower extremities; oedema of feet and legs. A sinus was found over the left 
gluteal region, 1£ inches from the anus, also another over the left sacro-iliac synchondrosis. 
Both communicated with a common abscess cavity about the size of a hen's egg, which 
was found in the left sacro-iliac synchondrosis. Heart and lungs normal. Liver, spleen 
and kidneys showed slight amyloid degeneration, most marked in the liver. Stomach 
and intestines normal. Brain not examined. 
SPECIMEN. 
Examination of the spinal column showed caries of the last dorsal and first lumbar 
vertebrae, with fungoid implication of the intervening intervertebral substance. The 
bodies of the first and second lumbar vertebrae are partially destroyed and broken down 
into several pieces. The bodies of the twelfth dorsal and third lumbar vertebrae are in a 
condition of beginning caries. The dura mater, at a point opposite the diseased ver- SECTION IX PATHOLOGY. 
373 
tebræ, is thickened and covered externally with a layer of carious pus. The thickening 
is limited to the site of the carious disease of the vertebrae, and appears to encircle only 
the central half of the spinal cord and cauda equina. The internal or medullary surface 
of the dura is smooth and apparently normal. The anterior vertebral ligament is 
destroyed at a point opposite the second lumbar vertebra. The opening formed by the 
destruction of this anterior ligament leads to a pus cavity, the walls of which are par- 
tially formed by the diseased bones. In the recent state this cavity contained about 
three drachms of carious pus. 
Microscopical Examination.-Examination of the vertebrae gives well-marked evidence 
of caries. The dura mater at the site of the lesion is markedly thickened and in the 
condition of pacchymeningitis externa caseosa. The external layers of the diseased portion 
are infiltrated with numerous granulation cells, and there are also nodules, apparently of 
a tubercular character, but careful examination fails to detect either bacilli or giant cells. 
Spinal Cord.-The cauda equina is partially surrounded by the thickened and 
diseased membrane. Cross section of same shows destruction of some of the nerve fibres. 
Many of the nerve fibres of the cauda equina, upon piercing the diseased dura mater, 
pass directly into the caseous thickening on its external surface and are lost in same. 
Examination of sections of nerves just at point of passage through the thickened dura 
shows the thickening of the endo- and perineurium and destruction of nerve fibres, many 
of the latter being totally destroyed and replaced by connective tissue. Sections of 
the spinal cord give evidence of ascending degeneration of the posterior columns. In 
the lumbar region the degeneration involves the postero-median and postero-lateral col- 
umns. In the upper dorsal region the columns of Goll only are degenerated. Changes 
in the first cerebellar column are but slightly marked. 
Unfortunately the upper part of the cord was not obtained, and thus we were deprived 
of tracing the changes above the upper dorsal region. 
This case is instructive in showing a compression lesion situated so low. I have 
failed, in my researches, to find a similar case reported where the lesion was due to cari- 
ous involvement. A number of cases where the compression of the cauda equina occurred 
from tumors. Among those who have reported such cases may be mentioned Simon,* 
Fisher,! and Graves. J 
A PRELIMINARY REPORT OF EXPERIMENTAL RESEARCHES CON- 
CERNING THE INFECTIOUS NATURE OF TRAUMATIC TETANUS. 
RAPPORT PRÉLIMINAIRE DES RECHERCHES EXPERIMENTALES SUR LA 
NATURE INFECTIEUSE DU TÉTANOS TRAUMATIQUE. 
EIN VORLÄUFIGER BERICHT ÜBER EXPERIMENTALE UNTERSUCHUNGEN DER INFEC- 
TIÔSEN NATUR DES TRAUMATISCHEN TETANUS. 
Of Philadelphia, U. S. A. ; Pathologist to the Philadelphia Hospital, etc. 
BY EDWARD ORAM SHAKESPEARE, A.M., M.D., 
On the five pages immediately following the details of experiments are tabulated, 
for more convenient reference. 
* Archiv f. Psych, u. Nervenkr., v, p. 114, 1874. 
f Transactions Prov. Med. and Surg. Assn., 1882, x, p. 203. 
J Transactions Path. Soc., Lond., 1875, '76, xxvn, p. 19. 1887. 
Aug. 1. 
A white rabbit was tre- 
phined and the brain acci- 
dentally wounded to depth 
of a inch; this followed 
by transient paralysis. 
Not inoculated. 
A culture started,! 
in neutral glycerine 
agar, as prepared by 
Roux for tubercle 
cultures, from the 
medulla. 
At 5 p.m. a mouse-colored 
rabbit inoculated, sub dura, 
with emulsion of a portion 
of medulla. 
At 5.30 p. m. a white rabbit 
inoculated, sub-dura, with a 
similar emulsion. 
At 5.30 p.m. medulla put 
back on ice. 
At 6 p.m. inocu- 
lated, under skin 
above the tail, a 
black and white 
rabbit. (See previ- 
ous column, 9th.) 
At 6 p. m. inocu- 
lated, under skin 
above the tail, a 
black rabbit. 
" 2. 
In early morning had tris- 
mus and tetanus, which be- 
came pronounced in a few 
hours; in afternoon ex- 
tremely marked intermit- 
tent opisthotonos. 
In afternoon had trismus 
and convulsive movements of 
legs when disturbed. 
At 4.15 p.m. a 
At 4 p. m. spotted white 
inoculated, and gray 
s u b-d u r a, a rabbit i nocu- 
white rabbit, la ted, sub- 
dura. 
*' 3. 
In afternoon still living 
in tetanic convulsions ana 
trismus, but former less in- 
tense. 
In afternot 
thotonos; jaw 
cord put to d 
II 
At 4 p.m. in- 
oculated, 
sub-dura, a 
white rabbit 
>n dead in opis- 
s set ; portion of 
ry in jar.* 
II 
At 4.15 P. m. in- 
oculated , sub- 
dura, half white 
and gray rabbit. 
In afternoon 
sick; slight In afternoon 
trismus; great down on side; 
difficulty in head back; 
eating; slight trismus; died 
tetanic con- next day. 
vulsions when 
moved. 
" 4. 
Still living in tetanic 
spasms and trismus. 
At 4 P. m. 
slight tris- 
mus and 
convulsions 
when 
moved. 
Died in the 
night in 
opisthoto- 
• nos. 
At 2 p.m. trismus 
and marked tet- 
anic spasms; at 
5.30 p. m. found 
dead in marked 
opisthotonos 
and stiff. 
At 6 p.m. inocu- 
lated, sub-dura, 
a mouse-colored 
rabbit. 
In morning worse; at 3 p.m. 
found dead in extreme opis- 
thotonos; portion of cord put 
to dry in jar.* 
At 6 p. m. inoculated yellow 
and white rabbit. 
" 5. 
Died in morning, in 
marked tetanic spasms ; put 
on ice. 
Dead in 
opisthotonos. 
Died in tetanic spasms dur- 
ing morning; kept on ice. 
" 7. 
At 12 m. inoculated a 
mouse-colored rabbit; at 6 
p. m. trismus and tetanic 
spasms. 
At 12.15 p.m. inoculated a 
black and white rabbit; at 6 
p.m. trismus and tetanic 
spasms. 
" 8. 
Found dead in early morn- 
ing in marked opisthoto- 
nos ; a portion of cord put 
- 
Found dead in early morn- 
ing; portion of cord removed 
and put in drying jar;* 
animal placed on ice. 
to dry in jar*; animal placed 
on ice. 
" 9. 
a 
In afternoon inoculated a 
mouse-colored rabbit. 
b 
c 
In afternoon inoculated a 
black and white rabbit (he 
had been inoculated undei 
skin on the 1st, from horse 
medulla, and had remained 
perfectly well). 
AUGUST 1, 1887, A HORSE DIED DURING THE EARLY MORNING OR NIGHT, AT THE VETERINARY DEPARTMENT OF THE UNIVERSITY OF 
PENNSYLVANIA, OF WELL MARKED TRAUMATIC TETANUS. ITS BRAIN, MEDULLA AND SPINAL CORD WERE 
REMOVED BETWEEN THREE AND SIX HOURS POST-MORTEM, AND IMMEDIATELY PLACED UPON ICE. 
374 1887. 
Aug. 10. 
a 
Died in morning, of tris- 
mus and opisthotonos; put 
on ice. 
b 
Died in morning, of tris- 
mus and tetanic spasms; por- 
tion of cord removed and put 
to dry in jar;* animal put on 
ice. 
d 
" 11. 
In afternoon inoculated a 
mouse-colored and white 
rabbit. 
In afternoon inoculated a 
black and white rabbit. 
Died greatly 
emaciated, with- 
out having shown 
signs of tetanus; 
put on ice. 
" 12. 
Trismus and tetanic 
spasms. 
Marked trismus and opis- 
thotonos. 
" 13. 
Found dead in opisthoto- 
nos; put on ice. 
Marked trismus and opis- 
thotonos. 
" 14. 
In afternoon inoculated a 
gray rabbit. • 
Marked trismus and opis- 
thotonos 
" 15. 
Early morning, squealing; 
spasms; at 2 p.m. dead, and 
portion of cord put to dry.* 
At 3 p. m. inoculated' a 
gray rabbit with right white 
shoulder. 
Marked trismus and opis- 
thotonos. 
Inoculated, sub- 
dura, a white 
rabbit. 
This rabbit still 
living, Sept. 4th, 
and always well. 
" 16. 
Died without fits; he ate all 
the time and died suddenly. 
Inoculated a gray rabbit 
with white shoulders. 
Dead ; cord put to dry.* 
Inoculated a brown and 
white rabbit. 
" 17. 
Early morning found dead 
in extreme opisthotonos ; 
animal put on ice. 
1 
Died at 2 p. m. with marked 
trismus and opisthotonos; at 
noon had 
- 
ZZ1 
" 18. 
Inoculated 
in afternoon 
a yellow rab- 
bit with 
white collar. 
Cord put in drying jar;* 
animal kept on ice. 
Inoculated a mouse- 
colored rabbit with 
a white collar. 
ii 
In afternoon in- 
oculated a black 
and white rabbit. 
in atternoon inoc- 
ulated a black rabbit 
with white collar. 
h ii 
T "i * j Inoculated 
Inoculated a gray rabbiti 
gray rabbit. whiteshoulder 
" 19. 
Early 
morning not 
eating; jaws 
set; slight 
spasms when 
disturbed ; 
between 7 
and 12 a. m. 
died in opis- 
thotonos. 
Early morning 
eating; seems well; 
ät noon a little ten- 
dency to spasms ; 
at2 p.m. moribund; 
head back; no tris- 
mus; breathing 
heavily; soon died; 
jaws not set at any 
time. 
At 3.30 p.m. inoculated a 
mouse-colored rabbit. 
Early morning not eating; 
jaws set; head back; spasms 
when moved ; at 2 p.m. better; 
at 6 p.m. worse. 
• EarlZm°r°; Not eating; 
eat-'jawsdset- 110 tendency 
eat, jaws set, t spasms but 
whgen X d >ws sli*ht'y 
u. " 7 set at 3 p-M- ; 
at 5 p.m. died 
12 a m died .n marked 
nos °P1S^0^0' opisthotonos. 
Early morning 
not eating; jaws 
set ; spasms when 
moved ; at 2 P. m. 
better. 
---------- 
375 1887. 
Aug. 20. 
Culture renewed. 
At 5 a.m. found dead and 
still in marked opisthotonos. 
II 
At 3 p. m. inoculated into 
muscles of the back a large 
yellowish-gray rabbit. 
4th Sept. This rabbit still 
perfectly well. 
At 2 p.m. better; jaws less 
set, but spasmodic movements 
of them; will not eat; dead 
between 3 and 6 p. m., in 
marked opisthotonos and stiff. 
Jaws not set at 
noon; at 2 p. m. 
nearly moribund 
and jaws set ; at 6 
p. m. died, limp. 
.......... ............ .......... 
" 21. 
At 4 p.m. in- At 
oculated, sub- inocu 
dura, spotted under 
yellow and back, a 
white rabbit, rabbit. 
P. M. 
lated, 
skin of 
white 
At 6 p. m. At 6. 
inoculated, inocu 
under skin of under 
•back, a white back, 
rabbit. rabbit 
30 P. M. At 6 
lated, inocu 
skin of under 
white back, 
box 8). rabbit 
ri F1a ' At 4 P. m. inocu- 
lated a yellow rab- 
sk'"°I bit; at 10 p.m. tt 
(box2\ seemed well. 
" 22. 
• 
At 5 p.m. no 
trismus or 
Still living 
and well, Sept. 
• 
At 7 a. m. very 
ill; jaws set and 
intense spasms; 
died between 7 
and 12 a. m. 
II 
At 5 p. M. inocu- 
spasms. 
4 th. 
lated, with great 
difficulty, an Al- 
derney Cow, 
which had tuber- 
culosis pulmonum; 
brain wounded to 
depth of one inch. 
" 23. 
A 
Head back ; 
unsteady on 
legs, but no 
trismus. 
e 
f 
ff 
Kept 
sion 
d u 11 a 
night 
oculate 
dura, a 
a youn 
rabbit. 
emul- 
of me- 
over 
ind in- 
d, sub- 
4 p.m., 
g white 
In morning no 
symptoms; at 3 
p.m. difficulty of 
breathing, which 
was not noticed at 
noon; at 3.30 P.M. 
distinct trembling 
of muscles of hind 
legs; at 5 p.m. 
down; could not 
cause movement 
of jaws or make 
her open the 
mouth; at 6 p.m. 
no trembling of 
legs; jaws mov- 
able; breathing 
easier. 
376 1887. 
Aug. 24. 
Died greatly emaciated, 
having shown no signs of 
tetanus. 
A 
e 
J 
Died with tris- 
mus and tetanic 
spasms. 
Found dead in 
morning; legs 
drawn up; head 
straight out; au- 
topsy showed 
wound in dura 
and correspond- 
ing cerebral hemi- 
sphere; intenseen- 
gorgement of that 
side of brain ; no 
marked congestion 
of lungs or trachea 
" 25. 
At 5 p.m. inoculated, sub- 
dura, a small white rabbit. 
This rabbit quite well up 
to Sept. 4th. 
A Mule died of 
Traumatic Tetanus, 
and the brain, me- 
dulla and cord were 
placed on ice. 
II 
At 5 p.m. inocu- 
lated, sub-dura, a 
white rabbit 
Head back ; 
tendency to 
spasms. 
1 
At 5 p. m. a 
young white rab- 
bit inoculated, 
sub-dura. 
" 26. 
At 1 p m. sick; ten- 
de n c y to spasms ; 
head back; jaws set; 
at 5 p. m. and later 
in evening severe 
tetanic convulsions; 
head back; jaws 
firmly set; fore legs 
stretched out. 
Above condi- 
tion more 
marked. 
Found dead in 
morning, but no 
signs of tetanus. 
II 
" 27. 
Early morning 
found dead; put on 
ice. 
II 
At 5 p. m. inocu- 
lated a gray rabbit 
with white collar. 
Marked tet- 
anic convul- 
sions, but jaws 
seldom set. 
Inoculated a yel- 
lowish brown rab- 
bit with white 
collar. 
" 28. 
Early morning 
found dead, in 
marked opisthoto- 
nos; put on ice. 
Early morn- 
ing found dead 
in marked 
opisthotonos. 
This rabbit still 
living and well 
Sept. 4th. 
II 
..... . 
" 29. 
At 3 p. m. inocu- 
lated a yellow rabbit 
with white shoul- 
ders; at 10 p.m. appa- 
rently well. 
" 30. 
Early morning 
found dead in marked 
opisthotonos. 
h 
e 
1 
377 1887. 
Aug. 31. 
JI .. 
e 
Virus from cord 
of 8th, in column 
3, kept in drying 
jar. 
/ 
Virus from cord 
of 3d, column 4, 
kept in drying jar. 
g 
Virus from cord of 4th, column 
5, kept in drying jar. 
II 
At 6.30 p M; 
inoculated, 
subdura, a 
brown and 
white rabbit. 
II , 
At 6 p.m. inocu- 
lated, sub-dura, a 
white rabbit; at 10 
p. M. not eating. 
At 6.15 p. m. inoculated, sub- 
dura, a yellow rabbit ; at 10 
p. m. not eating 
. II . . ..... II 
II ...JI............ 
Sept. 1. 
Quite well. 
In morning and 
at 3 P. M. same con- 
dition, but no tris- 
mus or spasms, at 
5.30 and at 7.30 p.m. 
trismus. 
In morning, at noon and at 
3 p. M. same condition, but no 
trismus or spasms ; at 5.30 p.m. 
trismus. 
Inoculated, Inoculated, 
sub-dura, a sub-dura, the 
mouse-colored white rabbit 
rabbit. in box 6,which 
had been inoc- 
ulated under 
skin on Aug. 
21st; at 10 p.m. 
seemed well. 
Inocula- Inoculated, 
ted, sub-du- sub-dura, the 
ra, a gray white rabbit 
rabbit. in box 8,which 
had been inoc- 
ulated under 
skin Aug. 21st. 
Inoculated, sub- 
dura, the yellow 
rabbit in box 2, 
which had been 
inoculated under 
skin Aug. 21st. 
Inoculated, sub- 
dura, a gray rab- 
bit. 
" 2. 
Quite well. 
Not eating ; jaws 
set; at 9.30 P. M. eat- 
ing a little; jaws 
only stiff. 
Eating in morning ; at 2 p.m. 
jaws not set ; at 4 p. m. eating. 
i nw V'h tTlT fol"'d 7(1 ® • 
otherwise weli 8"8 
and eats. of_tetanus. 
Well and Well and 
eating. eating. 
Welland eating. 
Well and eating. 
" 3. 
Quite well. 
In morning not 
eating; jaws stiff ; 
at noon jaws set; at 
3 p.m. same; at 5 p.m. 
jaws movable, but 
not eating. 
In morning not eating; 
noon same ; jaws set ; at 3 p.m. 
same ; at 5 P. m. jaws slightly 
movable. 
Quite well. 
Welland Well and 
eating. eating. 
Well and eating. 
Well and eating. 
" 4. 
Quite well. 
Same condition in 
morning and at 2 
P.M. 
Eating a little, but jaws stiff. 
Quite well. 
Eats but Eating 
little;jaws little; jaw 
a little stiff, little stiff. 
but 
8 a 
Well and eating. 
Welland eating. 
Explanation.-The lines - indicate end of the series ; the lines || indicate an inoculation ; the line | indicates continuation of remarks. All 
inoculations, unless otherwise stated, were made between the dural and arachnoid membranes of the brain. 
378 SECTION IX-PATHOLOGY. 
379 
First Series.-Eight rabbits were inoculated sub dura from the medulla of a horse 
dead from traumatic tetanus. 
The first rabbit showed the first symptoms of tetanus within 15 hours, and died in 
tetanic convulsions within 48 hours after inoculation. Both the period of incubation 
and that of death became markedly shortened in continuing the inoculations from rabbit 
to rabbit. 
Second Series.-Four rabbits were inoculated sub dura from the same medulla of 
tetanic horse. The first rabbit showed the first symptoms of tetanus within 20_hours 
and died within 48 hours after inoculation. Continuing the inoculations from rabbit to 
rabbit, the period of incubation and of death shortened. 
Third Series.-Four rabbits were inoculated sub dura from the medulla of the same 
horse after it had been kept on ice 24 hours. The first rabbit showed the first symp- 
toms in 24 hours, and died in 48 hours after inoculation. Continuing the inoculations 
from rabbit to rabbit, the period of incubation and of death became shortened. 
Fourth Series.-Three rabbits, in series, were inoculated sub dura from the medulla 
of a mule which had died of traumatic tetanus, with the same results as in the previous 
series. 
Fifth Series.-Seven rabbits were inoculated under the skin from the medulla of the 
horse above mentioned (either into subcutaneous or intermuscular tissue of the back). 
One died within 18 hours and one within 10 days, but neither of them showed any signs 
of tetanus, either externally or internally. A rabbit inoculated sub dura from the 
medulla of the latter on August 15th is still (September 4th) living and quite well. 
The rest remained well. 
Sixth Series.-A rabbit which had been inoculated under the skin eight days prior 
was inoculated sub dura from the last rabbit of the third series. It became ill and 
died promptly of tetanus in the shortened period. 
A rabbit inoculated sub dura from its medulla showed signs of tetanus within 20 
hours, but did not die until five days after inoculation. 
Seventh Series.-Six rabbits were inoculated sub dura with emulsions of the spinal 
cords of tetanic rabbits which had been treated in a manner similar to that which 
Pasteur employs for the attenuation of the virus of hydrophobia, during periods varying 
between three and fifteen days. Five of these died of marked tetanus, the symptoms 
appearing and death occurring within periods longer than those of the corresponding 
rabbits from which the cords had been obtained, and usually proportional to the length 
of time in which the cord had been drying. One of the six showed doubtful signs of 
tetanus, but nevertheless very promptly died. 
Eighth Series.-A. rabbit was inoculated sub dura with the medulla of the rabbit 
which had died after inoculation with the cord which had been 15 days drying, and it 
showed the first signs of tetanus in 40 hours, and died in tetanic convulsions seven days 
after inoculation. 
A rabbit was inoculated sub dura with cord which had been drying 14 days, and it 
died of tetanus in 20 hours. A rabbit and a cow were inoculated sub dura from its 
medulla, and the former died of marked tetanus, while the latter died without marked 
symptoms. (From the autopsy, it is probable that death was caused by injury to the 
brain.) 
A young rabbit was inoculated sub dura, August 27th, from the cow's medulla, and 
died within 16 hours, but showed no signs of tetanus. 
A rabbit was inoculated sub dura from its medulla, and is still living (September 
4th), with no signs of illness. 
Ninth Series.-Three rabbits were inoculated sub dura, September 1st, from cords 
which had been drying, respectively, 23, 27 and 28 days (the three oldest cords used in 
RÉSUMÉ OF RESULTS. 380 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the seventh series). Those inoculated with the 23- and 28-day cords showed no signs 
of illness up to the afternoon of September 4th. The one inoculated with the 27-day 
cord for the first time showed stiff j aws and ate but little on afternoon of September 4th. 
Tenth Series.-Three well rabbits which had been inoculated under the skin, 
August 18th, were inoculated sub dura, September 1st, with the same cords as above, 
viz., 23-, 27- and 28-day cords. That of 23-day cord found dead next day, but had no 
signs of tetanus, either externally or internally. That of 28 days had stiff jaws and 
would not eat for the first time on afternoon of September 4th. That of 27 days 
showed no signs of illness up to September 4th inclusive. 
Eleventh Series.-Three rabbits were inoculated sub dura, August 31st, from cultures 
from the horse's medulla which had been started August 1st. One rabbit refiiained 
quite well up to the afternoon of September 4th. One showed slight signs of tetanus 
September 2d, which continued through September 3d and 4th. One showed slight 
signs of tetanus September 3d, which continued through September 4th. 
Twelfth Series.-A trial attempt was kindly made for me by Dr. L. Wolff, of Phila- 
delphia, to isolate a ptomaine from the brain, medulla and cord of the above-mentioned 
mule and cow. 
The method of Stass-Otto was more or less closely followed. The product obtained 
from the mule was injected into two rabbits under the skin of the back. Within 
twenty minutes they became very ill, slightly paralyzed, and very restless, with much 
difficulty of breathing, but had no trismus or decided convulsions. They entirely 
recovered in six hours. 
The product obtained from the cow produced but little and only very transient 
effect. 
Note.-The autopsies of the tetanic animals showed intense congestion of the lungs 
and trachea and of the kidneys. Sometimes congestion, but oftentimes none at all, of 
the cerebro-spinal central nervous system. Only in one (the cow) was there any indi- 
cation of injury or local inflammation at the seat of inoculation. 
Some of the series of experiments are still in progress, and only the results already 
obtained are announced. Upward of fifty inoculations have already been made, 
including control experiments. Two methods of inoculation have been employed. 
Intracranial inoculations, after the method of Pasteur in the case of rabies, and sub- 
cutaneous or intermuscular injections by means of hypodermic syringes. The inocula- 
tions were always made under thorough antiseptic precautions and with sterilized 
instruments. In none of the experiments was there any sign of accidental infection, 
such as suppuration, etc. The material used for inoculation was, in general, obtained 
from the medulla or the spinal cord, and cultures in neutral or slightly alkaline flesh, 
glycerine-agar, as recommended by Roux for the culture of tubercle bacilli. The 
tetanus material was taken, under aseptic precautions, from a horse and a mule, 
dead of traumatic tetanus, in the Veterinary Department of the University of Penn- 
sylvania, the brain medulla and cord being removed one and three hours respectively, 
post-mortem, and immediately kept on ice until used. The inoculation material was, 
in general, prepared in the following manner : a small piece of the medulla or cord was 
thoroughly rubbed in sterilized distilled water; after the solid particles were allowed 
for a few minutes to subside to the bottom of the vessel, the opalescent emulsion thus 
obtained was drawn off by means of sterilized pipettes and placed in small sterilized 
vials until used, never having been thus kept longer than three hours before inocula- 
tion. Eight control experiments were made. 
Conclusions drawn from the author's personal researches :- 
1. Traumatic tetanus of the horse and mule is, at least sometimes, if not always, an 
infectious disease transmittible to other animals, and, therefore, possibly also to man; 
and during the progress of this disease a virus is elaborated and multiplied, which is SECTION IX PATHOLOGY. 
381 
capable of producing the same infectious disease in some other animals, when placed 
beneath the dura mater of the cerebrum. 
2. This virus is contained in the medulla and spinal marrow of the animal suffering 
with the disease. It is, like the virus of hydrophobia, capable of being strengthened 
in virulency by inoculation sub dura cerebri from rabbit to rabbit, and, like the virus 
of hydrophobia, is capable of attenuation by exposure for a sufficient time to the action 
of the dry air at a temperate or summer heat; and, still again, like the rabic virus, its 
effects are far more intense when the virus is inserted beneath the dura mater cerebri 
than when injected beneath the skin or between the muscles of the back. 
3. The author reserves his conclusions concerning a prophylactic effect of inocula- 
tions of the attenuated virus until the completion of experiments which are at present 
in progress. 
Conclusions drawn from the author's experiments when correlated with those of 
Nicolayer, Carle and Ratone, Rosenbach, Ferrari, Flügge, ei al :- 
Traumatic tetanus of the lower animals and of man, at least sometimes, possibly 
always, is a specific infectious disease, due to the action of a specific infectious virus 
which exists in the tissues at the seat of infection, in the blood and in the cerebro-spinal 
nervous system. 
In view of the experimental evidence which we possess at present, and of many 
unassailable observations of many surgeons and veterinarians, there seems to be ample 
warrant for the admission that not infrequently tetanus in man is acquired directly and 
indirectly from some of the domestic animals which surround him, notably the horse. 
DISCUSSION. 
Dr. Lester Curtis said that in a recent number of the Berliner Klinische 
Wochenschrift he had noticed an article describing two fatal cases of tetanus in the 
human subject. The first of these was that of a man who contracted tetanus from a 
splinter under the nail while rolling tenpins. Portions of this splinter were thrust 
into the skin of guinea pigs and resulted always in tetanus. 
The other was that of a boy who thrust a small stone under the skin of the foot 
while barefooted. Portions of the earth from the playground inserted under the 
skin of rabbits resulted in tetanus. 
The observer found two bacterial forms in the blood of the patient and the 
infected animals ; one of these was an ordinary micrococcus, and seemed to be that of 
putrefaction;' the other was a small rod bacterium, not very minutely described. The 
latter form he thinks to be the agent in producing tetanus. But the active agent he 
thinks was a ptomaine which has been before described and named tetanin. 
Cultures were made of this rod form, and tetanus resulted from inoculation of this 
culture, though the methods are not given in the paper. 
Dr. Lewis P. Bush, of Wilmington, Delaware, asked the question whether the 
experiments of Dr. Shakespeare did not prove that tetanus was not communicated 
by mere contact of animal to animal-inasmuch as hypodermic injection failed to 
produce tetanic symptoms-but only when the substance taken from the spinal cord 
is njected beneath the dura mater of the brain. 
To which Dr. Shakespeare replied that although his experiments seemed to 
admit of that conclusion, in Europe the hypodermic injection did produce tetanus, 
as reported. 382 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Victor C. Vaughan, Ann Arbor, Mich., read a paper on- 
TYROTOXICON : ITS NATURE, ITS CHEMISTRY, AND ITS ACTION 
UPON ANIMALS. 
TYROTOXICON : SA NATURE, SA CHIMIE, ET SON ACTION SUR LES ANIMAUX. 
TYROTOXICON: SEIN WESEN, SEINE CHEMIE UND WIRKUNG AUF THIERE. 
In 1885 the writer announced the discovery in poisonous cheese of a ptomain, which 
produced upon man symptoms identical with those observed in persons who ate of the 
cheese.* Since that time, aided by my laboratory assistants, Messrs. F. G. Novy and 
E. V. Riker, I have continued the study of this poison, with the results to be given in 
this paper. 
In November, 1885, a student brought me a bottle of milk which had stood tightly 
closed, with a glass stopper, for about six months. From this I isolated tyrotoxicon by 
the method which had been employed with the cheese. It was presumed that this 
milk was normal in composition when first obtained ; but of this we could not be 
certain.f 
I then put several gallons of normal milk in perfectly clean bottles with glass stop- 
pers, and allowed these to stand in my work room. From time to time a bottle was 
opened and a test for tyrotoxicon was made. These tests were followed by negative 
results, until about three months after the experiment was begun. I then succeeded 
in getting the poison from one of the bottles. The method of testing for it was as fol- 
lows : The coagulated milk was filtered through heavy Swedish filter paper. The fil- 
trate, which was colorless and strongly acid, was rendered feebly alkaline by the addi- 
tion of potassium hydrate, then agitated with ether. After separation the ethereal 
layer was removed with a pipette, allowed to run through a dry filter paper to remove 
a flocculent, white substance which floated in it, and then allowed to evaporate spon- 
taneously. If necessary, this residue was dissolved in water and again extracted with 
ether. On the evaporation of the ether, the tyrotoxicon was recognized by its crystalline 
appearance, by placing a small bit upon the end of the tongue, and by its effects upon 
animals, which will be discussed later. 
In June, 1886, I obtained tyrotoxicon from some ice cream which had seriously 
affected all who had eaten of it. J This cream had been flavored with vanilla, and the 
ill effects were at first supposed to be due to the flavoring, some of which* fortunately, 
remained in the bottle, and was sent to me along with the cream. As the surest 
means of deciding whether or not the vanilla extract was poisonous, Mr. Novy and I 
each took thirty drops of it. No ill results following this, Mr. Novy took two tea- 
spoonfuls more, with no results. This settled the question of the poisonous nature of 
the vanilla more satisfactorily than could have been done by a chemical analysis. 
Moreover, it confirmed the views of Preusse, who, some years ago, from experiments 
with vanillin and vanilla extracts, reached the conclusion that the popular belief that 
poisoning from vanilla cream is due to the flavoring is erroneous. £ Tyrotoxicon has 
been found not only in vanilla cream, but in that flavored with chocolate and lemon, 
also in custard which contained no flavoring whatever, and in milk, cheese, cream 
puffs and oysters. 
* Zeitschrift für physiologische Chemie, B. x, Heft ii. 
f " Report of Michigan State Board of Health," July, 1886. 
J " Report of Michigan State Board of Health," July, 1886. 
§ Zeitschrift für physiologische Chemie, B. IV, £ 209. SECTION IX-PATHOLOGY. 
383 
The tyrotoxicon obtained from this cream was administered to a cat, with results to 
be given further on. 
We also ascertained that when normal milk was inoculated with some of the solid 
portion of the poisonous cream, the whole became poisonous after being kept in a warm 
room tor a few hours This indicated that the poison was due to the growth of a germ. 
In August, 1886, the poison was found in milk by Drs. Newton and Wallace,* 
chemists to the New Jersey State Board of Health, and later by Prof. Scherer,! chem- 
ist to the Iowa State Board of Health. An English Army medical officer seems to 
have been equally successful. | Dr. Stanton, § Health Officer of Cincinnati, has obtained 
tyrotoxicon from some poisonous cream-puffs, while still more recently Dr. Wallace || 
has detected it in some cheese which seriously affected those who ate of it, and Prof. 
Ladd, of Geneva, N. has obtained it from some poisonous chocolate cream. 
In January, 1887, we ascertained that if some butyric acid ferment be prepared as 
is ordinarily done in the preparation of butyric acid, and some of this be added to nor- 
mal milk, and the whole be kept in closely stoppered bottles for eight or ten days, the 
poison will be developed in the milk in considerable quantity. The milk should be 
filtered, the filtrate neutralized with sodium carbonate, and then extracted with ether. 
Having a strong solution of the poison in absolute alcohol, which had been obtained 
from milk inoculated as stated above, I added it to some platinum chloride and began 
to evaporate on the water-bath. As soon as the alcohol evaporated the residue 
exploded with great violence. The vessel, a glass'evaporating dish, was broken into 
fine fragments, and these were scattered over the room, while the gaslight under the 
water bath was extinguished. The experiment was repeated a number of times with 
like results. From some of this alcoholic solution the platinum was removed with 
hydrogen sulphide gas ; but the filtrate was then found to have lost its explosive 
property. This reminded us that diazobenzol compounds form with platinum chloride 
a highly explosive compound, and that diazobenzol is also decomposed by hydrogen 
sulphide. Some diazobenzol nitrate was prepared, according to the method of Griess, ** 
and comparisons made between this and tyrotoxicon. 
With equal parts of sulphuric acid and carbolic acid the prepared diazobenzol nitrate 
gave a green coloration, while with the same reagents tyrotoxicon gave a color which 
varied from a yellow to an orange-red. But the diazobenzol nitrate dissolved in the 
whey of normal milk, and extracted with ether or in the presence of other proteids, 
gave the same shades of color as the tyrotoxicon did, and the potassium compound of 
tyrotoxicon prepared by the method to be given later produced the same shade of green 
as did the artificial diazobenzol. This color test may be used as a preliminary test in 
examining milk, or other suspected material, for tyrotoxicon. It is best carried out as 
follows : place on a clean porcelain surface two or three drops each of pure sulphuric 
acid and pure carbolic acid. This mixture should remain colorless or nearly so. Then 
add a few drops of the aqueous solution of the residue left after the spontaneous evapo- 
ration of the ether. If tyrotoxicon be present, a yellow to an orange-red color will be 
produced. This test is to be regarded as only a preliminary one ; for it may be due to 
the pressure of a nitrate or nitrite. The tyrotoxicon must be purified according to a 
method to be given further on before the absence of nitrate or nitrite can be positively 
demonstrated. 
In the filtrate from milk which is rich in tyrotoxicon, after neutralization -with 
sodium carbonate, filtration and acidifying with hydrochloric acid, gold chloride pro- 
* Medical News, Sept. 25th, 1886. 
f Iowa State Register, Oct. 12th, 1886. 
! The Lancet, June 29th, 1887. 
§ Cincinnati Lancet and Clinic, April 23d, 1887. 
|| JfedtcaZ News, July 16th, 1887. 
Unpublished. 
**AnwaZen der Chemie und Pharmacie, B. 137, $ 39. 384 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
duces a precipitate, which is insoluble in water, but soluble in hot alcohol, from which 
it separates on cooling, in golden plates, which are more or less imperfect. Diazobenzol 
compounds give with gold chloride a precipitate having all these properties. In both 
cases the gold compound is decomposed by frequent treatment with hot alcohol, and 
this fact prevented any satisfactory ultimate analysis of this salt. It should be remarked 
here that from some samples of milk this gold salt is obtained much more easily than 
from others, and the difference is dependent not so much upon the amount of tyro- 
toxicon present, as upon the condition of the other organic matter present. It is best 
obtained from samples which have stood in well stoppered bottles for a month or 
longer. 
Tyrotoxicon obtained from milk was treated according to the method recommended 
by Griess* for the preparation of diazobenzol potassium hydrate, and the per cent, of 
potassium in the compound obtained was determined. The filtrate from the milk 
which had been inoculated with the ferment and kept in a stoppered bottle in a warm 
room for ten days, was neutralized with sodium carbonate, agitated with an equal 
volume of absolute ether, allowed to stand in a stoppered flask for 24 hours, the ether 
removed and allowed to evaporate from an open dish. The aqueous residue was acidi- 
fied with nitric acid, then treated with an equal volume of a saturated solution of 
potassium hydrate and the whole concentrated on the water-bath. On being heated 
the mixture became yellowish-brown and emitted a peculiar aromatic odor. Both the 
color and the odor corresponded exactly with the color and odor produced by carrying 
some of the artificial diazobenzol through a comparative test. On cooling, the mass 
crystallized, the resulting compound appearing in the test with the tyrotoxicon, and in 
the comparative test also, in beautiful, six-sided plates, along with the prisms of potas- 
sium nitrate. The crystalline mass obtained from the tyrotoxicon was treated with 
absolute alcohol, filtered, the filtrate evaporated on the water-bath, the residue dis- 
solved in absolute alcohol, from which it was precipitated in a white crystalline form 
with ether. The precipitate was collected, washed with ether, dried, and the per cent, 
of potassium estimated as potassium sulphate. 
.2045 gram of the substance yielded .109 gram of potassium sulphate. 
Per cent, of potassium calculated in C6H5N2 OK 24.42 ; found 23.92. This analysis 
establishes the identity of tyrotoxicon and diazobenzol. 
Chemists will now appreciate the great difficulty that has been experienced in iso- 
lating the active agent of poisonous cheese. The readiness with which diazobenzol 
decomposes is well known. When warmed with water it breaks up into carbolic acid 
and nitrogen. 
Recently, we received from Amboy, Ohio, two four-ounce bottles filled with melted 
cream. One kind was flavored with lemon and the other with vanilla. Both had 
proved poisonous, over 150 persons having been affected from eating the cream. The 
bottles were tightly corked, and a few hours after coming into our possession the bottle 
containing the vanilla cream burst, from the accumulated gas, and the contents were 
lost. The other bottle was then opened under water and its contained gas collected 
and analyzed. It yielded 88.8 per cent, of nitrogen. SoiAe undecomposed tyrotoxicon 
was separated from the cream and its toxic effect was demonstrated on a kitten. 
Hydrogen sulphide decomposes tyrotoxicon ; therefore, all attempts to obtain the 
poison by precipitating it with some base, such as mercury or lead, and then removing 
the base with hydrogen sulphide, have failed. Moreover, diazobenzol is only a transi- 
tion product of putrefaction. 
I have frequently found that leaving some milk rich in the poison in an open 
beaker for twenty-four hours would be sufficient to destroy the whole of the poison. 
* Annalen der Chemie und Pharmacie, B. 137, § 54. SECTION IX-PATHOLOGY. 
385 
We know nothing positively concerning the acid with which diazobenzol is com- 
bined in the milk or cheese. We prepared some diazobenzol butyrate, C6H5N2C4H7O2, 
and ascertained that the crystals of this compound correspond with those of tyrotoxicon, 
and that they decompose in moist air with the same rapidity. This is the first time 
that diazobenzol has been found as a product of putrefaction, and it is possible that 
many of its allied compounds may be formed in the same way. 
The following experiments will show that the effects of tyrotoxicon and diazobenzol 
upon the lower animals are identical:- 
Experiment 1.-From one-half gallon of some milk which had stood in a tightly 
stoppered bottle for three months, there was obtained quite a concentrated aqueous 
solution of the poison after the spontaneous evaporation of the ether. Ten drops of 
this placed in the mouth of a small dog three weeks old caused, within a few minutes, 
frothing at the mouth, retching, the vomiting of frothy fluid, rapid breathing, muscu- 
lar spasm over the abdomen, and after some time, watery stools. The next day the 
dog seemed to have recovered partially, but was unable to retain any food. This con- 
dition continuing for two days, the animal was killed with chloroform. No examina- 
tion of the stomach was made. 
Experiment 2.-To a small kitten, nine days old we gave some tyrotoxicon obtained 
from lemon cream received from Amboy, Ohio. Within a few minutes there was 
violent retching, but no vomiting or purging. Death resulted within fifty minutes. 
The stomach contained some food. The mucous membrane of the stomach and intes- 
tines were not reddened, but the lungs were congested. 
Experiment 3.-Tyrotoxicon obtained from poisonous ice cream was given to a cat. 
Within ten minutes the cat began to retch, and soon it vomited. The retching and 
vomiting continued for two hours, during which time the animal was under observa- 
tion, and the next morning it was observed that the cat had passed several watery 
stools. After this, although the cat could walk about the room, it was unable to retain 
any food. Several times it was seen to lap a little milk, but on doing so it would immedi- 
ately begin to retch and vomit. This condition continuing, after three days the 
animal was placed under ether, and its abdominal organs examined. We certainly 
expected to find marked inflammation of the stomach; but, we really did find the 
stomach and small intestines filled with a frothy, serous fluid, such as had formed the 
vomited matter, and the mucous membrane very white and soft. There was not the 
slightest redness anywhere along the alimentary canal. 
Experiment 4--Some tyrotoxicon obtained from milk which had been inoculated 
with poisonous cream and allowed to stand for 48 hours was administered to a large, 
old cat. It soon produced retching, but no vomiting or diarrhoea. The amount of the 
poison administered in this case was small. 
Experiment 5.-Some tyrotoxicon from milk was given to a young but full grown 
cat. Within 15 minutes there was marked and evidently painful retching, and within 
half an hour vomiting accompanied by rapid breathing. Later there were several 
stools, the first two of which contained fecal matter; but the subsequent ones were 
rice-water-like and wholly free irom fecal odor. After two days some more of the 
poison was given, and the vomiting and diarrhoea again induced. The animal was then 
anæsthetized, and examination of the stomach and intestine showed the mucous mem- 
brane blanched, as was found in Experiment 3. 
We have records of a number of other experiments with tyrotoxicon on cats and 
dogs, but as the symptoms induced in all were substantially the same, it is unnecessary 
to note them here. 
We will now give the effects observed in these animals after the use of the prepared 
diazobenzol :- 
Experiment 6.-Gave to a large, old cat 100 milligrams of diazobenzol butyrate. 
Vol. Ill-25 386 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Immediately the animal began to purge. Then she lay upon the floor breathing rapidly 
and retching severely for two hours, when she died. The retching was most violent, 
but vomiting seemed impossible. Post-mortem examination showed the lungs greatly 
congested, but the mucous membrane of the stomach and intestines was not reddened. 
The stomach contained some food. We suppose that the congestion of the lungs was 
due to the violent retching and to the feeble action of the heart. 
Experiment 7.-To a young but full-grown Maltese cat we gave 100 milligrams of 
diazobenzol butyrate. With most violent retching, but without vomiting or stool, the 
animal died within 30 minutes after the administration of the poison. The lungs were 
found acutely congested and the stomach free from any redness. The circular fibres of 
the small intestine were tightly contracted. 
Experiment 8.-Gave to a full-grown cat 25 milligrams of diazobenzol butyrate. 
Within ten minutes vomiting and purging were induced. The first stools contained 
fecal matter, but the subsequent ones were like rice-water and wholly free from fecal 
odor. After two days the cat was able to take food, then ten milligrams more of the 
poison was given, with the reproduction of the vomiting and purging. The animal 
then rapidly emaciated, and after a few days it was anaesthetized and the mucous mem- 
brane of the stomach and intestine found blanched. The lungs were not congested. 
Experiment 9.-Ten milligrams of the poison produced profuse diarrhoea and con- 
tinued vomiting in a cat. 
Experiment 10. -Seventy-five milligrams produced vomiting and diarrhoea with con- 
gestion of the lungs in a dog. 
It is worthy of notice that guinea-pigs and mice are not affected by tyrotoxicon in 
the same manner that cats and dogs are. We administered five milligrams of the arti- 
ficially prepared diazobenzol to each of four guinea-pigs. No effects were observed until 
the next day, when there seemed to be paralysis, first of the posterior, and then of all 
the extremities. This paralysis gradually extended, until within two or three days 
death resulted. There was neither vomiting nor purging. 
Prof. Ladd, of Geneva, N. Y., writes me that he administered the poison obtained 
from ice cream and mixed with meal, to two mice. This produced, after about twenty- 
four hours, paralysis of the legs. The legs were spread out, he writes, and the animals 
moved as though they were swimming. There was no vomiting or purging. 
It seems unnecessary to detail any more of these experiments, as the identity of tyro- 
toxicon with diazobenzol is now established, not only by chemical analysis, but this 
proof is strengthened, if chemical analysis can be strengthened, by the action of the 
poison on the lower animals and by post-mortem appearance. 
We think it highly probable that diazobenzol, or some closely allied substance, will 
be found in all those foods which, from putrefactive changes, produce nausea, vomiting 
and diarrhoea. In some oysters which produced these symptoms I have recently found 
tyrotoxicon. 
Milk or other fluid to be tested for this poison should be kept in well stoppered 
bottles, for if the fluid be exposed to the air, the tyrotoxicon may decompose in a few 
hours. The filtrate from the milk or the filtered aqueous extract of cheese should be 
neutralized with sodium carbonate, then shaken with half its volume of pure ether. 
Time should be given for the complete separation of the ether. Purified tyrotoxicon is 
insoluble in ether, and it probably owes its solubility in ether, at this stage, to the pres- 
ence of impurities. After complete separation, the ether should be removed with a 
pipette and allowed to evaporate spontaneously from an open dish. The residue from 
the ether may be dissolved in distilled water and again extracted with ether; but 
repeated extractions with ether are to be avoided, for as the tyrotoxicon becomes purified 
it becomes less soluble in ether. To a drop of an aqueous solution of the ether residue 
apply the preliminary test with sulphuric and carbolic acids. To the remainder of the SECTION IX-PATHOLOGY. 
387 
aqueous solution of the ether residue add an equal volume of a saturated solution of 
caustic potash, and evaporate the mixture on the water bath. The double hydrate of 
potassium and diazobenzol will be formed if tyrotoxicon be present, and this may be 
recognized by its properties and reactions, which have already been described. 
The physiological test should also be made, and for this purpose a young animal 
should be selected as the most susceptible. 
Chemically, tyrotoxicon is diazobenzol; pathologically, it is a ptomain, i. e., a basic 
chemical body produced by the putrefaction of organic matter. It is now a demonstrated 
fact that putrefaction is always due to some microorganism or germ. Just what germ 
tyrotoxicon owes its existence to, we are not positive; but it is either the butyric acid or 
some closely allied ferment. We have seen that if normal milk be inoculated with the 
butyric acid ferment prepared in the ordinary way, and then the air be excluded, tyro- 
toxicon will be developed in the milk. That the germ which produces this poison 
belongs to the anærobic class we have frequently demonstrated by the following simple 
experiment:- 
Inoculate two portions of the same milk with some poisonous milk or cream. Place 
one portion in a bottle, filling the bottle completely and stopping closely in order to 
exclude the air. Place the second portion in an open dish and stir occasionally, in order 
to bring the milk freely in contact with the air. After a few days, it will be found that 
although both portions of milk have decomposed, the nature of the decomposition has 
not been the same in them. Tyrotoxicon will be found only in that portion from which 
the air has been excluded. 
A nice practical application of this was furnished by a case occurring at Long Branch, 
N. J., and reported by Drs. Newton and Wallace. A number of persons at the hotels 
were poisoned by milk. Investigations showed that the cows were healthy, their food 
good, and their pasture and stables all in good sanitary condition. The milking was 
done at the usual hours of midnight and noon. The milk drawn at midnight was cooled 
by being left in cans surrounded by water until morning, when it was sent to the hotel. 
This milk never produced any unpleasant effect. The noon milk was placed in closed 
cans as soon as drawn, with all the animal heat still in it, and carted a distance of eight 
miles during the very hot days of August. This milk was poisonous, and from it Drs. 
Newton and Wallace separated tyrotoxicon.* 
The relation between this poison and cholera infantum I have discussed elsewhere, 
and it will be referred to further, in a paper to be read before another Section of this 
Congress. 
* Medical Newt, September 25th, 1886. 388 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Henry Sewall, of Ann Arbor, Michigan, read an abstract of a paper 
entitled- 
EXPERIMENTS ON THE PREVENTIVE INOCULATION OF 
RATTLESNAKE VENOM. 
EXPÉRIENCES SUR L'INOCULATION PROPHYLACTIQUE DU POISON DU 
CROTALE. 
EXPERIMENTE ÜBER PRÄVENTIVIMPFUNG DES GIFTES DER KLAPPERSCHLANGE. 
This work was undertaken with the hope that it might form a worthy contribution 
to the theory of Prophylaxis. 
I have assumed an analogy between the venom of the poisonous serpent and the 
ptomain produced under the influence of bacterial organisms. Both are the outcome 
of the activity of living protoplasm, although chemically widely distinct, the ptomains 
belonging to the group of alkaloids, while the active principles of the venom seem, 
according to Mitchell and Reichert and Wolfenden, to be of proteid nature. 
I have assumed, further, that it is through the ptomains produced by their vital 
metabolism that bacteria cause disease. Jf immunity from the evil effects of snakebite 
can be produced in an animal by means of repeated inoculation with small doses of the 
fatal poison, we may suspect that the same sort of resistance toward germ disease might 
follow the inoculation of the appropriate ptomain, provided that it is through the pro- 
ducts of their activity that bacteria produce their fatal effects. 
It is a matter of common experience that the repeated exhibition of poisons of various 
kinds gradually endows the organism with a power of resistance against the drugs 
employed. And yet there is reason to believe that this resistance may result from either 
of two opposite conditions impressed upon the living parts of the body-a pathological 
or a physiological. In the first case the sum total of energy of the protoplasm is dimin- 
ished; its irritability is lowered as well as its efficiency as a machine. In the second 
case, the total energy of the protoplasm is not diminished, but, perhaps, is even 
increased as the effect of the inexplicable tendency of living matter to adjust itself to its 
environment. Such a physiological resistance is shown by the secretory cell, which does 
not digest itself, and by the unicellular animals, which dissolve ingested matter but 
spare their own substance. 
The venom used in these experiments was obtained from the Massasanga, Crotalo- 
phorous tergeminus, one of the smallest of the rattlesnakes. 
A few drops of the poison were diluted with glycerine, and known quantities of this 
mixture, added to water, were injected hypodermically into pigeons. The minimal fatal 
dose caused death in from fifteen to twenty hours; large doses in from two to three 
hours. Pigeons were inoculated with amounts of the poison less than the fatal quantity, 
and after recovery from the more or less severe illness which usually succeeded the 
inoculation, the operation was repeated again and again, at intervals of one to three 
days, with gradual increase in the amount of the poison used. 
The pigeons thus treated appeared to retain perfect general health, and could bear, 
without injury, constantly increasing doses of the venom; in one case seven times the 
fatal amount of poison was injected without effect. The prophylaxis gradually fails 
after the inoculations are discontinued; for an amount of poison which may be injected 
with impunity at the end of a series of inoculations, may be fatal if given a few months 
after the prophylactic treatment has ceased. It has been found, however, that immu- 
nity from the effects of ordinarily fatal doses of the venom is retained over a period of at 
least five months after cessation of the course of preventive inoculation. SECTION IX-PATHOLOGY. 
389 
In answer, then, to the main question proposed at the beginning of this research, it 
can be said that repeated inoculation with sub-fatal doses of rattlesnake poison produces 
in pigeons an immunity from its ill effects when much more than the usually fatal 
amount is administered; this condition of prophylaxis persists with gradually failing 
perfection over a period of many months. 
Dr. N. S. Davis, Jr., of Chicago, Ill., presented a paper entitled:- 
CELLULAR DIGESTION ; ITS UTILITY IN PATHOLOGICAL 
PROCESSES. 
DIGESTION CELLULAIRE ; SON UTILITE DANS LES PROCEDES PATHOLOGIQUES. 
ZELLENVERDAUUNG ; IHR NUTZEN IN PATHOLOGISCHEN PROZESSEN. 
I offer the present paper, not because the views expressed therein are definitely 
proven, but hoping that they may be suggestive, and by discussion lead to an elucida- 
tion of some points now obscure. 
In pathological processes cellular digestion is useful in the removal of foreign bodies, 
if we understand by foreign bodies such as are unnatural or no longer useful in the 
tissues. It is not every foreign body that is digestible; it is only those of organic origin. 
They consist chiefly of dead tissue, fibrin, ligatures, silk, cotton, etc. These substances, 
as it were, melt away under the influence of the living tissue about them. They are 
not soluble in the lymph or blood, as is readily shown by noticing that no change occurs 
on placing them in these fluids which have been drawn from the body, and are main- 
tained at the bodily temperature. 
Other insoluble substances exist that, when imbedded in living tissues, are slowly 
transported piecemeal and deposited elsewhere in the body, and often scattered widely in 
it. Such are pigments, charcoal, carmine, and silicious and calcareous substances. 
That this transportation is accomplished by the white blood cells, is a fact well estab- 
lished. The process is too well known to require illustration. This group of substances 
differs completely from the first one mentioned, in not undergoing true absorption, since 
the particles composing them remain in the tissues, though not perhaps where origi- 
nally deposited. Substances of the first group disappear entirely. 
The query naturally arises how are these insoluble substances so completely removed. 
That the vitality of the surrounding tissue is an all important element is evident, since, 
when the same substances are placed in dead tissue, no disappearance takes place. The 
authors of most text-books content themselves by simply saying that these bodies are 
capable of solution in the living body, without telling us how. 
Within the last three or four years, almost simultaneously, several have tried to 
explain this disappearance of non-soluble bodies, upon the ground that they were 
digested by the living tissues, and chiefly, if not wholly, by the leucocytes, which mass 
themselves about foreign bodies and sources of irritation. 
In 1884 I began to advocate this view to my students, for it seemed the most pro- 
bable explanation of the phenomena. It was self evident that the presence of living 
tissue was essential, and the uniform presence of leucocytes covering and permeating 
the disappearing body suggested that their vital activity was the essential factor, and 390 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
that probably they acted as an organized ferment or digester. The existence of a non- 
organized ferment has been suggested but never proven. 
A few months later the articles by Metchnikotf, which are now well known and 
which first appeared in ' ' Rouskaia Medicina, " * on intra-cellular digestion, attracted my 
attention. To him belongs the credit of placing in form the theory of intra-cellular 
digestion as applied to insoluble but removable bodies. He did more than affirm this 
theory, for he cited proofs of such action by leucocytes and their analogues in inver- 
tebrates. All cells possessing this power he termed phagocytes. He found this func- 
tion most fully developed in mesodermic cells, many of which are amoeboid and devour 
foreign substances, for instance, elements already used and dead in the organism. The 
ability of leucocytes to take up and transport particles of foreign bodies has long been 
known, but Metchnikoff was the first to demonstrate their power of digesting some par- 
ticles within themselves. This he showed in the atrophying tails of tadpoles,! which 
are filled with amoeboid cells containing distinguishable particles of nerve and muscle 
fibres of varying size, according to the degree of intra-cellular digestion that has taken 
place. A similar removal of useless parts was observed in invertebrates. J In the lowest 
forms, the sponges and coelenterates, the property of intra-cellular digestion is pos- 
sessed by both ecto- and endo-dermic elements, and in those a little higher by mesoder- 
mic elements also. When the body to be removed was too large for a single cell to 
manage, several united, and thus produced what is analogous to the giant cells of ver- 
tebrates. Invertebrate cells were found to exercise a power of choice in regard to what 
they would thus appropriate. 
These views have been placed before English readers most clearly and attractively 
by John Bland Sutton, in delivered at the Royal College of Surgeons, London, 
in 1886, and since elaborated in the volume known as " An Introductory to General 
Pathology." || Sutton cites additional illustrations of the power of intra-cellular 
digestion by the cells of invertebrates, and confirms the observations of Metchnikoff 
on the atrophying tails of tadpoles. 
These observations enlarge the function of the leucocyte and make its analogy 
to the amoeba perfect. For within the living body they lead an independent existence, 
taking up nourishment, doubtless, usually, in liquid form, but at times in the form of 
solids, which must be digested by them. They take within themselves these solids by 
movements of their protoplasm precisely similar to those of the amoeba. 
To illustrate intra-cellular digestion in pathological processes, mention may first be 
made of its utility in the removal of blood that has extravasated into the tissues. In 
such cases the liquid portion of the blood is rapidly removed through the lymph chan- 
nels. A part of the solid cellular constituents is also thus removed. Another portion 
breaks down into a granular mass which causes the pigment of the red cells either to 
go into solution in the plasma, thereby producing characteristic staining of the sur- 
rounding tissues, or to crystallize and be deposited in them. The largest part, how- 
ever, of the solid and cellular elements, as well as of the granular matter thus formed, 
is taken up by the leucocytes which rapidly fill the extravasated tissues. Not 
unfrequently, a perfect red corpuscle can be found within a leucocyte, and others in all 
stages of disintegration and dissolution can be seen there. The red corpuscles when 
thus swallowed diminish in size and gradually disappear, numerous minute granules 
of brown pigment being all that is left of them. Thus the leucocyte is transformed into 
* Nos. 1, 3, 4, 5, 6, 1884. 
f " Rouskaia Medicin a" No. 1, 1884, and Revue des Sciences Médicales, Tome xxv, p. 69. 
J " Rouskaia Medicina," Nos. 3, 4, 5 and 6, 1884, and Revue des Sciences Médicales, Tome 
xxv, p. 70. § See British Medical Journal, 1886. 
Il Published in America by P. Blakiston, Son <t Co., Philadelphia, 1886. section ix-pathology. 
391 
a pigment carrier which may transport the pigment granules to a considerable distance 
and cause finally their elimination from the system, or their deposition elsewhere. In 
the course of these changes, undoubtedly the dissolution of the stroma of the red cell 
is brought about by the power of the leucocyte of intra-cellular digestion. 
We, without doubt, see this same power exerted in the removal of fibrinous clotsand 
exudates. For example, the fibrin which forms a thrombus may be thus removed, 
although it is liable to other methods of disposal. It may shrink into a dense com- 
pact mass, and thus remain almost indefinitely or undergo calcification. More fre- 
quently, organization or simple softening of the clot occurs. When organization takes 
place the mass of fibrine is first permeated from without inward by leucocytes. As 
these increase and fill the clot the fibrine disappears, and finally is completely replaced 
by embryonic cells which subsequently are transformed into fibrous tissue. The appar- 
ent melting away of the fibrine when invaded by leucocytes, is probably due to their 
digestion of it and appropriation of it as nourishment. 
When such clots undergo simple softening and not organization, we cannot name so 
confidently the agent by which the softening is accomplished. Living cells do not play 
an important part in the process. For, according to the usual description, the clot is 
not filled with such cells, nor does the liquid composing the softened centre contain 
them. It may be said that, if in this case living cells do not cause liquefaction, there is 
no reason to suppose that they do in the former. The only answer that can yet be given 
is, that, from the fact that the fibrin, when organization occurs, disappears just in 
proportion as it is invaded by leucocytes, and begins to disappear about the edges and 
along lines where the leucocytes are most numerous, it would seem probable that their 
presence influences its disappearance. 
The removal of fibrinous masses in this way is also seen in the changes that occur 
in the absorption of the exudate which fills the air cells of the lungs in croupous pneu- 
monia. In the first stage of croupous pneumonia the alveoli contains serum, red and 
white blood cells, and desquamated pulmonary epithelium. After a time coagulation 
takes place, fibrin filaments appearing and binding together the cells. This constitutes 
the stage of red hepatization. As resolution begins the red corpuscles disappear, and 
hence the lung becomes decolorized and gray. The other cells become fatty. Many of 
the white corpuscles present the appearances of pus cells. Simultaneously with these 
latter changes leucocytes migrate freely from the vessels and mingle with the liquefying 
exudate. The lymph channels are crowded often with granular white corpuscles that 
undoubtedly have found their way back from the alveoli loaded with its contents. It 
is thus that resolution takes place under the influence of actively vital leucocytes in 
patients who scarce expectorate any of the exudate that has filled considerable areas of 
their lungs. 
Cellular digestion in pathological processes is probably illustrated again in the sepa- 
ration of dead from living tissue when sloughs and sequestra are formed. The line of 
demarcating inflammation is filled with leucocytes, which, apparently attack the dead 
tissue, and undoubtedly the dead cells in the inflamed zone ; thus leading to the production 
of a line of separation or a solution of continuity in the solid structures. Indeed, the most 
important phenomenon of inflammation is the migration of leucocytes from the vessels 
and the filling of the tissues by them. In the lowest animals, which do not possess a blood 
vascular system, the process that is analogous to inflammation in vertebrates consists in 
the unusual activity and massing of amoeboid cells about the source of irritation. The 
activity of these cells is for the purpose, if possible, of removing or destroying the irritant. 
The purpose is furthered in higher animals by the first outpouring of serum, since often 
the irritant is thus dissolved or diluted so as to destroy or neutralize its toxic power. 
When the serous exudate is inefficacious it becomes the function of the white corpuscle to 
attempt to remove the irritating body, if solid, either by transporting it granule by 392 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
granule to a distance, and thus lessening its amount, or by digesting it and producing 
chemical changes that will alter its character. Inflammation from this standpoint is a 
conservative process. While the process is conservative, it is provoked by those things 
that cause always some destruction of tissue, or of the cells composing it. Even the 
simplest trauma that may provoke inflammation, and whose action may only be 
momentary, causes destruction of tissue elements. The removal of these is probably 
the duty and reason for the migration of the leucocytes. They accomplish the object 
by transforming the albuminous substance of the dead cells into soluble substances, or 
by appropriating them to their own nutrition. 
The behavior of the leucocytes in the walls of abscesses suggests that in the forming 
of such cavities they take an important part. The tissue cells are probably destroyed 
by the cause of the purulent inflammation, but their removal cannot be thus accounted 
for, and as they disappear only in the presence of leucocytes, and in proportion to the 
abundance of the latter they would seem dependent on them for solution. Lining the 
abscess cavity are found a mass of round cells which, by becoming detached and 
mingled with the fluid contents, are transformed into pus cells. As we pass outward from 
the cavity these round cells are at first so abundant as to be the only visible elements ; 
further out they are infiltrating tissue that is in an atrophying or disintegrating condi- 
tion, and in proportion as we pass from the centre the infiltrating cells are less numerous 
and the normal cells more perfect and natural, until the healthy tissue is reached. 
Metchnikoff has urged that the leucocytes are the natural enemy of pathogenic bac- 
teria. He points to the numerous examples that have come under the notice of pathol- 
ogists, of the occurrence of bacteria within the white blood cells. He thinks that this 
is brought about by an attempt on the part of the leucocyte to destroy and remove the 
offending body. This endeavor is not always successful, for the protoplasm of the 
white cells seems to be a favorite place for the growth of some bacteria, but when it is 
successful recovery takes place. Metchnikoff first described the absorption of bac- 
teria by leucocytes in a fungoid disease which attacked Daphniæ, or water-fleas.* The 
colorless corpuscles of the Daphnia could be watched as they attacked, devoured and 
digested the foreign substances. When anthrax bacilli were introduced into the tissues 
of frogs similar changes were produced, the leucocytes devouring and causing the disap- 
pearance of the bacilli, f The examination of two fatal cases of erysipelas J showed 
the cocci free in the tissues, never enclosed in cells. However, in numerous convales- 
cent cases they were found in great numbers enclosed in leucocytes. Thus imbedded, 
all stages of transition, from fresh, apparently normal cocci to those consisting of mere 
grain-like detritus, could be observed. That leucocytes remove bacilli that are dead or 
inactive is quite evident, but that they are generally inimical to bacteria, or that they 
generally attempt to destroy them, is not proven. For instance, the experiments of 
Dirckinck-Holmfeld with anthrax bacilli, whose virulence was made of different 
degrees by Pasteur's method, show that when introduced subcutaneously into rats, cats, 
etc., it produces local suppuration, and more perfectly in proportion as it has been weak- 
ened, or as the animal is resistant to it. He, therefore, in agreement with Metchnikoff, 
regards the purulent inflammation as a conservative process. But he did not agree with 
him as regards the mode of destruction of the bacilli. He found only a few of the 
microorganisms in the pus cells and many in the fluid of the pus, where they died and 
disintegrated. The bacilli in pus in the animals most resistant to them underwent 
changes according to the age of the inflammation. In pus twenty-four hours old they 
were shorter and thicker than natural and surrounded by a clear, capsule-like zone. 
These rods grew well on culture media and were fatal to mice. In pus forty-eight 
* Sutton, J. B., "Introductory to General Pathology," p. 123. 
j" Virchow's Arch., Bd. 97, Seit 502. J Virchow's Archiv, cvn, 2, p. 209, 1887. SECTION IX-PATHOLOGY. 
393 
hours old the bacilli had become finely granular, many even mere granules or short, 
glistening, often irregularly formed rings. They were no longer capable of cultivation 
nor toxic to mice. Living bacilli were found very exceptionally in older pus. In reply 
to the query whether the bacilli had not been first swallowed and destroyed by the 
pus cells, and subsequently disgorged, the author urged the lesson of the following 
experiment. If pus containing living bacilli is sealed in a tube that is kept at 36° C. 
from forty-eight to seventy-two hours the changes above described will take place, but 
if bacilli growing in bouillon is similarly treated, they lose neither life nor toxicity. 
He supposed that the pus cells cease to be active, living factors when thus treated. It is 
evident, however, that the richly cellular pus is inimical to the bacilli, and probably if 
the cells are not their destroyers, something resulting from the presence of the cells is. 
While calling attention to the utility of intra-cellular digestion in pathological pro- 
cesses, I have mentioned only the white blood cells as possessing the power. Undoubt- 
edly connective tissue cells and granulation tissue cells, or embryonic cells, also possess 
it, and probably some forms of tumor cells. 
It is a well-known fact that inflamed or dead bone will undergo absorption unless 
suppuration intervenes. Numerous theories have been propounded to explain the phe- 
nomena. Rindfleisch has suggested that the blood in the congested vessels contains an 
excess of carbonic acid, which may dissolve the lime salts, forming an acid carbonate.* 
Others have supposed that lactic acid is formed, which produces a soluble calcic sarco- 
lactate. These hypotheses are improbable, for bone exposed indefinitely to the influ - 
ences of purulent inflammation loses little of its substance and its surface may remain 
smooth. Virchow believes that cells derived from proliferation of bone corpuscles are 
the active agents. There is little doubt that the living cells which surround or perme- 
ate bone when it is undergoing absorption are the active factors in its removal, although 
most pathologists do not wholly agree with Virchow as to their origin. Usually the 
absorption power is ascribed to granulation cells or to osteoclasts, both of which origi- 
nate from leucocytes. To illustrate, recall the appearance of the changes that occur in 
rarefying osteitis. The bone is indented by deep or shallow, simple or complex depres- 
sions that are filled with cells of varying size. These cells originate as do granulation 
cells, but among them giant cells are offener found than in ordinary granulations. 
Frequently they are continuous with or outgrowths of neighboring granulation tissue. 
These so-called osteoclasts fill the pockets in the bone, which so evidently melts before 
their encroachments that no one can doubt their activity in its removal. It is literally 
eaten away by them. 
Tumor cells are so various in character that we cannot affirm of all kinds digestive 
power, but some undoubtedly possess this function. The cells of infiltrating tumors 
have absorptive powers. This capability is most noticeable when bone is involved, for 
then the hard, compact bone is readily seen to have disappeared and to have been 
replaced by the new tumor tissue. When tumor cells infiltrate other tissues, the normal 
cells are seen to undergo atrophy and to finally disappear and be replaced by the tumor 
structures. This process is ordinarily explained by assigning to the growing tumor à 
mechanical power of interfering with the blood supply of the neighboring tissue, and 
therefore inducing atrophy. However, the disappearance of inert lime deposits in 
bone can scarcely be explained in this way. The influence of the contact of active, 
growing cells seems more important. 
Can living cells render solid materials soluble by simple contact with them ? There 
is little doubt that intra-cellular digestion takes place. But in the absorption of bone 
there is no evidence that particles of it are first detached, swallowed and then digested 
by the osteoclasts. On the contrary, the latter apparently erode it by their contact. 
* Pepper, A. J., " Surgical Pathology," p. 234. 394 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In this respect they behave as do many bacteria, which liquefy solid culture media by 
the changes incident to their own multiplication and growth while in contact with 
them. The living cell thus behaves like an organized ferment. When, however, the 
substance to be removed is granular, the granules are generally taken within the cell 
before solution or digestion occurs. It would, therefore, be better to describe these pro- 
cesses by the term cellular digestion, rather than by the more limited appellation used 
by Metchnikoff. of intra-cellular digestion. 
In the course of such digestion, it is probable that various chemical decompositions 
are produced and new bodies formed, according to the nature of the substances attacked 
and the needs of the digesting cell. What these chemical changes are we do not know. 
There are, however, a few facts that may throw light on the subject or form a starting- 
point for an investigation to elucidate it. It seems probable that leucocytes have a 
predilection for peptones, and if so, the thought suggests itself whether this is not the 
form in which they require their nourishment, and whether its formation is not the 
first step in the process of cellular digestion by them. Hofmeister believes that in the 
subepithelial tissue of the digestive tract leucocytes take up peptone that has been 
formed in the alimentary canal.* That they play an important part in the absorption 
of nutriment is evident, since they are much more numerous during digestion than at 
other times, and it is known that they take up the emulsified fat and aid in its trans- 
portation. The absence from the blood, during digestion, of dissolved peptone is most 
easily accounted for, upon the supposition that it has been appropriated by the cellular 
elements. Hofmeister has also shown that the peptone which is found in pus is con- 
tained in the corpuscles, f There is no evidence as yet, however, that peptone can be 
produced by the corpuscles, since in the wall of the intestines it is furnished to them 
already formed, and also probably in pus. For the microorganisms peculiar to the 
latter have the power of forming peptone from albumins on which they are grown. 
The streptococcus pyogenes, when grown in a vacuum on white of egg or on beef 
albumin, causes their disintegration and energetic peptonization, j: The micrococcus 
pyogenes aureus also converts albumins into peptones. § 
The peptone in pus may, therefore, be formed by its bacteria and absorbed by its 
corpuscles. 
If these views in regard to cellular digestion are true, we must recognize among 
bodies foreign to the living tissues a group of digestible substances. We canthen classify 
foreign bodies into : 1, soluble bodies; 2, insoluble but digestible bodies; 3, insoluble, 
granular and transportable bodies; 4, insoluble bodies, completely impregnable to 
leucocytes and the surrounding tissues. 
DISCUSSION. 
Dr. Danforth thanked Dr. Davis for his very able and scholarly paper, but 
thought its scope was too narrow-that the digestive power alluded to was not lim- 
ited to the leucocytes alone, but that the nuclei of all the tissues took part in the 
process. In traumatic states all the tissues become embryonic-the nuclei are liber- 
ated by the softening of their surrounding primal material, and become "amoeboid" 
cells, or practically leucocytes. These amoeboid cells acquire the digestive power 
which Dr. Davis claims for leucocytes alone. 
* " Zeitschrift für Phys. Chemie," 4, pp. 253-281 ; 5, pp. 127-rl51 ; 6, pp. 51-73. 
f"Studies from the Biological Laboratory, Johns Hopkins University," Vol. iv, No. 1, pp. 
8-10. J " Crookshank's Practical Bacteriology." £ Ibid. SECTION IN-PATHOLOGY. 
395 
Dr. Shakespeare regretted that he had not heard the paper just communicated, 
but he inferred from the discussion that the cellular organisms active in the process 
of destruction and repair of the tissues were under consideration. He wished to 
call attention to some observations he had the opportunity to announce in a series of 
lectures before the College of Physicians of Philadelphia, an abstract of which was 
published some years ago in the Medical News, of Philadelphia. The subject of 
those lectures was the intimate nature of inflammation in the non-vascular tissues. 
The minute normal structure of the cornea and hyaline cartilages was revised as a 
foundation for the study of inflammation of them. He had found, with Thin, of Lon- 
don, that the ultimate bundles of fibrils in the cornea, as recognized by most histolo- 
gists, have not the simple constitution commonly described. There is a further sub- 
division of the fibrils into much smaller bundles. But the point he wished to call 
especial attention to is the fact that each of these minute smaller bundles is enveloped 
more or less completely by a single layer of exceeding small, thin, flat cells, resemb- 
ling, in shape and relations to each other and to the bundles which they cover, the 
flat, fixed cells which we are very well acquainted with in silver and gold-treated pieces 
of tendon. The apposition of three or more of these minute bundles causes the forma- 
tion of linear lymph spaces, parallel with the direction of the bundles. 
I found, with Thin, and Spina, of Austria, that hyaline cartilage is not the simple 
structure so commonly described, but that it has a framework of fibrous connective 
tissue which is normally masked by the hyaline substance which envelops, and by 
similarity of index of refraction renders the real complex structure ordinarily invisible. 
I have found the same minute bundles of fibrils and their enveloping, minute, thin, 
flat, fixed cells, as in the cornea. I may say that they are to be found also in bone 
and in the central nervous system. 
Now, what I wish to say is, that in the non-vascular tissues I have found these 
minute, flat, fixed cells in the immediate vicinity of the point of irritation, showing 
all the evidences of reawakened activity, viz., cloudy swelling and division, accom- 
panied by the signs of softening, to a slight extent, it is true, of the fibrils with which 
they are in contact, in advance of the invasion of the emigrant white blood cells. 
In advanced inflammation the progeny of these cells, with that of the recognized com- 
mon fixed cells and the emigrant cells of the blood, constitute the mass of cells in the 
so-called embryonal tissue which replaces the normal structure, and it becomes 
impossible to definitely settle the origin of any single one of them. Dr. Shakespeare 
holds that these minute, thin, flat cells, which may be regarded as fixed, play an 
exceedingly important rôle, either in destruction or repair, possibly in both. 
Dr.N.S.Davis, Jr., closing the discussion, said:-Dr. Danforth has remarked that 
I limited the power of cellular digestion too closely. I wish to state that my feeling 
is that other tissue elements contribute to the so-called absorption process, but on 
thinking over the various pathological lesions, I could find no illustration of digestion 
by the higher forms of cells, but only by those of embryonic form. The suggestion 
of Dr. Danforth and of Dr. Shakespeare, that the higher forms of tissue elements, 
under conditions of inflammation, return to an embryonic state not distinguishable 
from wandering blood cells, and then exert the same function, may be true. 
To the question of Dr. Vaughn, whether any chemical ferment had been isolated 
in the cells, I can only say that in my search through the literature of the subject I 
have found no evidence of the existence of such substances. 396 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. S. K. Jackson, Norfolk, Va., read a paper on- 
NATURAL AGENCIES INHIBITING THE LIFE-PROCESSES OF 
PATHOGENIC ORGANISMS CONSIDERED WITH A VIEW 
TO THEIR THERAPEUTIC EMPLOYMENT. 
AGENCES NATURELLES, ARRÊTANT LES PROCEDES VITAUX DES ORGANISMES 
PATHOGÉNIQUES, CONSIDÉRÉS AU POINT DE VUE DE LEUR EMPLOI 
THÉRAPEUTIQUE. 
NATÜRLICHE AGENTIEN, WELCHE DIE LEBENSERSCHEINUNGEN PATHOGENER ORGA- 
NISMEN VERHINDERN, MIT RÜCKSICHT AUF IHRE THERAPEUTISCHE 
ANWENDUNG BETRACHTET. 
In considering the statements and estimates of bacteriologists as to the vast num- 
bers, the rapid and indefinite multiplication, and general distribution of parasitic 
organisms (which we have no inclination nor reason to question), we are struck by the 
great disproportion between these numbers and the disturbances they occasion. We 
might suppose, from such an ubiquitous distribution of such vast multitudes, that 
zymotic diseases were everywhere and at all times prevalent, and that no one would 
be able to escape them. 
It becomes an interesting subject of inquiry as to what prevents the ravages of 
these organisms, which are so freely taken into our systems with the food we eat, the 
water we drink, and the air we breathe, and why and how they are restrained in their 
work of devastation. Why is it that in an atmosphere surcharged with these patho- 
genic organisms many persons are unaffected by them, and only a limited number suc- 
cumb to their attacks ? It has been a generally satisfactory explanation that the vital 
force, the vital energy, the "principle of life," has enabled some to resist, and that 
those only yield to an attack whose vitality is diminished, whose vital power is 
crippled. This explanation might be in some degree satisfactory were it not for the 
fact that very frequently the most robust, those of greatest constitutional vigor, become 
victims of these attacks, and, vice versa, those of feeble constitutions escape ; and thus 
the exactions of science require a more searching investigation into the causes of immu- 
nity on the one hand and of liability on the other. 
These investigations have a high practical value; for while we are ascertaining the 
modes or agencies employed by nature for preventing, arresting, or crippling the preda- 
tory attacks of these microorganisms, we are at the same time learning the most effi- 
cient means that can be employed for these purposes, and may be able to assist her in 
this beneficial work. 
Let us then study, by the light of science thus far vouchsafed to us, the conservative 
processes of nature whereby we are protected from ' ' the pestilence that walketh in 
darkness, or from the sickness that destroyeth in the noonday. ' ' 
As heat is the physical agent most generally recognized as affecting the life of 
microorganisms,its effects upon them have been so carefully studied as to render unneces- 
sary anything more than a mere allusion to it here. The degree most favorable to their 
propagation and development-that above which they cannot live, as well as that below 
which they are either destroyed or rendered dormant until revivified by higher temper- 
ature-have been so accurately determined as to leave nothing to be added. But there 
is one point, in this connection, to which I wish to call attention, on account of its 
bearing on the recent popular practice of reducing the temperature of the body, in 
fevers of zymotic origin, by the external application of cold. 
It has been found that the temperature most conducive to the vigorous activity of SECTION IX-PATHOLOGY. 
397 
pyrogenetic organisms is between 68° and 75° F. A departure from this either way 
cripples or retards their growth more or less in proportion to its distance above or below 
this temperature. Now, this being the case, the departure above, as in typhoid fever, 
for instance, is at least 30°, and 30° still higher is the temperature which Sternberg has 
declared to be the highest that can be borne by them ; that is, that they are destroyed 
at 132.8° F. While it is not claimed that this destructive temperature could ever be 
reached or could be endured by the human system, still it is a fact, that as the tem- 
perature of typhoid fever reaches at least half-way between these points, the parasitic 
microbes, by the heat themselves have generated, are in a medium less favorable to their 
life and growth and more nearly approaching the point of destruction; and when the 
system of their host, the medium in which they are living, becomes cooled down, say, 
to its normal degree (98.6°), a point more favorable to them is reached; that is, one fur- 
ther removed from that which is calculated to destroy them. Thus, by this reduction 
of temperature, by means other than that of destroying the pyrogens themselves, the 
system is brought into the same condition in which the inception occurred, and the para- 
sites, instead of becoming enfeebled, actually become reinvigorated, and the consequent 
disturbances are repeated. 
Is it not reasonable to suppose that the reaction, the increase of heat, which I 
believe invariably follows the use of cold affusions, may be owing, to some extent at 
least, to the impulse imparted to the fever-producing organisms by the restoration of 
this favorable condition ? 
Fortunately we have more efficient, and in my opinion, more philosophical and less 
deleterious means of reducing the temperature of fever, which it is not our purpose 
now to discuss. But in view of the proposition herein advanced, it becomes a question 
of much interest and importance, whether it is not an advisable practice not to reduce 
the temperature of the body below a point which may safely be endured, until the 
destruction of the pathogenic parasites, when most probably of its own accord or with- 
out assistance the normal temperature will be attained. In my treatment of enteric 
fever I am perfectly satisfied with a temperature of 102°, which is not a dangerous 
degree, for it is borne for weeks without disaster. 
Next to the destructive effects of extremes of temperature, the most clearly recog- 
nized natural agency which affects the vitality of pyrogenetic organisms is the produc- 
tion, in the medium in which they live, by means of their vital processes, of substances 
which are poisonous to them and cause them to die ; that is, they are killed by the 
products of their own life processes. 
No living being can long be kept alive when so confined in the medium in which it 
exists as to absorb the products of its own life processes, its own excreta. It might be 
supposed to die from exhaustion of food, but that this is not the case can easily be 
proved by replenishing the supply. A fish in a limited supply of water cannot long be 
kept alive, even though abundant and generous food be supplied. The experienced 
agriculturist knows that successive crops of rank-growing plants cannot be cultivated 
for a length of time in the same soil, even though that soil be liberally supplied with 
plant food. 
The excretions, then, of all living organisms are inhibitory to their life processes, 
and to avail ourselves of this law with a view to its therapeutic employment, requires a 
minute study of diseases of zymotic origin, and may necessitate a new treatment, 
directed to the destruction of the particular organism which may be ascertained to be 
the pathogenetic factor in each of them. I do not suppose that this new treatment will 
require an entire abandonment of many of the reliable remedies which have been so 
long successfully employed, for it so happens, and it was the merest happening, 
that these remedial agents are, in many instances, the very best germicide that prob- 
ably ever will be discovered for the very diseases for which they have been used. 398 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
We need not expect, for instance, to relinquish mercury in syphilitic disease, nor 
iodine in scrofula, nor arsenic and sulphur in herpetic affections, nor quinine in mala- 
rial fevers. We have been using these for years; we know not for what reason; but we, 
fortunately, in these conditions; have stumbled on the right remedies, and it may be 
we will never find any more efficacious. 
But what is especially necessary to ascertain is: 1st. The particular organism pro- 
ducing each disease; and, 2d. The most efficacious means of crippling or destroying it, 
and, if possible, nature's mode of effecting its destruction. 
Each of the agents claimed as "germicides" are not equally efficacious for the 
destruction of all organisms. Quinine, which we recognize as, par excellence, the anti- 
dote for the malarial poison, has no power to destroy the organisms which, if they do 
not cause, exist in dyspeptic conditions. And on the other hand the salts of sulphur- 
ous acid, which are so destructive of the latter, have been proved to have no effect on 
the malarial organisms. (Sternberg.) Thus we see the absolute necessity of ascer- 
taining the particular organism we wish to destroy. We must know to what class it 
belongs-whether animal, vegetable or fungus; we must know its life history, its life 
processes; the metamorphoses through which it passes-the length of time in passing 
through each ; the stage of its life in which it is most virulent-that in which it is most 
vulnerable; the pabulum necessary to its growth and development ; the toxic agents it 
is least able to endure-Nature's mode of destroying it, whether by limiting the dura- 
tion of its life, or by poisoning it by the resultants of its own life processes ; its natural 
enemies-in a word, what it has to contend with in its struggle for existence. 
When we have acquired definite knowledge on these several points, the various 
germicides will be more intelligently employed than they are at present. Mercury and 
nux vomica, so destructive to animal life, will not be used for the destruction of a 
vegetable organism ; chlorine, which hastens germination, will not be used to destroy 
spores; the manganates will not be relied on to cripple aerobiotic forms, whose very 
existence depends on the oxygen which these salts supply. We will soon find that 
there is no one germicide, but they may be as numerous as the germs to be destroyed. 
But the object of this paper is not to study the numerous germicides that have been 
proposed or that may be employed ; nor the strength needed for accomplishing their 
purpose; nor how, in destroying the parasites, the system of the host can be protected 
from their poisonous influence. These important considerations must be left for others 
to discuss. Our object is to consider only those agencies which nature is known to 
employ, and our limited knowledge up to this time has enabled us to discover but 
a few. 
If any one is disposed to doubt the general proposition upon which this study is 
founded, let him examine closely any one of the various fermentations; for, as the 
organisms producing them are so similar in many respects, to each other, and also to 
those which we know to be pyrogenetic, the consideration of any one will unravel the 
mystery of all, to some extent at least, and will inform us as to the behavior of all 
those organisms which, like the Torula cerevisiæ, are fungoid in their character, and 
have the power of converting starch into dextrine and sugar, and sugar into alcohol 
with the evolution of carbonic acid gas. Suppose now a vat is supplied with the mate- 
rials necessary for this process, what occurs ? So soon as the yeast is added and the 
proper temperature secured, a violent action is set up, and the various stages in the 
process just alluded to occur. But the particular point to which I wish to call atten- 
tion is the fact that after a certain time a sudden stop occurs and the yeast, which was 
in lively motion all through the mass, suddenly falls to the bottom. What has arrested 
this activity? Perhaps it may be said that the sugar is all used up, and that.the organ- 
ism which has caused the fermentation has exhausted all of its pabulum and has died 
from starvation. This can easily be tested by adding more sugar, which would furnish SECTION IX-PATHOLOGY. 
399 
the necessary nourishment, and ought to start the process afresh, if it was food that 
was needed. The addition of sugar at this stage will have no such effect-it will only 
destroy the "dryness" of the fluid and communicate to it a dead sweetness. What 
then has been the cause of the stoppage of the fermentative process ? Clearly it is to 
be found in the fact that there has been produced in the liquor some agent that has 
destroyed the vitality of the fungus, which, by its life processes, had been causing the 
chemical changes that had occurred. If the process had been taking place in a closed 
vessel, it may have been a saturation by carbonic acid that inhibited the life process ; 
if in an open vessel, from which this gas could escape, it was evidently due to a satura- 
tion by the alcohol formed. Whatever it was, it is evident that the organism has been 
crippled or destroyed by something which has been produced by itself, a product of its 
own life processes. 
It matters not what may be the nature of the fermentation, whether vinous or 
acetous, or whether it be a putrefactive process-a decomposition of animal or vegetable 
matters, it may be stated as a fact, that whenever decomposition occurs from the pres- 
ence of a vitalized agent, this agent is eventually either arrested in its processes or 
destroyed by the resultants of that decomposition ; in other words, by the products 
of its own life processes, or really by its own excreta. If this be true, we can enunciate 
the general law, that no organism can live in its own excreta. 
This law furnishes us with a valuable hint in selecting the agents with which to 
lessen the vital activity of pathogenic parasites. If we surcharge them with these 
resultant products we can arrest their vital processes, before they would be arrested 
by the slow procedure offermentation, and thus we may be able to save the system of 
their host from the protracted disturbances which would otherwise continue throughout 
their whole life cycle. I shall suggest but a few, indeed, I am as yet prepared to suggest 
only a few, instances where this plan of treatment might be adopted to advantage. 
In the case proposed, where the organism is a true fungus, that is, without chloro- 
phyll, and therefore unable to assimilate or appropriate carbonic acid, but must exhale 
it, as do animals, the indication would be to saturate the system with alcohol, or with 
carbonic acid, by internal administration. Brunton asserts that the "yeast plant is 
killed by the alcohol which it produces, so soon as this amounts to 20 per cent., and 
other organized ferments have their lives limited in a similar way." According to the 
observations of the late Dr. W. Farr (quoted by Brunton), "Alcohol appears to arrest 
the action of zymotic diseases, as it prevents weak wines from fermenting; like cam- 
phor, alcohol preserves animal matter-this is not now disputed. But may it not do 
more ? May it not prevent the infection of some kinds of zymotic disease ?' ' It is 
constantly contended by persons in malarial districts that whisky increases the effects 
of quinine. 
With regard to the anti-fermentative power of carbonic acid, I have myself testedit 
by sealing apricots, of all fruits the readiest to sour, in a jar filled with this gas. The 
fruit remained firm for months without the slightest appearance of fermentation. That 
they lost their flavor is no argument against my position, for they did not ferment or 
decompose, and probably never would so long as they were tightly sealed. 
But the most valuable anti-ferment we possess, which we all recognize as the remedy 
par excellence in malarial fever, is quinine, and it is more than probable that its power 
may be accounted for on the very principle for which we are contending, for it is one 
of the most highly carbonaceous articles of the Materia medica. Its formula, accord- 
ing to Miller, is C20H24N2O2,3H2O = 324 + 54, and it is only exceeded in the amount 
of carbon by gallo-tannic acid, which, but for its unstable composition, might be sup- 
posed to be a more powerful anti-ferment, but by its absorption of oxygen gallo-tannic 
becomes converted into gallic acid, which contains much less carbon and could, there- 
fore, never be suspected of possessing this power of checking fermentation. The results 400 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of recent researches into the effects of quinine upon the malarial microbe are confirm- 
atory of this position. 
Again, in those dyspeptic conditions in which sulphurated hydrogen is freely gen- 
erated, how easily are they prevented by the use of condiments or salads which contain 
sulphur, or allyl sulphide, e. g., garlic, onions, leeks, cress, etc., and how decidedly is 
this condition corrected by asafœtida, "which contains a larger proportion of sulphur 
than garlic " (Miller), and still more quickly and radically by the salts of sulphurous 
acid, viz., the sulphites of soda or potash. 
Another remarkable instance of the effects of saturation by the products of the life 
processes of pyrogenetic organisms, I have elsewhere stated and explained, in a paper 
on "The Ammonia Treatment of Typhoid Fever" [Journal Am. Med. Ass., Vol. 
in, p. 183), in which disease a process occurs analogous to, if not identical with, putre- 
faction, in which ammoniacal gas is freely evolved. If I may judge from the reports 
of the various modes of treatment adopted in this country and in Europe, there has 
been nothing proposed or tried which has so controlling an influence on this fever as the 
saturation by the salts of ammonia, many times cutting it short at the end of the first 
or second septenary, and always keeping it under control and conducting it to a suc- 
cessful termination. 
Another striking illustration of the principle for which we are contending, is the 
new treatment proposed by Bergeon for phthisis pulmonalis. Every clinician must have 
observed the odor of sulphureted hydrogen arising from the sputum of a phthisical 
patient. Enclosing it for a few days in a closely stopped vial, its existence will be 
revealed by the smell and without a chemical examination. The bacillus tuberculosis 
is abundant in the fresh matter expectorated, but is soon destroyed by being saturated 
with this gas generated in the decomposition, and according to the principle herein con- 
tended for, we ought to be able to destroy the parasitic bacillus by infusing into the 
system of the host this very gas, as proposed by Bergeon. I am inclined to regard 
favorably this plan of treatment, not only because of its being consistent with this law 
as we have enunciated it, but also because of its similarity to a line of treatment which 
I have been employing for some years with marked success. I allude to the free 
administration of the salts of sulphurous acid and the sulphides, e. g., the sulphide of 
calcium. These means have a most controlling influence on the hectic paroxysms, 
and have effected the cure of five cases in my hands in the past ten years. Bergeon's 
method seems to do in a few weeks what it took some months to effect by my plan, 
and I believe is well worthy of trial. 
Other instances will occur to the ingenious physician, and I must pass from the con- 
sideration of this mode of checking the life processes of microbian parasites to still 
another which has lately loomed up into great prominence by a claimed successful appli- 
cation recently made of it in Italy. 
It is reasonable to suppose that these several parasitic organisms, in common with 
all organized beings, have enemies with which they have to contend in their struggle 
for existence. 
In the present state of our knowledge it is impossible to point out, in every instance, 
the modes of destruction, whether by directly devouring their prey-by robbing them 
of needed food-or by inhibiting the life processes, either by so altering the chemical 
constitution of the medium in which they live as to render it incapable of supporting 
life-or by the direct generation of poisons. 
Our study of this subject, so far as it has been pursued, seems to justify the conclu- 
sion that one or other of these modes of destruction occur in every instance in which 
different microbes are brought into contact. 
À number of these antagonisms have been known for a long time, at least by their 
effects, but these effects have only lately been suspected as being due to destructive SECTION IX PATHOLOGY. 
401 
warfare between pathogenic organisms. The antagonism between the malarial poison 
and the cause of typhoid fever was long ago noticed. In 1851, Valleix remarks that 
"Boudin has collected a great number of facts to prove it, but that the fact was not 
generally admitted at that day." Flint, in 1867, says: " It is certain that in some situ- 
ations in this country well-marked cases of typhoid fever were hardly known so long as 
malarial fevers were rife, but that the former became the common form of fever after 
intermitting and remitting fevers ceased to prevail.'1' Of this fact he " has been per- 
sonally cognizant in two situations, viz., Buffalo and Louisville." Wood, in 1858, 
speaks of typhoid fever as " the ordinary endemic fever of those portions of the United 
States in which miasmatic fevers do not prevail. ' ' 
We are aware that some authorities contend that the form of fever, first noticed dur- 
ing our war between the States, to which Woodward, of the Army, gave the name 
typho-malarial, is an admixture of the two diseases, or "a mild form of enteric fever 
complicated with symptoms of malarial poisoning ' ' (Sternberg) ; but it is more than 
probable that further investigation will demonstrate this to be a distinct form of fever, 
having no relation to either of these forms, but caused by a different pyrogenic organ- 
ism. During a residence of twenty years in a locality most favorably situated to have 
witnessed a commingling of these two poisons, if they ever were commingled, I never 
met a case of the kind. The location referred to was about midway between the banks 
of the Potomac river, upon which malarial fever was endemic, and the Catoctin range 
of mountains, at the foot and sides of which typhoid fever, if it was not always preva- 
lent, was only for want of subjects to attack. There was a distinct line between the 
two, which could be traced for miles, beyond which neither fever was ever known to 
cross. If there had been a possibility of their mingling it must have occurred on this 
middle ground, but as far as my knowledge extended (and my practice included almost 
every estate on this line, for many miles), not a case of admixture occurred. It was 
frequently the case that I was obliged to remove negroes from a ' ' quarter ' ' in the 
low grounds across the line to escape malarial influences, but when they were on the 
typhoid fever side I never knew them to have the two diseases at once. Indeed, I 
never met with a case of ' ' typho-malarial ' ' fever until my removal into the tidewater 
region. 
But my purpose is not to discuss this, but only to express my belief, and give my 
reasons therefor, that it does not furnish an argument against the antagonism of 
typhoid and malarial fevers. In my experience they have been so distinct that I should 
expect an impregnation of the one to prevent the pyrogenetic influence of the other. 
But there is another instance of antagonism which was not only known, but of which 
practical application was made, many years ago. I allude to the old-fashioned yeast 
poultice as an application to ill-conditioned ulcers, just as nowadays we use carbolic 
acid and the various anti-suppurants. This yeast poultice was the most valuable means 
at our command thirty or forty years ago, and it was but little, if at all, inferior to the 
agents at present used for this purpose. How can its effect be accounted for? Clearly 
by the antagonism between the Torula cerevisiæ and the pyogenic organism of the 
ulcer. What this antagonism is, and how the one organism cripples or destroys the 
other, is easily ascertained, and the study of it becomes interesting and valuable as 
furnishing a type of the antagonisms between animalcular microbes and those of a 
vegetable or fungoid character. 
If the bacillus subtilis be introduced into a fluid containing Torula cerevisiæ, the 
cells of which are in active multiplication, there 'will be observed the greatest activity 
on the part of the former microbe in feeding on the Torula cells, until he either becomes 
satiated or sickened and probably poisoned. The pyogenic microbe soon becomes slug- 
gish and remains so still and quiet as to enable us to examine him, as we had not been 
able to do before his fatal meal. It requires, however, further investigation to 
Vol. Ill-26 402 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
determine positively that death has occurred ; it is more than probable that it has, for 
long continued watching has not discovered a restoration of motion. 
The good effects, then, of the yeast poultice are to be explained by its furnishing 
the pyogenic microbe with a food which it devours voraciously, and which is evidently 
poisonous to it. 
Brunton alludes to yeast as being employed in typhoid fever and dysentery. If its 
administration in these diseases is beneficial, it is probably, as they are of microbian 
origin, due to this antagonism. 
Another remarkable instance of antagonism, and of which also practical application 
has been made, is that of the organism developed in the infusion of Jequirity (Abrus 
precatorius) to the parasite which is the acknowledged cause of trachoma. I do not 
contend for it as the best remedy for this disease, for the antagonizing organism may 
produce as much disturbance as the parasite. But this antagonism is none the less 
certain and has been demonstrated. Lupus, which has been proved to be occasioned 
by a parasitic organism, is said to be cured by the infusion of the same substance 
(Jequirity) in which its peculiar organism has been developed. (Journal Am. Med. Ass-, 
Vol. V, 324.) Chronic ulcers are also said to be improved by it (id.). 
It is probable that we are furnished with some instances of antagonism by the well 
known drug ergot. There has been much uncertainty and difference of opinion with 
regard to its therapeutical effects. This uncertainty is probably owing to the great 
changes which the fungus undergoes by age, and also by the processes required for the 
manufacture of its various preparations. It seems to me to be necessary to distinguish 
between the effects of the introduction of the fungus itself into the system, and those of 
its alkaloids. To the first, in my opinion, is due the stasis which is the cause of gangrene, 
and to the latter the disturbances of the nervous system. If its claim to be prophy- 
lactic and curative of pertussis is confirmed, it is a good illustration of the antagonisms 
for which we are contending. So, also, if we can establish its claim to be prophylactic 
of puerperal fever, we shall find it has been of more service than we had suspected 
when using it merely for its ecbolic effects. 
In conclusion we will hastily enumerate a few more instances of these antagonisms 
which have been proven or suspected. 
Koch has shown that the comma bacillus is destroyed by the bacterium termo, and 
that, therefore, ' ' in arresting putrefaction of the menstruum, you really preserve the 
comma bacillus." (N. Y. Med. Abstract, iv, p. 32.) 
The virus of swine plague has been proved to be destroyed by the bacterium of 
putrefaction. ("Special Report Dept. Agriculture," No. 34, pp. 15, 16.) 
Cantarin, of Naples, has claimed that the bacillus tuberculosis is also destroyed by 
the bacterium termo, and has reported a phthisical case in which it was being employed 
with much benefit. 
Erysipelas is said to be destructive of cancer. Profs. Janick and Weisser (Centrait), 
f. Chir., Edinburgh Med. Jour., Nov.) declare that "the cancer cells and nests can be 
seen to perish before the advance of the erysipelas cocci." 
Finally, one of the most remarkable evidences on this point is furnished by the 
reports of yellow fever, in New Orleans in 1832. It is recorded that so soon as the cholera 
made its appearance the epidemic of yellow fever declined. (Prof. James Jones, quoted 
by Dr. A. G. Tebault, Virginia Med. Monthly, Vol. I, No. 7, p. 397.) Tebault also 
asserts (ib.} that Asiatic cholera has been known " to displace remittent fever, and again 
give way to it." 
These facts are adduced to substantiate the position herein assumed, and to prove 
that the antagonisms claimed really do exist; butas to their employment as therapeutic 
means, we need more accurate knowledge of them, and must learn to modify them 
by cultivation or in some way to keep them under control, for fear of inducing by SECTION IX PATHOLOGY. 
403 
the antagonizing organisms a disease more to be dreaded than the one we wish to 
combat. 
Enough is known of them, however, to establish their importance as subjects of 
study, from which, it is more than probable, important results will be reached. 
[An Abstract.] 
D. E. Salmon, d. v. m., h. a. r. c. v. s., and Theobald Smith, m. d., Wash- 
ington, D. C., presented an abstract entitled- 
EXPERIMENTS ON THE PRODUCTION OF IMMUNITY BY THE 
HYPODERMIC INJECTION OF STERILIZED CULTURES. 
EXPÉRIENCES SUR LA PRODUCTION DE L'IMMUNITE PAR LTNJECTION SOUS- 
CUTANÉE DES CULTURES STERILISEES. 
EXPERIMENTE ÜBER HERVORBRINGUNG DER IMMUNITÄT DURCH SUBCUTANE INJEC- 
TION STERILISIRTER CULTUREN. 
Bacteriological investigations of the past few years have shown pretty conclusively 
that during the multiplication of pathogenic bacteria there are formed chemical sub- 
stances, or ptomains, which are poisonous to the animal economy. The researches of 
Brieger have done more than any others to strengthen this conclusion. It was sug- 
gested by some that it is these poisons (rather than any other vital manifestation of bac- 
terial growth) which produce such grave symptoms in infectious diseases. In the spring 
and summer of 1886, Sirotinin made some experiments (Zeitschrift für Hygiene I, 463) 
with the bacillus of typhoid fever, in which he endeavors to show that the smaller 
experimental animals cannot be infected by this bacillus, but that death caused by the 
injection of cultures subcutaneously or otherwise, must be attributed to an intoxica- 
tion caused by the presence of a ptomain in the cultures. The results actually proved 
that the injection of sterilized cultures may produce death accompanied by lesions 
resembling those produced by living bacilli. In a later publication (Zeitschrift für 
Hygiene I, p. 110) Beumer and Peiper, in a long series of experiments, are led to the 
same conclusion-that the typhoid fever organism does not multiply in the body of 
smaller experimental animals; that there is no true infection, and that the severity of the 
symptoms depends entirely upon the quantity of culture material injected-in other 
words, upon the quantity of the poison or ptomain therein contained. They also point 
out that death does not follow the injection of large doses, if small, non-lethal doses 
have been given previously, and from this fact they argue that perhaps immunity may 
finally be brought about by the injection of sterile cultures in successively large doses. 
That the chemical products of bacterial growth may produce immunity is no new 
theory, but it seems to have gained ground but recently among investigators. 
Before the publication of the researches mentioned, our own preliminary experi- 
ments had been published. (" Proceedings of the Biological Society of Washington," 
Feb. 22d, 1886.) They showed very decisively that immunity might be produced by 
the chemical products or ptomains present in the culture liquid. They received but 
very little attention, however, and the above writers were very likely ignorant of their 
existence. It is for this reason that it seemed justifiable to bring them once more 404 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
before the medical world, represented by this international gathering, in as brief a 
manner as possible. 
The experiments were made upon pigeons with sterilized cultures of the hog-cholera 
bacterium. Inasmuch as our investigations of this organism are but little known, a 
few facts concerning its nature should anticipate an account of the experiments them- 
selves. 
The bacterium was first described in the ' ' Report of the Department of Agriculture, ' ' 
for the year 1885, as the cause of the disease among swine known in this country as 
hog cholera, and we refer those interested to that publication and the recently published 
report for 1886, for a more detailed account of the biological and pathogenic character 
of this interesting organism. Suffice it to say in this connection, that it is a motile 
bacterium about 1.2 to 1.5 /z long and .6 to .7 /z broad, staining readily in aqueous 
solutions of aniline colors, decolorized by iodine according to Gram's method. It does 
not produce spores. It grows readily in the ordinary culture media, such as beef 
infusion, blood serum, beef-infusion peptone, agar-agar and gelatine, which it does not 
liquefy. It is destroyed by an exposure, for fifteen minutes, to a temperature of 58° C. 
It may resist drying for more than a month. 
In swine it produces a disease characterized by more or less extensive ulceration of 
the large intestine. It now and then assumes the character of a virulent and rapidly 
fatal septicaemia, the lesion being then ecchymoses in the subcutis and serous mem- 
branes, hemorrhages in all the internal organs, the lymphatic glands and in the stomach 
and large intestine. In all cases the bacterium is present in the spleen; in the hemor- 
rhagic type it is very abundant in the spleen, and more or less so in the other organs. 
In rabbits, mice and guinea pigs it produces a fatal disease characterized by an 
enlargement of the spleen and liver, by centres of coagulation necrosis in the latter 
organ. It is an organism easily recognized; for none has been described, thus far, iden- 
tical with it. Klein described an organism resembling this in 1884 (Virchow1 s Archiv, 
xcv, (1884) 468), as the cause of swine fever in Great Britain, but it needs more 
careful study before it can be identified with the one we have described. 
Rabbits, mice and guinea pigs are very susceptible to this organism. Cultures 
diluted to such an extent that but 15 to 20 bacteria are injected beneath the skin prove 
invariably fatal to rabbits in from six to ten days. 
Pigeons, on the other hand, succumb to this disease only when large doses are given. 
A culture in beef infusion, containing one per cent, of peptone in which active multi- 
plication of bacteria ceases in a few days, is fatal to adult pigeons, as a rule, when 
three-fourths cc. is injected subcutaneously over the pectoral muscle or superficially 
into the muscle itself. The intra-muscular injection is more rapidly fatal. 
The pigeon, after such an injection, may be dead within twenty-four hours. The 
inoculated pectoral muscle is more or less discolored throughout its depth. There may 
be a regurgitation of food from the crop, as grains are found mixed with mucus in the 
mouth and oesophagus. The injected bacteria are present in small number in heart's 
blood, liver and spleen. 
About one-half of the pigeons do not die so soon. The bird stands quietly in a corner 
of the coop, with feathers ruffled, wings slightly separated and tail feathers drooping. 
The discharges are usually abnormal liquid, at times mixed with considerable mucus. 
The bird usually dies within a week. . The pectoral will then be found extensively 
necrosed, the surrounding still living tissue very hyperæmic. The injected bacteria are 
found, sometimes in considerable number, in the liver and heart's blood. 
The rapidly fatal cases might be regarded as cases of simple intoxication or ptomain 
poisoning. There is, however, some bacterial multiplication. In the more chronic 
cases there is an undoubted infection, characterized by multiplication of bacteria in the 
internal organs. Pigeons are far more susceptible in winter than in summer. Conse- SECTION IX-PATHOLOGY. 
405 
quently in the heat of midsummer the control animals occasionally resist, and thus 
impair the value of the experiments. 
The experiments were carried out as follows :- 
Culture tubes, containing ten cc. of beef infusion with one per cent, peptone, were 
inoculated with hog-cholera bacteria and placed in the incubator at 34° to 36° C. After 
a certain quantity of days, varying from three to ten, the tubes were exposed to a tem- 
perature of 58° to 60° C. for about one hour. Inoculation of fresh tubes showed that 
the bacteria had been destroyed. This test was always resorted to to make sure that 
no living bacteria were injected. 
From 1 to 1.5 cc. of this culture liquid was injected, with a hypodermic syringe, 
beneath the skin of one pectoral muscle. This injection was repeated once or twice. 
Some days after the last injection the bird was inoculated with living bacteria. About 
three-fourths cc. of a beef infusion-peptone culture was injected beneath the skin of 
the other pectoral or into the superficial layer of muscular fibres. The vaccinated 
pigeons remained alive and well, the control pigeons nearly all died. 
These statements are best illustrated by the tabulated results of a few experiments. 
The first one, made in January, 1886, is given below. The control bird and the one 
which had received a very small quantity of sterile culture liquid died within two days 
after the test inoculation, the rest were well more than a week later. 
TABLE I. 
1885-86. 
Subcutaneous Injection of Sterilized Culture Liquid. 
Culture 
Liquid 
containing 
Bacteria. 
Remarks. 
Pigeon. 
Dec. 24th. 
Jan. 21st. 
Jan. 29th. 
Feb. 6th. 
Total. 
Feb. 13th. 
10 
.4 cc. 
1.5 cc. 
1.5 cc. 
1.5 cc. 
4.9 cc. 
% cc. 
Well Feb. 20. 
11 
1.5 cc. 
1.5 cc. 
1.5 cc. 
4.5 cc. 
CC 
cc cc 
12 
1.5 cc. 
1.5 cc. 
1.5 cc. 
4.5 cc. 
CC 
cc cc 
13 
1.5 cc. 
1.5 cc. 
3. cc. 
CC 
cc cc 
8 
.8 cc. 
.8 cc. 
CC 
Died in 48 
hours. 
CC 
Died in 24 
hours. 
A second series of injections, made to confirm these rather remarkable results, was 
equally unequivocal in its answer. 
TABLE II. 
1886. 
Subcutaneous Injection of Sterilized Cul- 
ture Liquid. 
Fresh Culture 
Liquid. 
Remarks. 
Pigeon. 
Feb. 19 th. 
Feb. 24th. 
March 2d. 
Total. 
March 8th. 
16 
1 cc. 
1 cc. 
% cc. 
2% cc. 
% cc. 
Well after several weeks. 
17 
1 cc. 
1 cc. 
1 cc. 
3 cc. 
u 
44 44 
18 
1 cc. 
1 cc. 
1 cc. 
3 cc. 
44 
44 44 
19 
1 cc. 
1 cc. 
2 cc. 
44 
44 44 
20 
1 cc. 
1 cc. 
2 'cc. 
<4 
44 44 
21 
1 cc. 
1 cc. 
2 cc. 
44 
44 44 
22 
<4 
Died March 9th. 
23 
<4 
44 44 
24 
44 
Remained well. 
The third control bird (No. 24) was of a different race of pigeons. A good authority 406 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
at the time regarded it as having some of the characters of the carrier pigeon. Leaving 
this aside, the result is sufficiently convincing. 
Since that time numerous other experiments have been made in practically the 
same way, to ascertain the effects of heat and extractives upon the ptomain. These 
experiments are not completed, nor have they any direct bearing upon the demonstra- 
tion of the subject of this paper. They have, however, confirmed it, for experiments 
like the above have been repeated in this work as control experiments with practically 
uniform results, if we keep in mind the fact that pigeons are less susceptible to this 
virus in summer than in winter. 
In a series of experiments made last spring, cultures were used which had been 
concentrated by evaporation in vacuo. About 100 cc. of beef infusion, containing 2% 
peptone and | % sodium chloride, was concentrated to 20 cc. by evaporation at 40° C., 
and sterilized at 60° C. for three-quarters of an hour. Subsequent inoculation of fresh 
tubes showed that the liquid was free from living bacteria. The injections were made 
as usual, the needle entering the pectoral muscle very superficially. 
TABLE III. 
1887. 
Sterilized Concentrated Culture 
Liquid. 
Fresh Culture 
Liquid. 
Remarks. 
Pigeon. 
April 19th. 
April 22d. 
Equivalent of 
ordinary culture 
fluid. 
April 25th. 
1 
cc. 
21$ cc. 
%cc. 
Well May 31st. 
2 
74 CC. 
n cc. 
u 
Well May 31st. 
3 
J4cc. 
cc. 
25$ cc. 
Cl 
Slightly ill April 26th ; 
well May 31st. 
4 
1 cc. 
5 CC. 
ll 
Well May 31st. 
5 
1 cc. 
5 cc. 
ll 
Well May 31st. 
6 
1 cc. 
5 cc. 
<1 
Well May 31st. 
7 
cc 
Died April 26th, 9 a.m. 
8 
cc 
Died April 26th, 1 p.m. 
9 
cc 
Died April 30th. 
The protected pigeons very rarely show any signs of illness. They are as active and 
as eager for food as before the final inoculation. In all, a small sequestrum is formed 
in the pectoral muscle, which at the end of a few weeks is surrounded by a dense 
membrane which seems to act as an absorbing surface for the sequestrum. 
The three tables may be summarized as follows: Of 24 pigeons, 16 received steril- 
ized cultures, eight being reserved as checks. Of the former none succumbed to the 
final inoculation; of the latter seven, or 87.5%. The conclusion to be drawn from these 
experiments is obvious. The birds are protected by the injection of sterilized cultures 
so as to resist a fatal dose of living bacteria. The sterilized cultures contain only the 
products of the bacterial growth. Among these the ptomain-like bodies-some of 
which we now know, owing to the researches of Brieger-are very likely the agents 
that produce immunity. 
In the pigeon the mode of infection before and after vaccination is probably as 
follows: The injected bacteria multiply very actively in the muscular tissue; the 
ptomains there produced may enter the circulation in quantities large enough to pro- 
duce speedy death. If the animal resist for a time, the absorbed ptomains reduce 
the vitality of the tissues to such a degree that bacteria entering the circulation begin 
to multiply in the internal organs. The additional quantity of ptomains thus produced 
finally kills the bird. SECTION IX PATHOLOGY. 
407 
When ptomains in culture liquid have been previously introduced, the first shock 
caused by the local production of ptomains in the muscular tissue is overcome. The 
bird resists successfully general infection until the bacteria have been destroyed locally, 
the process is then checked, and the sequestrum in the muscular tissue becomes 
encysted. 
Experiments made upon rabbits to produce immunity, uniformly failed to attain the 
desired object. The amount of culture liquid introduced under the skin was, relative 
to the body weight, somewhat less than that given to pigeons. Experiments upon 
swine have also failed. In both the failure was no doubt due to an insufficient 
quantity of the ptomain. The striking success with pigeons must be attributed to 
the fact that they are very near the border line of susceptibility, so that very little 
assistance from without decides the issue. 
Dr. I. W. Blackburn, Washington, D. C., read a paper on- 
A METHOD OF PREPARING BRAINS AND OTHER ORGANS FOR 
ANATOMICAL AND PATHOLOGICAL DEMONSTRATION, 
AND TISSUES FOR MICROSCOPICAL STUDY. 
METHODE DE PREPARATION DU CERVEAU ET DES AUTRES ORGANES POUR LA 
DEMONSTRATION ANATOMIQUE ET. PATHOLOGIQUE, ET DES TISSUS 
POUR L'ÉTUDE MICROSCOPIQUE. 
METHODE ZUR PRÄPARATION DES HIRNS UND SONSTIGER ORGANE FÜR ANATOMISCHE 
UND PATHOLOGISCHE DEMONSTRATION, UND VON GEWEBEN FÜR 
MIKROSCOPISCHES STUDIUM. 
The principle of the method is, that by prolonged immersion of the object to be 
prepared in a material which is liquid when warm, and solid at ordinary temperatures, 
the tissue may be so permeated by the material used that no change in size or shape 
can occur when exposed to the air. The material used for this purpose is the so-called 
"Japan wax," which is the product of Ehus Succedanea, Ln., a tree of Japan. It 
comes in large rectangular blocks about one and a half inch thick ; has a yellowish- 
white color, and a somewhat rancid smell and taste. It is saponifiable with the alkalies 
and is properly a concrete oil. Its melting point varies from 42° C. (107° F.) to 50° C. 
(131° F.), and at ordinary temperatures it is firm and solid. It is insoluble in water, 
scarcely so in alcohol, slightly so in boiling absolute alcohol, which deposits the greater 
portion of it on cooling, and to a limited degree in ether and in turpentine. It is very 
soluble in chloroform, benzole, and xylol. 
The method of using this wax is as follows : The specimen or organ, in this case the 
brain, is stripped of its membranes and carefully hardened so as to preserve its shape 
and to avoid shrinkage. The best hardening fluids for this purpose are Muller's fluid 
(bichromate of potash, two parts; sulphate of soda, one part ; water, 100 parts) or 
Erlicki's fluid (bichromate of potash, two parts ; sulphate of copper, one-half part ; 
water, 100 parts). Other hardening agents-such as alcohol, chloride of zinc, and nitric 
acid-shrink the tissues too much, though the color is, perhaps, more pleasing. The 
hardening may be hastened by injecting the fluid into the vessels before removing the 
membranes, and these may be removed just as well after three or four days' immersion 
in the fluid. 408 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
After hardening for about five weeks in Miiller's fluid, or a shorter time in Erlicki's 
solution, the organ is removed, washed, and placed in dilute alcohol, and gradually 
advanced through alcohols increasing in strength until absolute alcohol is used. When 
thoroughly dehydrated by the use of absolute alcohol, the organ is placed in a saturated 
solution of Japan wax in chloroform, and allowed to remain until the alcohol is 
displaced by the chloroformic solution. The advantage of chloroform as a solvent for 
this bath is, that the wax is deposited in an almost solid form after the evaporation of 
this solvent, whereas benzole and xylol leave it in a granular state. 
The organ is now transferred to a bath of melted wax, and kept therein, at the 
melting-point, until thoroughly infiltrated. The time required will vary according to 
the size of the specimen, but about three days are required to infiltrate a hemisphere. 
When the specimen is infiltrated it is removed from the bath, the wax drains from the 
surface, leaving it smooth, and the organ is allowed to cool ; it may then be varnished 
if desired, and, upon the varnish, it may be painted or lettered to suit the purpose of 
the operator. If the wax cannot be kept melted continuously during the process of 
infiltration, it is better to lift out the specimen and replace it in the chloroformic bath, 
as when cooled in large masses the wax has a tendency to crack, and if left in, the 
preparation might be injured. Cracking may be prevented by the addition of a small 
proportion of paraffine, with which the wax is perfectly miscible, and this will in no 
way interfere with the process. 
The color of brains hardened in the chromic acid salts, and prepared by this method, 
is an olive green or bronze; those hardened in alcohol or chloride of zinc become 
slightly darkened in the wax. There is no odor to the specimens except that of the 
wax, which is not disagreeable. 
By careful measurement I have found that no appreciable shrinkage occurs during 
the infiltration, and the shape is perfectly preserved. Whole organs, sections and dis- 
sections of any kind, and even entire animals, if small enough to be dehydrated, may 
be prepared for class demonstrations or for museums. The specimens are permanent 
in the air, and will stand more handling than wax models ; if broken, they may be 
repaired by dipping the parts in the melted wax and placing them in proper position to 
cool. 
The foregoing I believe to be the most satisfactory of all the methods of making 
dry preparations of the brain and other organs; but the process may be shortened and 
a very fair degree of success attained by dehydrating the specimen as far as possible in 
95 per cent, alcohol and placing at once in a bath of melted Japan wax. It is necessary, 
however, to heat the wax to near the boiling-point of alcohol to secure permeation, and 
this is likely to cause shrinkage. 
THE USE OF JAPAN WAX IN MICROSCOPY. 
In an article in the New York Medical Record, April, 1885, Dr. Maurice N. Miller, 
of New York, called attention to a new imbedding material, which he called "bayberry 
tallow," and though this is a common name for Myrtle Wax, the product of Myrica 
cerifera, an entirely different wax, I think it probable that Japan wax was the one 
used. 
In the article mentioned, Dr. Miller recommended the immediate transfer of the 
specimens from the alcohol used to preserve to the bath of melted wax, but as Japan 
wax is sparingly soluble in common alcohol unless heated almost to the boiling-point, 
a preliminary preparation, such as recommended for macroscopical objects, is to be 
preferred. The process used for interstitial imbedding is essentially the same as that 
for macroscopical preparations, but, of course, less time is required for the various 
steps. The pieces of tissue, when infiltrated, are fastened on cork by using the melted 
wax, or imbedded in blocks of wax or paraffine. They ate then cut dry, into benzole SECTION IX-PATHOLOGY. 
409 
or chloroform, to free the sections from wax, washed in alcohol, to remove the solvent, 
and stained and mounted as usual. The sections may be cut as thin as by any other 
interstitial imbedding method, and the most delicate tissues are uninjured by it. The 
blocks may be preserved in the dry state, as in the paraffin method, but if kept for some 
time the tissue becomes slightly harder and more brittle; it is, therefore, better to cut 
the specimens soon after imbedding. 
Dr. Chas. Warrington Earle read a paper entitled- 
PANCREATIC ANÆMIA, OR CIRRHOSIS OF THE PANCREAS. 
ANÉMIE PANCRÉATIQUE, OU CIRRHOSE DU PANCRÉAS. 
PANKREAS-ANÄMIE, ODER CIRRHOSE DES PANKREAS. 
> 
I desire to call your attention to a disease characterized by great loss of flesh, extreme 
whiteness of tissues, and, generally, pain at the ensiform cartilage. With these symp- 
toms the appetite sometimes remains perfectly good, and the patient may take food up 
to the hour of death. The pulse and temperature give no evidence of the degree to 
which the system is becoming impoverished. An autopsy will, in a typical case, reveal 
every organ normal except the pancreas. This will be found hard and white, with its 
connective tissue increased and its glandular and secreting structure greatly obliterated. 
My conclusions are based on observations in five fatal cases, and one which I believed 
to be a partial disease of the organs, which passed from under my care before recovery 
or death. 
I will give at this time the history of only one case, with the pathology of all and 
the microscopical appearances as far as possible. 
Case I.-In November, 1880, I was called to see Mr. Elwood Ewing, an American 
by birth, sixty-five years of age, a contractor and builder by profession. He had always 
been strictly temperate, had never had syphilis, and he came from an ancestry who 
were remarkable for longevity. Up to within a few months he had never been sick. 
During the latter part of 1880, however, he commenced to emaciate, and, applying 
to a neighboring physician, he was given a prescription for some malarial trouble. 
During these weeks he had not cared to eat meat, but preferred milk, mush and oat- 
meal. He became very weak, very greatly emaciated, and, at my first visit, I noticed 
particularly his white, anaemic look. I gave him a very thorough examination, extend- 
ing it through two or three visits. 
There was nothing abnormal as regards his nervous system. His intellect was per- 
fectly clear, and the only symptom referable to his head was a constant and continual 
roaring or noise within the brain. His lungs were without a trace of disease, but he 
complained of being short of breath on account of his great weakness. An anaemic 
murmur was heard with the first sound of his heart. The only point upon his entire 
body where pain or soreness was experienced upon pressure was at the epigastrium. 
He complained of thirst, and was occasionally sick at the stomach. There was no 
enlargement of any organ, and his urine was perfectly free from abnormal deposits. His 
legs were slightly swollen. His stools were black and thin, and occasionally contained 
small lumps of blood and mucus. I was not able to learn that there were fatty par- 
ticles passed with the evacuations from the bowels. His pulse was 100, and he had no 410 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fever. The most marked symptom was his extreme white color. His tongue was 
white, not coated, but anaemic, and his lips were without a particle of color. There 
was not the faintest tinge of yellow in the conjunctiva. I was unable to diagnosticate 
the case, but believed he was suffering from some disease of nutrition-the organ 
affected, however, I could not determine. I treated him for a few days with tonics, 
mineral acids, strychnia and a generous diet. There was no improvement, however, 
and Dr. N. S. Davis was called to see the case with me in consultation. There was no 
difference of opinion, and neither of us attempted to give a name to the disease. It 
appeared to us both that in some part of the digestive apparatus there was a very 
serious disease, which, in all probability, would cause death. He died one month after 
I made my first visit, having, however, passed into the hands of another professional 
gentleman. In company with this gentleman, a homoeopathic physician, I made the 
post-mortem. There was nothing unusual to be seen in any of the principal organs of 
his body, excepting the very marked whiteness of all the tissues, and not until I had 
removed nearly the entire viscera within the abdomen, and come upon a white, indu- 
rated pancreas did I find the seat of the disease. 
The gross and microscopical appearance of this organ are given by Dr. S. J. Holmes, 
Lecturer on Pathological Histology in Rush Medical College: "Pancreas contracted; 
consistency abnormal; fibrous to the touch; color white. Under the microscope the 
connective tissue is extensively augmented, with obliteration of certain glandular 
vesicles, and atrophy of others, induced by pressure on the newly-formed connective 
tissue, as it contracted at its maturity. There was a slight fatty degeneration of the 
parenchyma of the kidney." 
Case ii.-Mr. S. K. R. had always been a healthy and powerful man. Sick about 
two years. Characterized by great pallor, loss of flesh and strength. Autopsy. In 
compliance with the wish of his friends, the abdomen only was opened. There was 
considerable fat between the integument and the abdominal muscles, but nothing 
abnormal as regarded position of any of the viscera. The whiteness of the tissues, so 
marked at the autopsy of Mr. Ewing, were also present in this case. With this excep- 
tion, nothing pathological was found until the pancreas was reached. This organ was 
hard, evidently enlarged, and filled with white spots, plainly seen with the eye.- The 
colon was, perhaps, somewhat contracted in its calibre in some places; but in the 
rectum, where so much pain was experienced up to a short time before his death, there 
was absolutely no trace of disease. There was no abrasion in the continuity of the 
mucous membrane of the stomach, and the hæmatemesis, which was so profuse a few 
days before his death, was caused by pressure of the enlarged head of the pancreas on 
some blood vessel, or it may have been from minute capillaries upon the mucous sur- 
face of the stomach. 
The microscopical examination of this and the following three cases was made by 
Prof. Marie J. Mergler, Woman's Medical College, and resulted as follows: " The pan- 
creas measured nine inches in length; its breadth was two and a half inches at the 
head and two inches at the lesser extremity, and it was one inch in thickness. The 
whole organ was denser than normal, and its surface presented numerous yellowish- 
white spots, from one-quarter to one-half inch in diameter. These light portions were 
considerably larger than the rest of the organ. On microscopic examination, an 
increased amount of connective tissue was found throughout the organ, especially in 
the lighter-colored portions." 
Case hi.-This patient I saw through the kindness of Dr. Jos. Haven. Mrs. R., aged 
thirty-six; pregnant; died from exhaustion. Symptoms: great reduction of flesh; pale; 
pain at pit of stomach. Autopsy. Uterus enlarged to the extent of three months' 
pregnancy. All the other organs apparently normal, with the exception of the pan- SECTION IX-PATHOLOGY. 
411 
créas, which was hard and contracted, a portion of which was removed for microscopical 
examination. 
In the history of this case, from beginning to end, there has been a lack of symp- 
toms other than a general failing of the powers of life. There has been no pain or 
other symptoms to locate the trouble in any particular organ. An analysis of urine 
failed to establish renal complications. It is to be regretted that the character of the 
fecal dejections could not be ascertained as to the presence of fat. There is no family 
history of scirrhus, constitutional or wasting disease. 
The microscopical changes are described as follows: " On microscopical examination 
the entire organ is found more or less altered. In some portions, the connective tissue 
between the acini is increased and many of the gland cells have undergone fatty 
degeneration ; in others the broad bands of connective tissue encroach considerably upon 
the glands, and in place of their large polyhedral cells are found small, irregular, 
shriveled bodies, evidently atrophied gland cells; and still other sections do not even 
present a trace of gland structure; they consist entirely of connective tissue." 
Case iv.-Mrs. , twenty-one years of age. A history of emaciation and 
pallor. Appetite extraordinary. At the autopsy not an organ of the body was suffi- 
ciently impaired to cause any disease, except the pancreas, which was hard and white, 
and the microscopic examination of which gave us the exact results which we found in 
the preceding three cases-increased connective tissue and obliteration of the glandular 
apparatus. 
Case v.-Mr. D. B. C., aged fifty-nine. Symptoms of dyspepsia; ordered to 
Europe; great emaciation and pallor. Advised to return to this country by his Euro- 
pean physician. His friends now remember that he had pain at the end of ensiform 
cartilage for two years. Immediate cause of death, stenosis of coronary artery. A 
white and hard pancreas was found, which accounts for his pallor, emaciation and 
pain. 
I have come to believe that we have not, up to this time, paid as much attention to 
disease of this organ as we should, and that a considerable number of cases which we 
have called pernicious anaemia, leucocythæmia, general debility, etc., may be due to 
chronic disease of the pancreas. 
I have placed these cases on record, hoping to elicit inquiry and observation from 
other members of the profession. 
We frequently see cases in practice where there is very great emaciation, white color 
of all of the integument, showing want of blood corpuscles; and it may be that these 
changes are due, at least in some cases, to disease of the pancreas. 
' ' It has been regarded highly probable that the red corpuscles are produced by a 
gradual metamorphosis of corpuscular elements derived from the so-called cytogenic 
organs, ' '* such as the spleen, lymphatic glands, marrow of the bones, etc. To this list 
should, it appears to me, be added the pancreas. 
Anaemia with enlarged spleen is splenic anaemia; anaemia with hyperplasia of great 
numbers of lymphatic glands is leucaemic lymphoma ; and a malignant form of these 
last-named glands is malignant lymphoma, or Hodgkin's disease. To these should be 
added, if future observations demonstrate the correctness of my views, pancreatic 
anaemia, due to chronic inflammation of this organ, producing increased connective tis- 
sue and obliteration of gland cells, and which deserves as much attention as Hodg- 
kin's, Addison's or Basedow's disease. 
* Ziemssen, Vol. xvi, p. 335. 412 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. A. B. Palmer, Ann Arbor, Mich., read a paper entitled- 
THE PATHOLOGY OF RAYNAUD'S DISEASE, OR LOCAL SYNCOPE 
OR ASPHYXIA, WITH REPORT OF AN UNUSUAL CASE. 
LA PATHOLOGIE DE LA MALADIE DE RAYNAUD OU ASPHYXIE LOCALE, AVEC 
RAPPORT D'UN CAS EXTRAORDINAIRE. 
DIE PATHOLOGIE DER RAYNAUD'SCHEN KRANKHEIT ODER LOKALEN SYNKOPE ODER 
ASPHYXIE, NEBST BERICHT EINES UNGEWÖHNLICHEN FALLES. 
Different observers, during the last two hundred years, have noticed a class of affec- 
tions involving limited portions of the external and superficial parts of the body, 
oftenest of the extremities, characterized by marked changes of circulation and nutri- 
tion in the affected localities. These changes often come on very suddenly, sometimes 
paroxysmally, resulting in some cases in waxy paleness, in others in darker discolora- 
tions, in others in eruptions, in others still, in necrosis. The latter effect is sometimes 
confined to the skin, but it commonly involves deeper tissues as well. These local 
changes are generally attended with marked sensational phenomena, some of them with 
severe pain. These attacks have been variable in persistence and in their ultimate 
results. 
Though these phenomena have been known to practitioners for so long a time, the 
essential pathology of such cases has not, until recently, received much attention, and 
may still be considered as obscure. 
As pathological laws are more or less general in their application to different parts 
of the body, or at least as there are analogies between different parts, external and 
internal, it seems not improbable that changes of a similar character to those mentioned 
may occur in different internal viscera-in the brain, heart, stomach, intestines, liver 
and kidneys, and from similar causes, but producing more serious effects-and this 
consideration gives additional interest to this subject. If suspended circulation should 
occur in a portion of the brain or in the heart, however temporarily, marked symptoms, 
or even fatal results, would be likely to follow; and it is not improbable that some cases 
of sudden death are due to causes of this kind. 
The following unusual case, tending to throw light upon this subject, is thought to 
be worthy of being here presented in considerable detail. 
In December, 1886, there was brought to the Medical Clinic of Michigan State Uni- 
versity Hospital, from Caldwell, Ohio, by her physician, Dr. O. O. McKee, Miss L. B., 
aged forty, presenting this history. She was born of healthy American parents, in a 
country town in Ohio. She was one of several children, with no apparent morbid he- 
reditary tendency, and nothing in the case of the patient herself to produce the least 
suspicion of specific disease. She was entirely well until about twenty-one years of 
age, when she was reported to have had some nervous affection, supposed to have been 
hysterical. From that time up to the age of twenty-six, fourteen years ago, she is reported 
as having some " female complaint," the special character of which could not be ascer- 
tained. Her appetite, however, was good and her nutrition fair. 
At this time, her history states, she had an attack of" paralysis," motor and sen- 
sory, limited to the right side, which confined her to the bed for several weeks, but from 
which she recovered. Five years afterward-nine years ago-she had another similar 
hemiplegic attack of the same right side, from which she again recovered, at least suffi- 
ciently to enable her to perform ordinary feminine labor up to October, 1886. 
For the last fifteen years, commencing one year before the first hemiplegic attack, 
she has been addicted to the use of morphine, but to what extent has not been reliably SECTION IX-PATHOLOGY. 
413 
ascertained. Her bowels were during all this period often constipated, and the urine 
at times was particularly scanty. 
Her present physician was first called to her in April, 1885, and the history of the 
case is chiefly taken from his letters. She was then suffering from what he thought an 
acute attack of periostitis of the index finger of the right hand. He did not again see 
her for a week or more, when he found " several sinuses " opening on the surface of 
the finger. The finger was so much affected that he advised amputation, and after 
the operation he found the "second and third phalanges necrosed." The stump 
healed rapidly, but the "flexor tendon sloughed and all came away up to the annular 
ligament. ' ' 
Soon after this the most peculiar feature of the case appeared. An effusive eruption 
was seen on the right forearm, the vesicles not larger than a grain of wheat, but the 
parts involved became greatly swollen and were soon ' ' covered with a great many 
sores." It is presumed these sores, at that time, were produced by the coalescence 
of the vesicles and abrasion of the surface. The swollen and morbid condition of the 
arm and hand continuing, disease of the metacarpal bone of the amputated finger was 
suspected; but upon an incision being made the bone was found healthy, and the wound 
healed without difficulty. The swelling of the arm subsided, but ' ' sores ' ' appeared on 
other parts of the right side, but never on the left. One appeared upon the neck and 
one upon the face, an inch and a half in diameter, and several on the right arm, the 
size of a silver quarter of a dollar. Then one, two inches in diameter, appeared on the 
right side of the chest, another on the right leg below the knee, and more recently, 
since the patient was at the clinic, one came upon the limb above the knee, for the first 
time. 
From the time of the appearance of these " sores," in April, 1885, up to October, 
1886, though sometimes with as many as twenty-five on her at once, she continued at 
her occupation, and did not cease to labor until they appeared on her right foot, and 
were accompanied with so much swelling and pain as to prevent walking about. 
In the letters from Dr. McKee, the following account of the manner of coming on 
of these sores and the progress of the case is taken :- 
" On seeing the patient on February 2d, 1887, she said 1 a sore would appear at a 
certain spot, pointed out, to-morrow. ' She knew so because the part felt as though a 
thousand little ants crawled over the place. On February 4th, as predicted, a sore was 
present, two and a half inches in diameter. The skin was of a dark brown, almost a 
black color, but so thin and nearly transparent that the subcutaneous vessels could be 
seen beneath it. In these sores, of which the one mentioned is a type, the surface of the 
affected part sinks below the surrounding skin ; a distinct line of demarcation soon 
appears and a process of suppuration begins at once; the dark filmy surface dissolves 
away and disappears with but very little suppuration. The process of restoration is 
hastened by removing, with a scalpel and forceps, the necrosed skin and some of the 
subcutaneous connective tissue and vessels, when the superficial cavity fills up readily 
and scars over. Within two weeks before this account was written, about ten sores 
appeared on the arm and leg and went through this process. " 
This patient appeared but once at the clinic, and as a positive promise of cure was 
not made, she returned to her home without entering the hospital, and therefore an 
opportunity of more fully investigating and watching the case was not afforded me; 
but the kindness of Dr. McKee has enabled me to add to my own observation this 
account. 
The observation at the clinic showed a woman considerably, but not extremely, 
emaciated, rather tall, and of a nervous temperament. Her features expressed suffer- 
ing, though modified by the use of morphine, but her expression and replies to ques- 
tions indicated intelligence and sincerity. The diseased spots were numerous and in 414 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
different stages, all confined to the right side of the body, more numerous on the arm 
than other parts, but several were on the legs. She did not speak of any as about to 
occur, so that the appearance preceding the necrosis of the skin, whether blanched or 
congested, was not observed. Some of the spots were covered with patches of dead 
skin, dark in color, all with a line of demarcation separating them from the living 
cutis, the breadth of the red line depending on the age or advanced stage of the local 
change. From some the dead skin had disappeared, and a bright-red granulating sur- 
face was left exposed. Others were advanced to the stage of cicatrization, a thin, 
smooth cuticle forming over the granulations, while others were further advanced in 
the healing process. The necrosis in no place was deeper than the cutis vera, and in 
all the reparative process appeared to be actively taking place. The spots varied in 
size either way from an inch in diameter, and were not far from circular in form. 
It was evident that the necrosis speedily occurred, and that as speedily the process 
of separation and repair commenced. The cause of the morbid change was evidently 
paroxysmal in its action, the paroxysms occurring at irregular intervals, and continu- 
ing but a short time as affecting each place. The arrest of vitality in the skin was very 
complete, as the appearances of necrosis of that tissue so speedily occurred. 
I advised some eliminatives as correctives of the secretions, and of the stomach and 
bowels, and the use of as free doses of strychnine as could be borne, together with iron 
and quinine in tonic quantities. 
On June 3d, 1887, Dr. McKee reported that after returning home in December, 
1886, the sores continued to appear, three or four on the abdomen, for the first time in 
that situation, though a year previous, as before mentioned, a few appeared on the 
upper part of the thorax, and also upon the neck and face; but with these exceptions 
all have been upon the limbs, and without any exception all have been upon the right 
side, and never any upon a mucous surface. 
The report continues: On February 12th the patient was put upon strychnine alone, 
which has been pushed to its full limits ever since. The sores continued to appear 
until March 10th. From that time to June 3d only two have occurred, and those upon 
the leg; one two inches in diameter, and the other small; though several times others 
were predicted from the usual sensations of crawling insects, but no necrosis appeared. 
I have felt justified in describing this case at such length because of its exceeding 
rarity, if not its positive uniqueness; because of its relations to other forms of vaso- 
motor and trophic diseases, and because of its throwing light upon the pathology of this 
subject. 
The names which have been given to the class of cases mentioned at the beginning 
of this article, and of which the case related is a specimen, are, local asphyxia, local 
syncope, digiti mortui, and erythromelalgia ; and because, in 1862, M. Raynaud 
described this class of cases more fully than had been done before, the name of " Ray- 
naud's Disease " was given to it. 
Previous to the case I have described, those of the class coming under my observa- 
tion have been mostly obstructed circulation and necrosis of the fingers-digiti mortui- 
some in children, more in adults, and of the latter, mostly in women. 
The nearest to the case here related which I have seen reported, is one by Dr. T. C. 
Fox, published in the New York "Clinical Society Transactions," and referred to by 
Dr. J. C. Shaw in the New York Medical Journal for December 18th, 1886. 
In this case a woman, aged forty-one, mother of several children, after some 
exposure, was attacked at frequent intervals, with her fingers becoming "white, and 
dead, like wax," with excessive pain. Sometimes the fingers were slightly swollen and 
of various shades of lividity ; and " occasionally the asphyxiated condition of one of 
the fingers will lead to the formation of blood blisters ; the contents subsequently SECTION IX-PATHOLOGY. 
415 
become puriform, and on the rupture of the bullæ, an ulcerated surface is left which is 
very slow to heal. ' ' 
Dr. B. W. Richardson, of London, in the Asclepiad, describes cases of what he calls 
' ' local syncope, or suspended life of local surfaces, ' ' occurring in paroxysms at consider- 
able intervals; but in neither of his cases was the suspended lifç sufficiently complete 
or long continued to cause necrosis of the surfaces. Dr. Richardson also treats, in a 
subsequent article in the Asclepiad, of what he calls "chilblain circulation," as those 
having such an abnormal circulation are particularly liable to chilblains in cold 
weather. He details three cases of constitutionally feeble and nervous persons whose 
general circulation was deficient, but more particularly that of the extremities and sur- 
face, the hands and feet being habitually cold, with weakened vitality and reduced 
chemical action in the parts. 
Dr. C. L. Dana, of New York, has given an interesting account of what he calls 
"vasomotor and trophic acro-neuroses," and has examined the history of a group of 
allied cases, referring to numerous authors, among them, of course, to Raynaud, 
but also to Nothnagel and various others in Europe, and to Drs. Allan McL. Hamilton, 
T. A. McBride, S. Weir Mitchell, Charles K. Mills, W. W. Johnson and others in 
America. None of all the cases reported presents a complete parallel to that which is 
related in this paper. The resemblance, however, is sufficient to bring them all into 
one general class. 
The phenomena of these cases point to the nervous system for an explanation of the 
pathological condition. There seems to be a general agreement that these affections 
have their origin in this system, involving especially the vasomotor and trophic centres 
and nerves. The case which I have related, from the affection appearing only upon the 
right side, which had been previously affected with paralysis, probably from some cere- 
bral change, would seem to indicate that the cause was in some centre within the brain, 
rather than in any ganglia or nerves without it. The paroxysmal character of the cuta- 
neous asphyxia and necrosis, preceded by the peculiar sensations and followed by such 
rapid repair, suggests an analogy to epileptiform seizures and the allied nervous affec- 
tions, that have their acknowledged seat in the brain. 
That the vasomotor and trophic functions are particularly involved is evident; but 
whether through the influence of excitor or inhibitory actions, whether from paralysis 
of the excitor or stimulation of the inhibitory, is not so clear. 
That, however, there is depression of the vasomotor system as an important factor 
in causation, seems indicated by the fact that strychnia, which is regarded as a special 
tonic to this system, is shown by experience to produce improvement, at least in the 
several cases which have come under my observation. 
The whole subject of paroxysmal and nervous affections, including those producing 
trophic changes, is involved in obscurities which await the investigations of the future. 
Any new facts, however apparently unimportant in their individual character, but 
which may in any way throw light upon this subject or attract attention to it, are 
worthy of notice and record among pathologists. 416 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. L. Servais, of Antwerp, presented a paper entitled- 
PATHOLOGICAL ANATOMY OF THE SUPERIOR MAXILLARIES IN 
A PRACTICAL VIEW. 
L'ANATOMIE PATHOLOGIQUE DES MÂCHOIRES SUPÉRIEURES. 
DIE PATHOLOGISCHE ANATOMIE DER OBERKIEFERBEINE. 
The superior maxillary differs from the other bones of the skeleton by the presence 
in it of a pyramidal cavity whose base is turned toward the nasal fossa, and whose 
summit corresponds with the malar bone. (Heath.) This cavity, narrow in youth, is 
clothed by a diverticulum of the mucous membrane. This sinus occupies the body of 
the bone, and in a healthy state communicates with the nasal fossa by a narrow orifice. 
The presence of this cavity does not in any way modify the essential character of those 
complaints of which the superior maxillary is sometimes the seat. (Heath.) The 
affections to which this cavity is liable are simple and exempt from practical difficul- 
ties. (Garretson.) One may class the affections special to the superior maxillary 
under the following heads :- 
Abscesses, Cysts, and Tumors of various kinds. 
It is with these last that we are about to occupy ourselves. It might seem, at first 
sight, that the physiological fact of the implantation of teeth upon these bones should 
modify their pathology, compared with those of other bones of the skeleton, but it is 
rare that.dental diseases, common as they are, affect the bones which support the 
teeth. It is probable that no genuine neoplastic tumor has ever owed its origin to a 
genuine dental complication. (Fergusson.) Prof. Fergusson observes that the extrac- 
tion of the teeth does not appear to influence the progress of a tumor, as one might be 
tempted to suppose. 
The pathology of the maxillaries is the same as that of the other bones of the skele- 
ton, and the same rules ought to govern the treatment of the tumors of which they are 
the seat. (Fergusson.) 
One is no more justified in sacrificing the whole of a maxillary because it is the 
seat of a tumor which only occupies part of it, than one is justified in taking off the 
whole of an arm on account of an affection of the hand or even of the scapula. There is 
always time enough for such extreme measures, but yet the surgeon should not hesi- 
tate to cut a cancerous tumor from the superior maxillary any more than from another 
part of the body, in the hope, if not of curing, at least of warding off functional incon- 
veniences, and above all, of assuaging. This last motive will be the most frequent 
guide. (Heath. ) 
By the word tumor, from tûmes, I swell, we understand every increase in volume, 
whether that increase be in connection with the normal anatomy and physiology of the 
region where the swelling appears, or whether it be the result of a pathological cause, 
and so reveals the direct and constitutional origin. 
The surgeon studies the means of controlling the tumors which present themselves 
to his investigation, while the physiologist studies their essential character and their 
composition. 
From a clinical point of view, we may range tumors in two great classes-those 
whose explanation is to be found in the parts which support them, or in the functions 
proper to them, such as a sebaceous tumor, a ranula, a hernia. 
The second class comprises all the others; that is to say, those whose presence is not 
explained by the anatomy of the parts which support them, or by the functions which SECTION IX-PATHOLOGY. 
417 
are their seat, such as nodules of syphilis, a tubercle, or the numerous expressions of 
cancer. (Garretson.) 
All the tumors of the first class are mild; all the others indicate a dyscrasia. 
Tumors of the first class, or those whose existence is explained by the place where 
they are met, only require a local treatment. 
The others require a treatment directed against the vice to which they owe their 
appearance, accompanied by a local treatment in order to avoid the inconvenience due 
to their presence. 
Tumors that have no history are cancers. 
So tar it has been impossible to decide exactly what is a cancer, but it is at least 
necessary for the modern surgeon to know what .is not a cancer. If he does not, then 
woe to the patient who is under his guidance, and who confides his existence to him. 
We offer some clinical considerations calculated to aid the surgeon in forming his 
diagnosis :- 
1. Homologous tumors tend to isolate themselves and to preserve their special char- 
acters, while the malignant tumors invade the neighboring tissues or betray a tendency 
in that direction. 
2. Homologous tumors increase regularly, and when they have reached a certain 
volume, either rest stationary or begin to suppurate ; their treatment is purely local. 
Heterologous tumors behave in quite a different manner ; they have a pronounced ten- 
dency to reappear. There are two means of resisting them : 
(a) By combating the vice whose existence they reveal ; 
(&) By rendering the constitution unsympathetic to their invasion. 
3. Homologous tumors are generally solitary; or, if they are multiple, they all 
appear in the same tissue; heterologous tumors, on the contrary, appear in different 
parts of the economy, and in no wise respect the limits of the tissues. 
4. Homologous tumors cause pain in the region which supports them, while malig- 
nant tumors have a special and characteristic way of expressing pain. 
Tumors of the superior maxillary take, as a rule, their birth in the subperiosteal 
connective tissue of the antrum of Highmore ; they often invade and at times efface it ; 
nothing, however, can give an idea of the persistence which this cavity shows in resist- 
ing every means of destruction. (Garretson.) 
The causes of these tumors are unknown. 
They may also take their rise in the alveolar periosteum, rarely in the bony tissue 
itself. 
From the histological point of view one may divide tumors of the upper maxillary 
in the following manner :- 
Carcinoma. 
Cystoma. 
Gelatinoid polyps. 
Sarcoma. 
Fibroma. 
Melanotic sarcoma and Carcinomata. 
Osteoma. 
Enchondroma. 
Angeioma. 
These varied demonstrations, which owe their origin to the resemblance of those 
tumors with bodies of which these denominations recall the external features, have, 
practically, only a very secondary importance, for each one of them represents both a 
mild and malignant tumor. The clinic alone, in the present state of our knowledge, is 
able to enlighten us as to their real nature, and it will find the elements of a good 
diagnosis in the state, the progress and tendencies of the tumor, and the general man- 
ner in which it conducts itself. 
As to their frequency: among 307 cases analyzed by O. Weber, there were found- 
133 Carcinoma. 
32 Osteoma. 
17 Fibroma. 
7 Gelatinoid polyps. 
1 Angeioma. 
34 Sarcoma. 
20 Cystoma. 
7 Enchondroma. 
5 Melanotic Sarcoma and Carcinomata. 
Vol. Ill-27 418 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
This author observes that the sarcoma has often been confounded with the carcino- 
mata, the first of these tumors being by far the most frequent. (Gross.) 
APPLICATION OF GENERAL ANATOMO-PATHOLOGY TO TWO LARGE TUMORS OF THE 
FACE. TREATED SUCCESSFULLY BY REMOVAL. 
The patient, G. V. C., aged nine years, and born and living at Wouwo, Holland, 
was of good constitution, but he had hemorrhage, which would soon have produced a 
catastrophe. The tumor which afflicted the little patient's face had equally invaded 
the two superior maxillary bones. This gave the patient a strange and repulsive appear- 
ance; one would have said, at first sight, that it was the highly-enlarged tongue which 
hung out of the mouth. 
The tumor, when more closely examined, and when the patient let fall the inferior 
maxillary, had a lengthened form and filled the whole of the mouth, under the shape 
of a full, rough surfaced pear; its color was a bluish-red, and its surface was overrun 
in every direction by a network of thick vessels gorged with arteriosa-venous blood. 
One might have confounded it with an erectile tumor; its length was nineteen centi- 
metres and its circumference twenty-three centimetres. 
The tumor, which had developed principally at the expense of the right superior 
maxillary, and which had thrown the other forward, while partially invading it and 
exhausting it by compression, had also acted upon the inferior maxillary-all the teeth 
were horizontally crushed forward and outward. 
The right nasal cavity was invaded; that of the left effaced. On the right side the 
nasal process of the maxillary bone, the orbitary border and the malar bone were 
strongly upraised and thrown forward, the right turbinated palate bone was invaded, 
the greater part of the ethmoid bone and the os planum were also invaded. 
The tumor was ulcerated in two points in the front; these ulcers were due to exter- 
nal violence; they supported rqdimentary teeth which had been driven forward by the 
tumor; this part had the appearance of the groin of a well-known animal; the veil of 
the palate was upraised and driven against the roof of the pharynx. The functions of 
swallowing and of sound were preserved, and respiration took place by the mouth. 
Hearing was difficult. It is worthy of remark that the general state of the patient's 
health had not been influenced by this enormous tumor. It produced no suffering, but 
the weight was so great as to drag the head forward and to the right. The mucous 
membranes which covered it had remained healthy, except those which covered the 
extra-buccal portion and which were unprotected. There was a complete absence of 
swollen glands. The development had been very slow, for it was six years since it first 
appeared, under the form of a little motionless ball, in the left canine fossa. Its appear 
ance was smooth and its substance suggested that of India-rubber; the exterior part of 
the mouth somewhat resembles a thick leaf of cauliflower. 
Clinically, I attributed it to cancer, for nothing justified the apparition of this tumor; 
I hoped, however, to obtain a good result from a radical operation, both because the 
development had been very slow, and also because there had been hardly any tendency 
to invasion; it had, if I may use the expression, preserved a life of its own, and 
appeared as though grafted upon the being it afflicted. 
CASE II.-This was the case of a young woman, A. C., from Bleharies Hainhault, 
near St. Armand, who had been some years isolated. Her disease began eleven years 
before, by the appearance of a hard and reddish lump in the canine fossa on the right 
side; this tumor, which was then the size of a pea, and hard and motionless, was, from 
its first appearance, the seat of intolerable suffering, comparable to a violent attack of 
dental neuralgia; it was on this account that the first practitioners that she consulted 
began by extracting all the corresponding teeth ; the result was a continuation of the 
pain, and beyond that a more rapid development of the tumor, which, of a very vascu- SECTION IX-PATHOLOGY. 
419 
lar nature, was attacked successively by several surgeons; the frightful hemorrhage 
which resulted from these efforts obliged them on each occasion to abandon their task. 
The caustics which were then recommended had no better success; after ten years 
of suffering the tumor had acquired a colossal development (the accompanying photo- 
graphs only give a feeble idea of it), and altogether this tumor was larger than the head 
of an adult. 
It bled frequently, and each hemorrhage helped to extenuate the patient. Per- 
chloride of iron alone was able to momentarily arrest these losses of blood. 
It -was under these conditions that I saw the patient for the first time, and that I 
resolved to undertake the operation. 
The antecedents of the family offered nothing noticeable; her parents were living 
and enjoyed good health, her brothers and sisters were robust. 
Notwithstanding the loss of blood that the patient had undergone on so many occa- 
sions, her general state appeared good. 
The effect produced by the appearance of this person was most painful ; one would 
have said a human form surmounted by the head of a hippopotamus. 
The right side of the upper maxillary region was considerably developed, and sur- 
passed and masked the whole of the ear; the orbitary border had been upraised from 
beneath it until it had become horizontal ; the nose was drawn outward and to the left; 
the left wing of this facial appendix corresponded with a line lowered perpendicularly 
from the middle of the lower left eyelid toward the opening of the mouth on that 
side; the bony apparatus of the face had altogether participated in the change of direc- 
tion which this enormous development of the tumor impressed upon it; the very bones 
of the nose deviated, and the base of the nose thus spread out measured seven 
inches. The left nostril preserved a small opening sufficient to admit a soft and very 
thin probe. 
The enlarged opening of the mouth measured 22 inches; from this opening proceeded 
an embossed tumor, which spread behind under the form of an oblique barrier, from 
left to right, and embraced all the solid parts of the palate. 
The part outside the mouth was bi-lobed; each lobe was of the size of the head of 
a full-grown fœtus ; a vertical groove two inches deep separated these two lobes at their 
extremities. This groove was due to the primary action of the inferior maxillary upon 
the tumor before it had grown out of the mouth cavity. This extra-buccal part was 
hard, embossed, smooth, and bluish, like a cartilage, and exhibited on its surface a 
network of blood vessels. It was the seat of erosions, and of ulceration also, for it 
bled at the least touch. 
The intra-buccal part appeared to have developed particularly at the expense of the 
antrum ; it had taken, under these circumstances, the proportions of the head of a full- 
grown fœtus; its lower roof had descended; the skin that covered its outer front was 
extremely extenuated; that which corresponded to the lips was tumefied, and overrun 
by arterial vessels as strong as the radials of an adult; thick, tortuous vessels agreed 
with them. 
The blood was very thin, so that a pin prick in this region would have sufficed to 
bring about death by hemorrhage. 
On the left side the tumor had invaded the nasal fossa, and had produced, by conden- 
sation, a compact bone, comprising the interior table of the superior maxillary, corre- 
sponding to the wall of the other, the flat bone and the ethmoid; the left nasal fossa 
was represented by a very minute canal. 
The front wall of the tumor was formed by a thick, bony slab of half a centimetre 
at its upper part; starting from the left orbitary border, it englobed the nasal processes 
of both the superior maxillary bones, all the front face of the right maxillary, and 
part of the front face of the left, spread out in the form of a fan, and became thinner NINTH INTERNATIONAL MEDICAL CONGRESS. 
420 
in proportion to their distance from their point of origin, losing themselves at its 
extremity in a bony pellicle, which covered, or rather closed, the front wall of the 
solid tumor, this pellicle became confounded on the hind side with a harder bone 
forming the zygomatic surface of the superior maxillary; but that zygomatic process 
had descended still lower than the angle of the jaw, such as it would exist in a healthy 
subject. 
Above and outside, the bony pellicle became mixed with the very much spread out 
and enlarged malar bone; below and behind it met an osseous blade which, being pro- 
duced by the descent of the palate process, of the superior maxillaries, and of the inci- 
sive bone, formed an enormous outburst into the cavity of the mouth; in this manner 
it succeeded in furnishing a solid shell to this strange zoophyte. 
The palate bones had done their share in the formation of this shell, but the tumor 
was clearly separated from the soft palate. The length of the tumor, measured from 
the middle of the orbitary border, was 15 inches. 
Its limits were distinct, there being no trace of ganglion nor invasion of neighbor- 
ing tissues. 
The orbitary cavity had remained unaffected by the development of the evil, if 
we judged of it by the position of the eye and by the normal functioning of that 
organ. 
It was not the seat of any pulsing or breathing. The function of swallowing was 
destroyed, but hearing was preserved. 
Swallowing required, in its first stage, the employment of a narrow pipe, which 
only allowed of the use of liquid matter. 
Here the question presented itself, What was the nature of this tumor ? 
It was composed of a bony shell, and of a fibrous tissue analogous to the con- 
struction of a wart; this fibrous tissue was overspread with knots of ossification. 
It had taken eleven years to develop itself, without ever stopping in its evolution, 
or melting away by passing into a state of suppuration. 
It had in no way affected the economy; there was nothing in it to justify its appear- 
ance; it was not a parasite, nor caries, nor a hypertçpphy; neither was it an odon- 
tocle, nor a dropsy of the antrum. 
It was not an accumulation of the plastic lymph ; and it was not an abscess. 
We had, therefore, before us one of those forms of cancer whose appearance, in 
the present state of our knowledge, is a mystery. 
From the histological point of view, it was an osteo-fibroma. 
Dr. C. F. Dight, Beirut, Syria, presented a paper on- 
THE BILHARZIA HÆMATOBIUM. 
Accompanying this brief paper on the Bilharzia Haematobium I send two mounted 
specimens of the ova and embryos of that parasite, which were passed, along with blood 
and mucous clots, in the urine of a young man-an Egyptian, aged nineteen years-who 
was under my treatment in the spring of 1884. 
Both specimens are mounted in glycerine, and one of them, as you will notice, is 
stained with Beale's carmine staining fluid. In both, the oval-shaped, granular-looking 
embryos are well shown, some of them inside their transparent envelope, others out of SECTION IX-PATHOLOGY. 
421 
it; it having been intentionally ruptured by pressure with the cover glass upon it in 
mounting. In some cases the embryo almost completely fills the envelope, in others it 
is retracted somewhat from the inner surface of the envelope, the space left between 
them being occupied by a transparent fluid. 
The Bilharzia Haematobium, or Dystoma Haematobium as it is called, is now well 
known to be the cause of the endemic hæmaturia which occurs in certain parts of the 
Cape of Good Hope, in Brazil, in Egypt and in Mauritius. This parasite was discovered 
in 1851 by Bilharz, a professor of anatomy in the Egyptian Medical School, who, with 
Griesinger, found the worm in the portal, mesenteric and vesical veins. These observ- 
ers found the parasite in 117 cases of autopsy out of 363, and they believed that probably 
more than half of the native inhabitants of Egypt suffered from it. Sonsino found it in 
30 cases out of 54, and he believes that nearly all the natives of Egypt have it. A dis- 
ease so common, and, as we will see, liable to be spread, is, therefore, worthy of careful 
study. 
The Worm, which produces the ova and embryos-specimens of which I send you- 
is a white, soft-skinned, non-hermaphrodite trematode worm, measuring from three to 
four lines in length. The female is slightly longer than the male, and filiform. The 
male is thicker than the female, and has on its ventral surface a long canal, "gynæco- 
phoric canal," into which the female is received during copulation. It inhabits the 
vesical, mesenteric and portal veins, and by its presence in their minute branches it 
gives rise to lesions of the mucous and other coats of the bladder, ureters, pelvis of kid- 
neys and intestines, with a discharge of blood, mucus and ulcerative products from 
these positions, especially from the bladder, mingled with which are found large num- 
bers of the ova and embryos, but never the worm itself, it is said, it being found only on 
post-mortem examination, in the circulatory system. 
The Ova of the worm, which, in case of persons suffering from it, are found usually 
in the blood and mucus clots discharged from the bladder, are about y-y o of an inch long, 
half of that broad, quite oval in form, with a spike-shaped process at one extremity, 
as will be seem in the specimens. The envelope or vitelline membrane surrounding the 
ovum is transparent, and when examined with a magnifying power of 250 or 300 
diameters- 
The Embryo is seen within, having a (distinct border of its own, and lying usually 
closely applied to the inner surface of the envelope, except at its two extremities. Often, 
however, there seems to be a considerable fluid everywhere between the surrounding 
envelope and embryo, separating them and floating the latter. The form of the embryo 
while at rest is also ovoid, having a bluntly pointed extremity which appears to be the 
head or mouth. 
In some of the ova which appear to be in a more advanced stage of maturity, but 
not in size, the embryo may be seen to expand and retract itself in the fluid which sur- 
rounds it. The envelope may be ruptured and the embryo liberated by firm pressure 
of the cover glass upon it. This can be done while the eye watches the process from 
above; and it is interesting to see the egg broken and the living embryo emerging from 
the interior, and its cilia, which project from either side in rows which meet behind 
put into vigorous motion. 
Occasionally, in fresh specimens of the discharged blood and mucus from the bladder, 
an empty envelope may be seen, and the escaped embryo racing across the field with 
almost incredible velocity. At other times the movements of the embryo consist of 
narrowing and stretching out the body to its full length and then retracting it to 
an oval or globular mass, or sometimes the head is retracted into the interior of the 
body. 
The source of the Bilharzia Hæmatobium in Egypt is believed, by those who have 
given it most attention, to be infected and unfiltered water, especially that of the river 422 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Nile. Sonsino adduces in support of this opinion the fact that Europeans and well-to- 
do natives never use the water of the Nile unfiltered, and they are exempt from the 
disease, while the lower classes use the water as it comes from the river, and they suffer 
accordingly. I am not aware, however, that any one has detected the parasite or its 
ova in the Nile water ; but water infected with the discharges of patients suffering 
from the parasite may, as in case of the specific fevers, be a source of its communi- 
cation to others. If this be true, it is, of course, a disease which, like cholera, might 
easily be introduced into places where it is now unknown, by immigration of persons 
affected, and Dr. Harley found that the ova hatch in water. In this light, it is as cer- 
tainly a preventable disease as is typhoid fever, and a careful study of its cause and the 
means of its restriction and prevention seems eminently called for. 
How the Bilharzia gains entrance into the circulation is still a mystery. Dr. Harley 
suggests that it may find its way through the urethra into the bladder and there colo 
nize and produce the vesical symptoms. If this were true, it seems probable that a man 
infected with the parasite would infect his wife ; but this did not occur in the case of a 
man who passed from his bladder numbers of the ova every day of his married life, 
and who had four healthy children. It seems to indicate, further, that the disease is 
not communicable from one person to another. Dr. Harley thinks, also, that it some- 
times gains admission through the skin, by the minute animal attaching itself to the 
skin of a person while bathing or wading, and implanting its ova in some superficial 
vein. In this latter case the parasite would certainly enter the veins of the general 
circulation and should be found there; but it is said to be found only in the portal 
circulation, which would seem to indicate that it is taken into the stomach, and from 
there or the intestines enters the portal radicals distributed in their walls. But the 
worm, its ova or embryo, as we know them, are all too large, it would seem, to pass 
through capillaries, or even through the smallest arteries and veins, and to enter the 
circulation in that way-unless there be a lesion of the walls of the canal with rupture 
of the vessels or other change in them, which renders entrance of the parasite easy ; 
and this seems a probable means of their entrance, especially since in these warm 
countries, where the parasite abounds, dysentery and other diseases of the alimentary 
canal prevail. Once in the portal circulation, we can understand why they should be 
mainly confined in that system of vessels, as they are too large to pass through the 
hepatic capillaries. Through the middle and inferior hæmorrhoidal veins, by way of 
the internal iliac, they could, however, reach the general circulation, and it seems 
probable that when they exist (alone, as it is said) in the portal system, they may by 
careful search be found in the general circulation also, and I have quite recently been 
informed that in an autopsy in Egypt the ova were found in the lung tissue, and prob- 
ably gave rise to haemoptysis, from which the deceased had formerly suffered. 
It is thought by some that the starting point, so to speak, of the Bilharzia in man, 
is neither the worm nor its ovum, but that the latter, after being discharged, undergoes, 
like the ova of the tapeworm, certain intermediate changes-possibly in the body of 
fresh water fish or mollusca as its host, before it can again infest man. 
The Lesions caused by the Parasite are the results of its local irritation upon the 
tissues in which it resides. They consist of congestion, extravasation, inflammation, 
exudation and sometimes ulceration, with their attendant symptoms. The most com- 
mon seat of these lesions is in the wall of the urinary bladder-the ova and embryos of 
the parasite in time breaking through from the vesical veins which they inhabit, into 
the interior of the bladder or ureters, from which they may pass up into the pelvis of 
the kidney, exciting pyelitis, nephritis, or forming the nuclei of renal calculi. The 
hepatic tissue and intestinal walls are sometimes the seat of these lesions also. 
The Symptoms produced, of necessity, vary in different cases, according to the position 
and extent of the lesions caused by the parasite, being vesical, intestinal (dysenteric), SECTION IX-PATHOLOGY. 
423 
hepatic, or renal, or a combination of two or more of these, as the case may be. The 
vesical symptoms are, however, by far the most common. Of these the earliest and 
most important are the passage of a small quantity of blood, varying from a few drops 
to a teaspoonful, just at the end of micturition, with a little pain in the loins or peri- 
neum, which continues for a short time afterward. Later on, riding horseback or 
unusual exercise, increases both the pain and the amount of blood passed. The fre- 
quency of micturition varies from a half a dozen to a dozen times a day, but the total 
quantity of urine passed and its specific gravity are normal. There is an excess of 
mucus, and in bad cases the urine is alkaline, with a precipitation of triple phosphates. 
A small amount of albumen exists, due to the presence of a little pus and the blood, and, 
as already stated, the ova and embryos of the Bilharzia are found mingled with the clots 
of blood and mucus, or sometimes floating free in the urine. There is usually more or 
less general anaemia and debility, with a feeling of fatigue after exercise. 
Prognosis.-This disease rarely proves fatal in itself, but the debility induced, with 
the slow septic poisoning which may occur from the dead and dying animals, which are 
said sometimes to form plugs in the portal vessels, prepares the subject for intercurrent 
diseases which readily prove fatal. Sometimes the hæmaturia ceases, the parasite 
remaining, as is indicated, even years after, by the passage of calculi or other products 
containing the ova. 
The Curative Treatment of the Disease-that of destroying the parasite-is most unsat- 
isfactory. We absolutely know of no medicine upon which reliance can be placed. 
Turpentine, once thought by some to be almost a specific, has been used by myself and 
others in Beirut, both internally and by injections into the bladder in full doses and 
long continued, without destroying the worm. Oil of male fern, chloroform, carbolic 
acid, quassia, wormwood, iodide of potassium and other remedies have been used, 
either topically or by internal administration, with a like result, although by the proper 
use of these, especially the iodide of potassium, the expulsion from the bladder of the 
ova and products of the parasite may be facilitated. Inability to remove the cause of 
the disease should not, however, deter from alleviating, as far as is possible, the distress- 
ing symptoms. 
The possibility of destroying the worm by the injection of large amounts of sulphu- 
rated hydrogen and carbon-dioxide into the rectum or bladder has been suggested to 
me by observing, only a few days ago, the effects of these gases upon the tapeworm 
and ascaris lumbricoides, as follows: I injected at once about three pints each of sulphu- 
rated hydrogen and carbon-dioxide into the rectum of a man in the St. John's Hospital, 
in Beirut, who was under treatment for phthisis. They were absorbed, and so rapidly 
eliminated by the lungs that the patient at once complained of smelling and tasting the 
sulphurated hydrogen, and after a few hours he passed a tapeworm and a number of 
the ascaris. This seems to indicate that the gases were the cause of the destruction and 
discharge of these worms, and it suggests a trial of this treatment for them, and for the 
bilharzia also, since these gases, by being injected into the rectum or bladder will be 
absorbed directly into the hemorrhoidal, vesical and mesenteric veins and meet the para- 
site there. An almost unlimited amount of these gases may in this way be brought to bear 
upon the bilharzia, probably without injuring the patient, since they enter at once the 
portal circulation, are carried to the right heart and to the lungs, where they are 
largely eliminated without passing on and entering to any great extent the arteries of 
the systemic circulation. 
The Prophylactic Treatment is a matter of great importance to the community among 
whom the parasite is found, and it is suggested by our knowledge of the cause of the 
disease. 
It consists of the prompt destruction by disinfection of the ova passed in the urine; 
of the adoption of measures which prevent contamination of drinking water or of food 424 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
with the urine or other discharges which contain the ova; of avoiding, if possible, the 
use of water already contaminated, or when it must be used, as in case of the Nile, it 
should be thoroughly filtered ; of thoroughly cooking all fresh-water fish or mollusca 
of the district where the parasite exists, before they are eaten, since these animals are 
probably the host in which the parasite undergoes its supposed intermediate or transi- 
tion stage of development. Finally, raw cabbage, lettuce or other vegetables which 
may entangle small mollusca containing parasites, should be carefully cleansed before 
being eaten. 
Dr. John North, Keokuk, Iowa, read a paper on- 
THE PATHOLOGICAL RELATION OF PTOMAINES AND 
LEUCOMAINES. 
LES RELATIONS PATHOLOGIQUES DES PTOMAINES ET DES LUCOMAINES. 
DIE PATHOLOGISCHEN BEZIEHUNGEN DER PTOMAINE UND LEUKOMAÏNE. 
Ptomaines are artificial alkaloids or bases found in decomposing animal matter, sup- 
posed to be the result of the action of certain micro-organisms upon protoplasm. They 
are only found in dead animal matter. Leucomaines are artificial alkaloids or bases 
found in the living animal, supposed to be either of bacterial origin or the breaking up 
of animal matter under the influence of metabolism, either physiological or pathological. 
It is of importance to the pathologist to know whether these artificial alkaloids are 
the cause of diseases in which they are found, or are generated as the result of the dis- 
eased process. 
The discovery of microorganisms of definite character in the body in certain diseases 
is well recognized. There is no limited region of natural science which, at the present 
time, attracts more zealous investigation in so great numbers as the microscopic deter- 
minations of the conditions of life and propagation of these microorganisms. Chemists, 
histologists, physiologists, pathologists, normal and pathological anatomists, surgeons 
and hygienists contend in the race in this realm of investigation. 
The microscope has, to a certain extent, overshadowed the test-tube in the investiga- 
tions of disease. In certain diseases, the pathological microscopists have been able to dis- 
cover organisms, and at once jump at the conclusion that the disease is a bacterial 
disease, forgetting that these .organisms may act as ferments or putrefactive agents, and 
the chemical change produced be the cause of the disease. Microscopy has done its 
work well, and physiology and pathology are greatly indebted to it for their present high 
positions. Without simultaneous chemical investigations microscopy cannot make great 
advances. 
The chemist finds a large number of nitrogenous bases, consisting of the natural alka- 
loids, artificial alkaloids, ptomaines, leucomaines, extractive matter, and the ordinary 
nitrogenous basic substance found in the human body. We are able to give the chem- 
ical composition of all of these that have been found in sufficient quantity to be analyzed, 
but we know nothing of their construction. Nitrogen may be present in organic com- 
pounds in three forms, viz. : ammonia, cyanogen, and nitric acid, or derivatives of these 
compounds. 
It is in this class of compounds derived from ammonia (NH3) that wTe find the 
ptomaines and leucomaines. All the nitrogenous compounds and bases in the animal SECTION IX-PATHOLOGY. 
425 
body are supposed to be ammonia derivatives. They are produced' from ammonia by 
the displacement of the hydrogen of the ammonia and the substitution of some organic 
radical or residue in place of the hydrogen. We have two general divisions of these 
compounds, the amines and amides. 
Amines are compounds derived from ammonia by the removal of a part or all of its 
hydrogen, and an alcoholic radical or hydrocarbon residue substituted for the hydrogen. 
Amines contain nitrogen, hydrogen, and carbon, but not oxygen, and resemble ammo- 
nia in their chemical properties. They are basic substances, combine with acids 
directly, and form salts without the elimination of water. 
Amines derived from one molecule of ammonia ( NH3) are called monamines, those 
from two molecules diamines, those from three molecules of ammonia, triamines. When 
only one atom of the hydrogen has been displaced, they are called primary amines. 
When two atoms, secondary amines. When all three atoms of the hydrogen have been 
displaced, they are called tertiary amines. Amides are compounds derived from 
ammonia by a substitution of all or a portion of its hydrogen by an acid radical. Thus:- 
AMMONIA. 
f H 
NI H 
(H 
ACETAMIDE. 
( c2h3o 
N-l H 
(h 
DIACETAMIDE, 
f C2H3O 
N i C2HsO 
IH 
CARBAMIDE OR UREA. 
H 
N H 
- co 
N H 
H 
Amides also resemble ammonia in their chemical properties, yet to a less extent than 
amines, because the acid radicals have a tendency to neutralize the basic property of the 
ammonia. They contain nitrogen, hydrogen, carbon and oxygen. 
Amines and amides may both be regarded as compounds derived from ammonical 
salts, by the loss of one or more molecules of water. 
Thus, if one molecule of water (H2O) is abstracted from carbolate of ammonia 
(NH4C6H4O), we have aniline (NH2C6H5), which is an amine. 
nh.c,h5o={^"}+h!o. 
If two molecules of water are removed from carbonate of ammonia (NH4)2 CO3, we have 
urea, CH4N2O, remaining, which is an amide. 
(NH4)2CO3 = CH4N2O 4- 2H2O. 
Amines and amides may also be formed by the action of the chloride or iodide of an 
alcoholic or acid radical upon ammonia. 
The terms vegetable or animal alkaloids have been given to the amines and amides 
found in vegetables and animals. When prepared in the laboratory they are called 
artificial alkaloids. When found in animal tissue undergoing decomposition they are 
called ptomaines or cadaveric alkaloids, the term leucomaines being applied to the 
artificial animal alkaloids formed during life. The attraction which the vegetable alka- 
loids have always possessed for the medical chemist is easily accounted for. Composing, 
as they do, so very small a portion of the plant in which they are found, and yet repre- 
senting in many cases the whole virtue and activity of such plants in their action upon 
the animal body, it is very natural that their composition should have been very care- 
fully studied, with a view to explain the changes by which they are produced in the 
plants, and, if possible, to imitate those changes in order to obtain the valuable reme- 
dies by artificial means. In this study, however, the chemist has to contend with diffi- 
culties of no insignificant character ; for even in the determination of the ultimate 
composition of these alkaloids, their high molecular weights, and comparatively small 
proportion of hydrogen render the exact determination of this element a matter of great 
difficulty, so that even at the present time the composition of some of the less known 
alkaloids can hardly be said to be definitely established. 426 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
At the present time chemists are attempting to produce the vegetable alkaloids 
artificially. So far, they have not been successful except in a few cases. They have 
been able to produce some compounds with the same ultimate composition. We are 
not able at the present time to understand their molecular construction. When we find 
out the exact radicals composing these alkaloids, and learn nature's method of putting 
them together, then we can make all the alkaloids to order. 
A number of the animal alkaloids have been prepared in the laboratory of the 
chemist. In 1828, Wöhler accomplished the synthetical formation of urea from cyanic 
acid and ammonia; for the first time urea, an animal alkaloid, which had previously 
been known only as a normal product of the process of life, was formed out of its in- 
organic elements. The cyanate of ammonia, a salt, differs only from urea in its 
molecular construction :- 
Cyanate of ammonia, NH4 CNO. 
Urea,C H4 N2O. 
We are well aware that the forces of nature are constantly at work in the human 
body. We have to do with forces as well as matter. Prof. Le Coutt says: " There 
are four planes of natural existence, which may be represented as rising one above 
another. These are: First. The plane of elementary existence. Second. The plane 
of chemical compounds or mineral kingdom. Third. The plane of vegetable exist- 
ence, and, Fourth. The plane of animal existence." It is in the fourth or upper plane 
that we find our ptomaines and leucomaines, from some chemical change taking place 
in the tissues or proximate principles of the living body, either decomposing or re- 
arranging the structure of the molecules. The force that operates on the first plane and 
changes it into the second is chemical. That from the second to the third is chemical 
force modified by vital force. That which operates on the third plane and converts it 
into the fourth plane is chemical force, also modified to a greater extent by vital force. 
That force which operates upon the fourth plane of material existence, that which pro- 
duces the phenomena of life, is vital force influenced by chemical force. A great num- 
ber of our eminent scientists contend that vital force is only transformed nascent 
affinity. That in all cases vital force is produced by decomposition of tissue or food. 
Several forms of decomposition take place in the living animal body-metabolism, 
fermentation, putrefaction, and suppuration. 
Metabolism is the transformation of matter under life forces. That which we call 
protoplasm, or the cell contents, is an albuminous substance in some form, tough and 
viscid before undergoing subsequent change. It coagulates under heat, or upon the 
death of the cell, as in rigor mortis. It swells up and becomes gelatinized by water, but 
is insoluble in water. It is from this cell contents or protoplasm that, by metabolism, 
are formed the normal nitrogenous compounds and bases of the animal body. What 
especially characterizes the nitrogenous substances is their instability of structure, 
that is, the readiness with which they may be broken up into new compounds, a 
large number of which are basic in properties and belong either to the amines or 
amides, being built upon the ammonia type. 
When this natural transformation is interfered with in the living cell and some 
microbe comes in contact with it, then we have putrefaction taking place, and then, 
instead of the albuminoid contents being changed by metabolism into harmless and 
in most cases useful nitrogenous bases, they are converted into artificial bases or alka- 
loids, called ptomaines and leucomaines. Anything that interferes with the metabolism 
of the normal nitrogenous bodies or bases, may give rise to ptomainesand leucomaines. 
The following amines and amides are found in the human body:- 
NH I 
Urea, CH4N2O. Its formula maybe written, jjjq2 | CO, in which one atom of 
hydrogen has been removed from two molecules of ammonia, and replaced by the biva- SECTION IX-PATHOLOGY. 
427 
lent radical carbo-oxide (CO). Urea is isomeric with the carbonate of ammonium 
(NH3NHCO), and the cyanate of ammonium (NH4CN). The source and properties of 
urea are too well known to require any further notice at present. In certain patho- 
logical conditions urea may undergo change and give rise to a more poisonous basis, 
which is the cause of the so-called uræmic poisoning. • 
Leucin (C6H13NO2). The leucic acid radical (C6HnO), replacing two atoms of 
hydrogen in one molecule of ammonia hydrate (NH4HO), q | O. Leucin is in- 
teresting, physiologically, as being one of the antecedents of urea, and pathologically, 
from its presence in the urine in certain diseases of the liver. 
Tyrosin in which two atoms of hydrogen in ammonia hydrate is 
replaced by the group composed of (C9H9O), as follows:- 
NH ) 
C H O J O' Tyrosin, when present in the urine, is always associated with leucin, 
although the latter may be present without tyrosin. It is found in small quantities in 
the spleen and pancreas, and is one of the products of the action of trypsin on albumin- 
ous matters. 
Creatin (C4H9N3O2 + HO) is an antecedent of urea, and is found in the juice of 
the flesh. It is converted into creatinin, and, under some circumstances, is decom- 
posed into urea and sarcosin. 
Creatinin (C4H7N3O) is derived from creatin by the removal of two molecules of 
water. It is a very powerful base. 
Sarcosin (C3H7NO2) is not found in the animal body in a normal condition. It is 
one of the substances obtained by the decomposition of creatin:- 
CREATIN. UREA. SARCOSIN. 
C4H9N3O2,HO = ch4n2o + C3H7NO2. 
In addition to these given above, we have other nitrogenous bases, among them:- 
Glycocin (C2H5NO2). 
Neurin (C5Hi5NO2). 
Xanthin (C5H4N4O2). 
Hypoxanthin (C5H4N4O). 
Allantoin (C4H6N4O3). 
Caruin (C7H8N4O3). 
Guanin (C5H5N5O). 
Uric acid (C5H4N4O6). 
Hippuric acid (CflH9NO3). 
Taurin (C2H7NSO3). 
Cystin (C3H7NSO2). 
Lecithin (C44Hh0NPO9). 
Protagon (C,b0H300N5PO35). 
Indol (C8H7N). 
Indigo (C16H!0N2O2). 
Indican (C52H62N2O34). 
A larger number have been discovered, but not in sufficient quantities to determine 
their composition. All those nitrogenous compounds are capable of undergoing chemi- 
cal changes and forming ptomaines or leucomaines. 
Fermentation is that form of decomposition produced, in non-nitrogenous material, 
by the action of some ferment which is a nitrogenous substance. The products of fer- 
mentation are usually free of offensive odors, and are not poisonous. The ferment 
grows and develops at the expense of nitrogenous matter in the air; if the material for 
fermentation consists of carbohydrates, or if the fermentation takes place in the animal 
body, then the growth of the ferment must take place at the expense of some nitro- 
genous matter in the body. 
Fermentation cannot take place between two hydrocarbons or between two carbohy- 428 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
drates. A number of ferments are found in the human body, and it is possible, by the 
breaking up of these ferments, that we may have amines and amides formed of such a 
nature as to act as poisons. 
True putrefaction takes place only in the presence of some microbe, and is the 
result of bacterial growth, and development. The putrefactive agent or germ must 
come in contact with the nitrogenized material under the proper conditions. Among 
these conditions we have warmth, moisture and oxygen. 
In addition to these artificial alkaloids, there has been discovered in both living and 
dead animal matter, non-crystallizable nitrogenous matter, called extractive matter. 
Lengthened putrefaction destroys the ptomaines. 
Panum was the first to isolate a putrefactive alkaloid, but Neucki was the first to 
investigate methodically the products of putrefactive decomposition. He was the first 
to isolate and make a quantitative analysis of a putrefactive alkaloid from gelatine, to 
which he got the formula (C8H11N). Gautier and Etard obtained the same base from 
putrid mackerel, together with another homologous base (CgHj 3N). Guareschi and 
Mosso analyzed a ptomaine from putrid fibrin, which gave the composition (Cj 0H] 5N). 
Breiger, in his recent work on ptomaines, gives the result of his investigation of the 
ptomaines as follows:- 
1. The ptomaines of gastric fibrin. 
2. The ptomaines from the putrefaction of albuminoids. 
3. The ptomaines from the putrefaction of mammalian flesh. 
4. The ptomaines from the putrefaction of fish. 
5. The ptomaines from the putrefaction of cheese. 
6. The ptomaines from the putrefaction of gelatine. 
7. The ptomaines from the putrefaction of yeast. 
He also gives a full description of his chemical results and physiological experi- 
ments. The following are the names and chemical composition of the ptomaines 
examined by him: 
(а) Peptonized Fibrin.-A toxic substance was obtained from this called peptotoxine. 
Its chemical formula was not discovered. 
(б) Albuminoids.-The same substance was discovered during the putrefaction of 
albumen. 
(c) Putrid Mammalian Flesh gave two ptomaines. Neuridine, (C5H14O2) and neu- 
rine (C5H13NO), both of which are crystallizable and form salts. 
(d) Putrid Fish, from which five ptomaines were obtained :- 
1. Neuridine. 
2. Ethylene diamine, C2H4(NH2)2H2O. 
3. Muscarine, C5H15NO3. 
4. Gadiniue, C7H17NO2. 
5. Triethy lamine N( CH 3 ) 3. 
(e) Putrid Cheese.-This yields the following bases :- 
1. Neuridine. 
2. Trimethylamine. 
(/) Putrid Gelatine gives three ptomaines. 
1. Neuridine. 
2. Dimethylamine, (CH3)2HN. 
3. Isophenylethylamine, C8HnN, (but not well established.) 
(y) Putrid Fish yields dimethylamine. 
Prof. Vaughan, of the University of Michigan, has discovered a ptomaine in putrid 
milk, to which he has given the name of tyrotoxicon. 
Ballard has found that flour which has been kept for some time in sacks contains 
traces of alkaloids, and the older the flour the greater the quantity of the alkaloids. SECTION IX-PATHOLOGY. 
429 
After extracting the flour with ether and evaporating the solution so obtained, the 
fatty residue is acid, and has an unpleasant penerating odor and an acrid taste. Alka- 
loids may be detected in the aqueous extract of the residue by • means of the usual 
reagents. Flour from twelve to eighteen months old contains appreciable quantities of 
alkaloids, and the extract proved fatal in several hours to sparrows to which it was 
administered, while extracts from fresh flour had no such effects. 
At present Dr. Brieger is engaged in an endeavor to ascertain what are the specific 
products of definite microorganisms, and settle the question whether the products 
depend upon the kind of nitrogenous matter undergoing decomposition, or upon the 
kind of microorganism causing the putrefaction. 
The majority of these artificial alkaloids have been produced synthetically. Neuri- 
dine is abundantly distributed, being not only met with among the products of 
putrescence of mammalian flesh, fish, casein and gelatine, but also in the eggs and brain 
substance. Neurine was only met with in the products of putrefaction of mammalian 
flesh, and dimethylamine in putrid gelatine and yeast. 
In almost all cases the alkaloids and extractive matter, the result of putrefaction, 
are poisonous in their effects. From the effect of the ptomaines and from eating of 
putrid meats and other nitrogenous matter, I have compiled the following symptoms:-- 
Brain.-Headache, throbbing of temples, vertigo, delirium, stupor and coma. 
Face.-Livid, pale, flushed. 
Eyes.-Red, suffused, lids swollen, pupils dilated. 
Tongue.-Fiery red, heavily coated. 
Throat.-Dry, burning sensation, extreme thirst. 
Stomach.-Want of appetite, repeated eructations, nausea, retching, violent vomit- 
ing, both bilious and alimentary. 
Bowels.-Tender, painful, griping, diarrhoea, violent colic, gastro-enteritis, very 
offensive stools, bloody stools, dark tawny liquid from bowels, stricture of rectum 
and colon, tenesmus, prolapse of rectum. 
Respiration.-Alternate strangulation and paralysis of lungs. 
Temperature.-Normal, 101° to 106° F., or below normal. 
Pulse.-Weak and slow, thin, thready, 100 to 150. 
Integument.-No heat of skin, skin hot and dry, profuse sweating, fiery red erup- 
tion all over the body, intolerable itching, rough skin, greenish or yellowish patches. 
Kidneys.-Urine scanty, loaded with urates, no sugar nor albumen. 
Muscles.-Convulsive tremors, all movements painful, cramps of thighs and legs, 
epileptiform convulsions, partial paralysis of extremities. 
General Symptoms.-Cross, irritable, great languor, extreme weakness, typhoid con- 
dition, cold extremities, etc. 
We find most of these symptoms in cases of poisoning by the narcotic alkaloids of 
hyoscyamus, conium, stramonium, etc. 
Considerable has been said and written in favor of the auto-intoxication as the 
cause of disease, before the French Academy of Medicine, and in opposition to the 
bacterial origin of disease. 
M. Gautier and M. Peter have suggested the name of leucomaines for those artificial 
alkaloids which are developed during the life of the animal body. Some writers use 
the term ptomaines to include all the artificial animal alkaloids, whether formed in 
living or dead animal matter. Some few of the leucomaines are very poisonous, and 
others are harmless. In the liquid from suppurative peritonitis, Spica obtained bodies, 
some of which were oily and volatile, with a strong alkaline reaction and capable of 
forming crystalline salts, and having the odor of conine. The chloroform extract was 
extremely poisonous in its action on frogs, and in its physiological effects resembled 430 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
that of curarine. An alkaloid resembling atropine has been found in patients dying 
from typhus fever. 
M. Peter read a paper before the Academy of Medicine of Paris, in 1886, in which 
he considers the animal alkaloid aud also the extractive matter found in animal bodies, 
which are very poisonous. In considering these bodies M. Peter says : " We naturally 
turn to the chemical side. Here chemical experience steps in and shows that in propor- 
tion to the poisonous effects of these two kinds of bodies, we have a corresponding dif- 
ference in heat. Poisoning by the extractive matters produces an increase in tempera- 
ture, while poisoning by the animal alkaloids produces a decrease in temperature. We 
may see in the same organism an association or alternance of increase or lowered tem- 
perature, according as there is an association or alternance of the different poisons. ' ' 
M. Peter believes that diseases are produced by animal alkaloids and extractive 
matters, and that microbes are mere accidents in the diseased process. That the series 
of partial deaths which make up life is the result of the working of the organs of ani- 
mal life. That by the use of any organ of the body both alkaloids and extractive 
matter are liberated. By brain-work we have neurine liberated. Muscular movement 
causes creatine to be liberated. In the normal condition these materials are eliminated 
from the body, but if from any cause they are generated more rapidly than nature can 
eliminate, then a disease is established, according to the kind of animal alkaloid and 
extractive matter generated. " Let us suppose, " he says, " that a certain quantity- 
say ten units-of extractive matters and alkaloids are produced in the organism of 
one man, and that he only eliminates eight per diem ; obviously in twenty days he 
will have retained in his system forty units, which is sufficient for intoxication and 
disease. Henceforth medical intelligence will not hesitate between the parasite doc- 
trine, full of dark hypotheses, and this new doctrine, as luminous as precise, which 
explains the normal and abnormal phenomena of life by life itself in action." 
Microorganisms are found in air at all times. In breathing we draw them into the 
lungs, they collect upon the mucous membrane. In most cases, when the membrane 
is normal, they are thrown out of the system and do no harm, but under some circum- 
stances they invade the system by passing through the membrane. They also enter 
the body with the food we eat. Whenever bacteria come in contact with animal matter 
and they commence to develop, we have artificial alkaloids and extractive matter 
formed. The septic process found when bacteria are present is not simply the bacteria 
themselves that do the mischief, but it is the products of their action upon tissue. 
The bacteria of decomposition brought into watery extracts of flesh in the presence of 
oxygen decompose albuminous matter, creatin, sugar and lactic acid into leucin, 
hydroparacumarsic acid, indol, skatol, ammonia, carbon dioxide, hydrogen and sul- 
phurated hydrogen. Here we have some of the nitrogenous bases formed, and we have 
the ammonia, alcoholic and acid radicals in a favorable condition to form our artificial 
alkaloids, either amines or amides. Under other circumstances all of these changes do 
not take place, but ammonia is always produced, and ptomaines and leucomaines are 
ammonia compounds. 
The action of water alone has the power of splitting up hippuric acid, and some of 
the nitrogenous bases in the living animal body under certain conditions, in that way 
producing the conditions and substances necessary to produce these artificial bases. 
There can be but little doubt that animal alkaloids and extractive matter do produce 
intoxication and disease, that these substances are always present where microorgan- 
isms are found. We also have the best of reasons to believe that these same, or similar, 
alkaloids and extractive matter may be found in the animal body without being of 
microbial origin. In a number of the recognized infectious diseases microorganisms 
have been discovered-one for each disease ; with these alkaloids have been found. 
The question arises, " Do the microbes produce the alkaloids and extractive matters, 431 
SECTION IX PATHOLOGY. 
or are the alkaloids and extractive matters auto-infectious, and give rise to proper soil 
for the microbes to grow and multiply?" It has been shown that in some cases the 
tuberculous bacteria have disappeared from the lungs, yet the disease has progressed 
and resulted in death. 
In my investigations and study of the ptomaines and leucomaines, I find that there 
are a few things in connection with this subject that we know, and that there are a 
great many more things that we do not know, and that the entire subject of the 
pathological relations of the artificial animal alkaloids is surrounded by hypotheses and 
theories, so that it is almost impossible to arrive at the exact amount of knowledge we 
possess in regard to them. But it is only by theories that we are able to arrive at a 
conclusion in some cases. A theory alone, not supported by facts and experiments, is 
of very little use to the pathologist and chemist. Ot the known facts in regard to the 
animal alkaloids, we know : First. That we have nitrogenous basic substances found 
in the animal body during health as well as in disease. Second. That these basic sub- 
stances have the properties of alkaloids, and that they are built upon the ammonia 
type, and derived from ammonia. Third. That they are either amines or amides. 
Fourth. That some of these are found in the human body in large quantities during 
health, and are not poisonous, but that some of them are unstable compounds and are 
capable of being broken up into other compounds which are poisonous. Fifth. That 
a number of poisonous alkaloids have been found in the human body during the 
progress of disease, or immediately after death. Sixth. That ptomaines are found 
when microbes have been at work upon animal tissue or product. Seventh. That nitro- 
genous bases or ptomaines have been found when no microbes have been discovered. 
Eighth. That nitrogenous extractive matter has been found in the animal body in dis- 
ease when microorganisms have been found, and also in disease when the microbe has 
not been discovered. 
It has been supposed that some of the known diseases depend upon the presence of 
microbes, and that the ptomaines were only the result of their action upon the cell 
and its contents, and that the poisonous extractive matter found in these cases was an 
excretion or secretion of the microbes, and that the intoxication and disease come 
from the ptomaines and extractive matter. By some, that the symptoms arose from 
the destruction of the cell and its contents, and not from the products of this destruction. 
Others believe that these ptomaines, leucomaines and extractive matter are found in 
the body as the result of normal tissue change, and that if from some cause they are 
liberated more rapidly than nature can eliminate them, or from defect in the elimina- 
tive process, they accumulate in the system and produce intoxication and disease; that 
the presence of microbes at these times are mere accidents ; that the soil being of 
proper condition, the microbe makes its appearance, but that it is not the first cause of 
the disease. 
There are a number of things that must be proven before we can arrive at a positive 
conclusion as to the pathological condition of the ptomaines and extractive matter. A 
series of experiments must be performed (some of which I hope to be able to perform at 
an early date), to prove whether any known form of microorganism, if separated from all 
alkaloids and extractive matter, and introduced into the system, will give rise to the 
disease or symptoms of the disease in which these same microorganisms are found. As 
far as I have been able to learn, the ptomaines and extractive matter have been intro- 
duced with the microbe, but the evil results following have always been attributed to 
the microbe. The alkaloids and extractive matter found in connection with these 
microbes must be separated from the microbes and then introduced into the system, 
to see whether we get the disease or symptoms of the disease. Then the alkaloids 
must be separated from the microbe and extractive matter, and it introduced and its 
effects watched; and again the alkaloid must be prepared synthetically, it being intro- 432 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
duced and its effects watched. The extractive matter should be separated from the 
microbe and alkaloid, and it introduced into the system and watched to see if it could 
act as the cause or ferment of the disease. 
Dr. M. Greeley Parker, Lowell, Mass., read a paper entitled- 
PHOTO-MICROGRAPHY THE BEST MEANS OF ILLUSTRATING AND 
TEACHING ANATOMY AND PATHOLOGY. 
LA PHOTO-MICROGRAPHIE LE MEILLEUR MOYEN DE DÉMONTRER ET 
D'ENSEIGNER L'ANATOMIE ET LA PATHOLOGIE. 
DIE PHOTO-MICROGRAPHIE DAS BESTE ILLUSTRATIONS- UND LEHRMITTEL DER 
ANATOMIE UND PATHOLOGIE. 
Photo-micrography is the art of producing enlarged pictures of microscopical objects, 
by projecting the image of the object through the microscope, or combination of lenses, 
and catching this image many times enlarged on the sensitive film. 
Micro-photography is a term sometimes used to express the same thing, but erro- 
neously, as it is the art of producing miniature pictures of objects so minute as to require 
a magnifying glass for their examination. Thus we see that photo-micrography is the 
reverse of micro-photography : the one being the art of obtaining a large picture of a 
minute object, the other the art of obtaining a minute picture of a large object, while 
photography is the art of fixing the image produced by the camera, or combination of 
lenses, on a sensitive film. 
Photo-micrography dates back to the discovery of Daguerre, published in 1839. 
After Daguerre came Reade, Donné, Hodgson, Kingsley and Talbot, early workers in 
this interesting field. After these, many in France, Germany, England and America 
took up this most interesting study ; among the' latter Woodward stands prééminent. 
His advantages in Washington enabled him to obtain photographs of diatomes which 
have never been surpassed. Koch used photo-micrography to delineate bacteria ; his 
first publication was in 1877, in which he speaks in the highest terms of the method. 
By photo-micrography we can demonstrate more clearly and teach more accurately 
the minute changes constantly taking place in disease than by any other means. 
Photo micrography is entirely void of any mental impression conveyed by the 
observer, through the engraver, to the picture. 
A photo-micrograph is the true picture engraved by the constant, faithful, all observ- 
ing artist ' ' Light, ' ' as the lens sees it, and we all know that the lens sees vastly more 
than the human eye, therefore it should be the instrument used to record scientific 
investigations. 
The oculist tells us that all eyes are not alike, and consequently do not see alike. 
The result is sometimes difference of opinion, and under such conditions the photo- 
micrograph is of value to settle the question. 
It is of the greatest aid in microscopic research, as we saw yesterday, when used to 
illustrate on the screen the valuable papers read before this Section. Among the 
illustrations were some beautiful and attractive colored microscopical specimens, but all 
depended on photo-micrographs to illustrate the detail of disease ; for in no other way 
can this be brought out as well. 433 
SECTION IX-PATHOLOGY. 
The photo-micrographs and transparencies for the above illustrations were made by 
the aid of an ingenious and cheap heliostat, arranged by Dr. Cushing, of Boston, which 
can be manufactured by any tinsmith at a price within the means of all. 
I shall not in this paper describe the process of making photo-micrographs, as this 
has been so well done in this country by Woodward,* Sternberg,f Walmsley, J Pier- 
soil, || Y. May King § and others, but say to the beginner much time can be saved, 
fewer plates spoiled, and more satisfaction obtained, by taking a few practical lessons 
from a good instructor at first, rather than work the art out from books alone, although 
good results will be obtained if one follows the directions given by the above writers. 
In focusing an object accurately, one will find some difficulty, owing to the great 
difference in eyes. It is true that blue glass or a solution of ammoniated sulphate of 
copper will greatly assist in getting a sharp chemical focus. The sharpness of this 
focus is what gives brilliancy and detail to the picture. 
In my opinion, it is incorrect focusing rather than jarring that gives a blurred pic- 
ture. What else can it be when the image is caught in the small fraction of a second ? 
This is further illustrated by the individual who possesses an eye color blind as to 
greens and reds.. For such an eye the blue glass is of little assistance, as it sees the 
chemical focus unaided, and in this branch of science possesses great advantages over 
the normal eye, which sees the many variations of color. 
For this work, the color-blind eye has a great advantage over the normal eye-a fact 
I have not seen mentioned before. 
There are many difficulties in photo-micrography yet unsolved, but good work can 
be done up to several hundred diameters, depending greatly on the specimen. The 
thinnest specimens, finely colored with alum cochineal, give admirable results ; thick- 
ness of specimen or diffuse coloring are fatal to clearness and brilliancy of detail. 
Having obtained a good negative of any valuable microscopical specimen, it is a 
satisfaction to know that the picture from this negative can be reproduced by various 
processes and at a price within the reach of all. 
Everything considered, the stippled electrotype plate, prepared from the negative for 
presswork, is probably the best. This is used in illustrating many of our best maga- 
zines. It would be an invaluable addition to our medical journals, and would have a 
far reaching effect on the study and demonstration of pathological questions. 
In studying microscopical objects it is impossible for several to examine the same 
object at the same time, unless the image Is projected on a screen ; even then it is inter- 
esting to know that the image would be found out of focus for any one who happened to 
be color blind. For the color blind a different adjustment must be made. 
All microscopists know that with high powers the slightest turn of the fine adjust- 
ment may cause the image to present different lights and shades or disappear entirely. 
The same instrument is not used by all microscopists, consequently they do not all have 
the same illumination and the same amplification. One may work with a large dia- 
phragm, the other with a small ; one with a condenser, the other without. These 
differences and many others occur, even when the same specimen is passed around 
* Woodward. American Journal of Science and Arts, Vol. xlii, Sept., 1866. Reports to 
the Surgeon-General, U. S. A., 1870-71. 
j- Sternberg. " Photo-micrographs and How to Make Them," published by Osgood & Co., 
1883. 
J Walmsley. Anthony's Photographic Bulletin, Dec. 25th, 1886, Jan. 8th-22d and Feb. 12th, 
1887. 
|| Piersoll. Medical News, Phila., June 19th, 1886; New York Medical Journal, June 26th, 
1886. 
£ Y. May King. New York Medical Journal, July 2d, 1887. 
Vol. Ill-28 434 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
for examination. Should each person prepare his own specimens a greater difference 
will occur. The method of preparing will not be the same, the cutting and staining will 
vary, and the mounting medium may not have the same refractive power. 
Under all these varying conditions, how can we expect all to agree as to what they 
see, and more especially when the objects have to be magnified from 100 to 200 diame- 
ters before they are seen at all. 
With these conditions, does any one wonder that varied opinions prevail, or that 
even the existence of some things is denied ? 
Under the existing circumstances it is impossible that it should be otherwise, and to 
settle the disputed points without the aid of something more is absolutely impossible. 
All this unrecorded microscopic study is lost to science. 
Fortunately, we have in photography a method of recording that is most accurate 
and valuable ; for no matter how careful one may be, his own drawings carry his own 
personal impressions, and when one attempts to record through the engraver, as we 
have before mentioned, he is no better off. 
A good photo-micrograph is often more valuable than the original specimen, as it 
places the object before the observer in such a way that he can compare, measure and 
make his own observations, and draw his own conclusions. This is not possible with 
drawings. 
Again, the photograph gives the picture with its lights and shadows. If these are not 
good in the specimen, one cannot improve them by photography. This, however, is not 
true with drawings ; one can make a very good drawing from a very poor specimen, and 
by so doing give no idea of the value of the specimen. Not so with photography. 
Photography reproduces the image so faithfully that in this reproduction it criti- 
cises the preparation of the specimen itself, and thereby claims its own superiority, a 
claim most valid, and one I think all will concede. 
To illustrate this difference of representation by photo-micrograph and engraving, I 
submit Figs. 1 and 2, both being reproduced from the negatives by the same stippled 
electrotype process. 
Fig. 1 is a copy of a wood-cut photographed from a book illustration, with its char- 
acteristic diagrammatic appearance of the arteries and columnar epithelium. 
Fig. 2 is a copy direct from the photo-micrographic negative, not so much enlarged, 
but representing the same pathological change. 435 
SECTION IX-PATHOLOGY. 
Fig. 1. 
Fig. 2. 436 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Pouzet, of Cannes, read a paper entitled- 
DE LA PIGMENTATION DE LA PEAU AU NIVEAU DES ARTICULA- 
TIONS DES PHALANGES DANS LA CHLOROSE. 
ON THE PIGMENTATION OF THE SKIN UPON THE LEVEL OF THE PHALANGEAL 
ARTICULATIONS IN CHLOROSIS. 
ÜBER DIE PIGMENTATION DER HAUT AUF DEM NIVEAU DER FINGERGELENKE IN DER 
CHLOROSE. 
Je viens attirer votre attention sur un signe clinique fourni par l'examen des doigts 
dans la chlorose. 
Depuis longtemps M. le Professeur Bouchard de Paris, chaque fois qu'une chloro- 
tique entre dans son service hospitalier, fait remarquer à ses élèves une coloration 
brunâtre spéciale de la peau sur la face dorsale de la main, au niveau de la deuxième 
articulation des phalanges. 
Dans la pratique, j'ai eu fréquemment l'occasion de vérifier cette coïncidence, et 
recémment, j'ai pu examiner, dans des ateliers où on travaille la soie, les mains d'un 
nombre considérable d'ouvrières atteintes de chlorose. 
Presque chez toutes, j'ai observé la pigmentation indiquée. 
Pour constater cette coloration il suffit d'examiner avec soin la face dorsale de la 
main, en la présentant un peu obliquement au jour, si c'est nécessaire. 
Au premier abord, les doigts, paraissent sales, on peut les faire laver, savonner avec 
soin, brosser, et après avoir attendu un instant pour laisser à la rougeur provoquée par 
cette petite opération, le temps de se dissiper, on aperçoit très distinctement une colo- 
ration brun-noirâtre sur toute la partie blessée de la peau qui recouvre l'articulation 
phalango-phalanginienne des doigts. Lorsque les doigts sont rapprochés, cette colora- 
tion est encore plus apparente, et l'on distingue comme un air de cercle brunâtre qui 
coupe les quatre doigts dans leur longueur. 
Nous avons observé ce signe aussi bien chez les jeunes filles qui ne se livrent à aucun 
travail manuel, et qui portent habituellement des gants, que chez les ouvrières. • 
Parmi celle-ci, nous l'avons constaté chez quelques unes qui travaillent une partie 
de leur journée dans l'eau. 
Ni la pigmentation de la peau, ni la couleur des cheveux ne parait créer une prédis- 
position. 
Nous n'essayerons pas de donner l'explication de- ce fait. Est-ce une pigmentation 
spéciale de la peau qui se fait dans ce lieu d'élection, ou bien, ses parties restent-elles 
pigmentées, tandis que les tissus voisins se décolorent sous l'influence de la chlorose ? 
C'est ce que nous ne savons pas. Il nous a seulement paru intéressant de signaler 
ce fait de simple observation clinique, et d'ajouter ainsi une indication nouvelle à celles 
que nous fournit l'examen des doigts. 
Nous devons déjà à M. le Professeur Bouchard de Paris, la connaissance des nodosi- 
tés des doigts dans la dilatation de l'estomac, nous lui devons aussi celle de la pigmen- 
tation des doigts dans la chlorose. SECTION X-DISEASES OF CHILDREN. 
OFFICERS. 
President: DR. J. LEWIS SMITH, New York. 
VICE-PRESIDENTS. 
Henry Ashby, m. d., Manchester, England. 
Dr. W. B. Atkinson, Philadelphia, Pa. 
Dr. A. Blackader, Montreal, Canada. 
Wm. D. Booker, m. d., Baltimore, Md. 
E. Bouchut, m. d., Paris, France. 
Wm. D. Hay, m.d., London, England. 
Prof. Ad. D'Espine, St. Malo. 
Dr. Cadet de Gassicourt, Paris, France. 
Dr. de Saint Germain, Paris, France. 
Jas. Fred'k Goodhart, m. d., London, England. 
Prof. H. Hirschsprung, Copenhagen, Denmark. 
Herr Prof. Hofrath, Vienna, Austria. 
Dr. Adoniram B. Judson, New York. 
Dr. Moncorvo, Rio de Janeiro, Brazil. 
Herr Prof. Alvis Monti, Vienna, Austria. 
Dr. Jno. Morris, Baltimore, Md. 
J. P. Oliver, m. d., Boston, Mass. 
Martin Gay Black Oxley, m. d., Liverpool, 
England. 
Jules Simon, m.d., Paris, France. 
Dr. Eustace Smith, London, England. 
Wm. Stephenson, m. d., Aberdeen, Scotland. 
Nicolas Tolmatochow, m. d., Kasan, Russia. 
Alfred Vogel, m. d., München, Germany. 
Dr. Charles West, London, England. 
Dr. Herman Widerhofer, Vienna, Austria. 
Oscar Wyss, m.d., Zurich, Switzerland. 
SECRETARIES. 
Dillon Brown, si. d., New York City. 
Henry Coggeshall, si. d., New York City. 
Lucien Damainville, si. d., New York, N.Y. 
I. N. Love, St. Louis, Mo. 
COUNCIL. 
Wm. T. Belfield, m.d., Chicago, Ill. 
Edw'd H. Bradford, m. d., Boston, Mass. 
H. Charlton, m.d., Seymour, Ind. 
W. H. Conklin, m.d., Canton, Ohio. 
W. J. Conklin, m. d., Dayton, Ohio. 
Wm. H. Doughty, m.d., Augusta, Ga. 
Jos. O. Dwyer, M. d., New York, N. Y. 
C. W. Earle, m. d., Chicago, Ill. 
Wm. D. Haggard, M. D., Nashville, Tenn. 
M. P. Hatfield, m. d., Chicago, Ill. 
J. A. Hodge, m.d., Henderson, Ky. 
W. F. Holt, m. d., Macon, Ga. 
A. A. Horner, m. d., Helena, Ark. 
G. K. Johnson, m. d., Grand Rapids, Mich. 
H. H. Middlekamp, m. d., Warrenton, Mo. 
W. P. Northrop, m. d., New York, N. Y. 
Jno. S. Reed, m. d., New York, N. Y. 
B. H. Riggs, M. d., Selma, Ala. 
Chas. A.,Leale, m. d., New York, N. Y. 
O. W. Sherwin, m. d., Woodstock, Vt. 
A. L. Steele, M. d., St. Louis, Mo. 
Edwin Walker, m. d., Evansville, Ind. 
Frank E. Waxham, m. d., Chicago, Ill. 
Edmund C. Wendt, m. d., New York, N.Y. 
Leroy M. Yale, m.d. 
>., New York, N. Y. 
437 438 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
OPENING ADDRESS OF THE PRESIDENT. 
Gentlemen :-The First International Medical Congress, held in Paris in August, 
1867, originated and guided to a successful termination by distinguished physicians 
of the French metropolis, continued two weeks. Inasmuch as many stibjects of 
universal interest are discussed at such a Congress, and the observations and expe- 
riences of physicians under very different circumstances are compared, a broader and 
more accurate knowledge of diseases is imparted, and discoveries of therapeutic 
interest and value become more widely known, so important is the work of an 
International Medical Congress, and so great its influence in advancing the highest 
interests of the profession, that it is, perhaps, a matter of regret that it has been 
thought best to limit its duration to one week instead of allowing two weeks, as in 
the First Congress. 
This Section will have nine sessions, and twenty minutes will be allowed for the 
reading of each paper, in compliance with the rules of the Congress. The Executive 
Committee have provided for the probable lack of sufficient time in the discussions 
by a resolution, allowing any member present at the reading of a paper, and not 
having opportunity to discuss it, to send in writing the remarks which he desires to 
make, to one of the Secretaries, and if the Council of the Section consider them 
appropriate and worthy of publication, they will appear in the printed Transactions. 
Those who participate in the discussions will recollect that the narration of accurately- 
observed cases will throw more light on obscure or disputed subjects than does the 
dogmatic expression of opinions unsupported by clinical experience. Clinical facts 
or statistics upon matters of importance always have permanent value. 
It will be seen by the programme that most of the papers to be read and subjects 
discussed are of a practical nature, and the profession will watch with interest the 
proceedings of this Section, and be benefited and instructed by the opinions expressed 
here. It cannot be doubted that the papers in this Section will promote a more 
accurate knowledge of several of the most important diseases of childhood, and lead 
to a better treatment of them. Some of these papers will, in my opinion, have a 
permanent place in pediatric literature. 
In behalf of the Council, I wish to acknowledge our indebtedness to the foreign 
members of the Section who will actively participate in it, men known and honored 
in both hemispheres for their contributions to medical science. Though actively 
engaged in professional duties at home, and their writings eagerly sought for else- 
where, they have consented to prepare papers for this occasion. Seven papers have 
been promised from Great Britain, five from France, two from Switzerland, two from 
Germany and three from South America, in response to the invitation to aid in this 
great international gathering. A few of the papers will, probably, not be received 
in time to be read in the Section, but they will, of course, be printed in the Trans- 
actions. SECTION X-DISEASES OF CHILDREN. 
439 
I may mention, in particular, among those who have aided in furthering the work 
of the Section, Dr. Eustace Smith, of London, and Prof. Grancher, of Paris. Nor 
should I forget to speak of Dr. Bouchut, whose classical treatise on diseases of 
children, translated into various languages, was a text-book in the schools when the 
seniors in our profession were students. He has sent us two instructive papers; one 
of them upon a subject new to the profession, and he writes to us of his great disap- 
pointment, on account of ill-health, in not being able to be present to participate in 
the discussions. His interest in this Congress is greatly increased by the fact that it 
will aid in establishing throughout the world a mode of treatment of a most painful 
and fatal disease which he recommended thirty years ago, but which, encountering 
strong opposition and adversely reported on by a committee of the most distinguished 
physicians of the French Academy, fell into disuse and was forgotten. Intubation, 
in the treatment of membranous croup, revived and greatly improved through the 
genius and perseverance of an American member of this Section, will soon, in the 
opinion of all who have witnessed its simplicity and the marvelously quick relief 
which it gives, be practiced in all countries where there is a medical profession. To 
acquire a knowledge of this operation and the manner of using the tubes is one of 
the chief inducements which we olfer to the foreign members for undertaking long 
voyages and incurring many inconveniences and sacrifices in coming to this Congress. 
The history of intubation is interesting and instructive. We shall see from M. 
Bouchut's paper that in the few instances in which he practiced it, with rude and 
imperfect instruments, it relieved dyspnoea and prolonged or saved life. But it was 
opposed and even ridiculed by Trousseau and his compeers, who were bringing for- 
ward tracheotomy, and it died out and was forgotten. The dictum of the great 
masters of the profession, at whose feet we sit and learn, has more influence than the 
plain teaching of the senses. To M. Bouchut the credit is due of demonstrating the 
fact that the larynx tolerates the presence of a tube, although it exhibits such extreme 
irritability when a foreign substance accidentally enters it. 
Intubation, as a means of relieving, not only membranous croup, but other 
forms of laryngeal stenosis, has, like vaccination, survived the opposition which it 
encountered in its earlier days, and the name of M. Bouchut will always be honorably 
mentioned in connection with this operation, while that of O'Dwyer will go down to 
posterity, along with that of Jenner, holding a conspicuous place among the bene- 
factors of mankind. In justice to my countryman, I may say that he was ignorant 
of Bouchut's work in the same direction until, after many disappointments and 
failures, he had so improved his instruments that success was certain. 
It is with pleasure that we are able to welcome South America to the sisterhood 
of countries represented in this Congress. Among the first of the foreign papers 
designed for the Congress, which arrived, were five from South America. South 
America, from whose flora we obtain some of our most useful medicines, will, if we 
may judge from our experiences in this Congress, have, in the near future, a medical 
literature of its own, and will contribute its full share of interesting topics for discus- 
sion to future Congresses. The papers which we have received from South America 
are the more interesting and important because we in the Northern Hemisphere 
have heretofore been very ignorant, not only of the diseases, but of most other 
matters of medical interest pertaining to this great Continent. 
The first paper to which we will have the pleasure of listening relates to diph- 
theria, which is gradually extending throughout the civilized world, and is perma- 
nently established in many of our large cities. In New York City from 1000 to more 
than 2000 children die of this disease every year, and if we include those who die of 440 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
diphtheritic croup, which is a form of diphtheria, the number is one-third larger. 
Any facts or observations which will throw light on the nature of this fatal and now 
prevalent malady, or aid physicians in its treatment, will have a great and permanent 
value. 
AN INVESTIGATION TO DETERMINE WHETHER THE ABSENCE OF 
SEWERAGE AND OF WATER POLLUTION DIMINISHES THE 
PREVALENCE AND SEVERITY OF DIPHTHERIA.* 
INVESTIGATION POUR DETERMINER SI L'ABSENCE D'ÉGOUTTAGE ET DE LA 
POLLUTION DE L'EAU DIMINUE LE POUVOIR ET LA SÉVÉRITÉ ' 
DE LA DIPHTERIE. 
EINE UNTERSUCHUNG, UM ZU ENTSCHEIDEN, OB DIE ABWESENHEIT VON ABZUGS- 
KANÄLEN UND VON WASSERVERUNREINIGUNG DIE HÄUFIGKEIT 
UND STÄRKE DER DIPHTHERIE VERMINDERT. 
Professor of Diseases of Children, Woman's Medical College; Professor of Obstetrics, College Physicians 
and Surgeons, Chicago, U. S. A. 
CHAS. WARRINGTON EARLE, M.D., 
It may truthfully be said that no one cause has up to this time been named as 
producing diphtheria which has been universally accepted by the great mass of the 
profession. 
All kinds of dirt-all kinds of emanations from every kind of filthiness-atmo- 
spheric influence and germs have been included in the etiology of this disease. 
It has been claimed by many that imperfect sewerage has been the cause, and the 
people, urged on by the opinion of the doctors, frequently blame a sewer for poisoning a 
family and producing diphtheria, when, in my judgment, the cause should be placed 
elsewhere. It is much better for us to recognize the true cause, if it is possible to find 
it, rather than to attack an imaginary one, for it is possible that while we are fighting 
the supposed gas as the cause, we are losing sight of the real enemy which should 
engage our attention. 
Jacobi says that cases of diphtheria which are traced to exhalations from sewers, or 
even to filthy habits of life, are very frequent. This opinion, especially in regard to sew- 
erage, has been reiterated by scores and hundreds of physicians. It represents the 
prevailing idea of American physicians. 
* The following named physicians have kindly contributed information embodied in this 
paper :- 
Drs. J. S. Kreychie, I. R. Spooner, R. A. Cushman, from Dakota. 
Drs. G. G. Tyrrell, Charles Ambrook, H. C. Croweler, C. M. Bates, F. II. Payne, from Cali- 
fornia. 
Drs. W. W. Hammond, J. D. Carnahan, August Boucher, Gilbert Gregor, F. S. Kahler, A. C. 
Ormsby, Jno. Alfred, from Utah. 
Drs. E. A. Spaulding, Herbert Hulburd, from Minnesota. 
Drs. G. B. Snyder, E. E. Hazlett, J. M. Wade, from Kansas. 
Drs. A. D. Kibbie, J. K. Dubois, from Idaho. 
Dr. J. C. Watkins from Wyoming. 
Drs. B. B. Kelly, Alex McLeod, from Montana. SECTION X-DISEASES OF CHILDREN. 
441 
English practitioners are particularly the advocates of sewer-gas theory. In the 
British Medical Journal, December 1st, 1883, J. Emmett Holt gives an account of the 
disease as it occurred in Canterbury. Investigation showed the well water to be exten- 
sively contaminated with sewer gas in every instance. In addition to the drinking 
water being polluted, there was found a drain running under the parlor, letting sewer 
gas enter the living room of the family. 
I cannot hope to have discovered the one cause of diphtheria, or to prove that sewer 
gas does not in many cases influence this disease. But I have been impressed for many 
years that undue importance was given it as a causative factor, and have thus been led 
to investigate the prevalence of this dreadful disease in locations remote from any sewer- 
gas influence. 
It appeared to me that investigations to demonstate my theory should be conducted 
at great distances from sewers, and the location must have a pure air with pure water, 
and that in the great Northwest of the United States of America these conditions could 
best be found. In the following briefly described States and Territories I concluded to 
make my inquiries :- 
Minnesota.-Population (1885), 1,117,798; square miles, 83,531. Rolling prairies, 
dotted with lakes and belts of timber. The summers are cool and pleasant, and while 
the winters are cold, the air is dry and clear. 
Dakota.-Population, 415,263; square miles, 150,932. In the main prairie; climate 
mild and genial; winters cold and dry; bracing and invigorating air; average rainfall, 
twenty inches. 
Montana.-Population (1880), 39,159; square miles, 143,776. Climate milder than 
would be supposed from the altitude; soil exceedingly fertile; a great grazing country. 
Wyoming.-Population (1880), 20,789; square miles, 97,980; rich in minerals, and 
its surface is broken by mountain ranges and deep river canyons. 
Kansas.-Population (1880), 996,096; square miles, 81,318. The surface, which is 
made up of prairies and river bottoms, slopes from the Rocky Mountains to rivers on 
the east. The climate is healthful. 
Utah.-Population (1880), 143,963; square miles, 84,476. An immense plateau 
between the Rockies and Sierras, consisting of smaller mountains, plains, valleys and 
basins. Climate mild and dry. 
Idaho.-Population (1880), 32,610; square miles, 86,294. Climate cool and health- 
ful. This territory is rich in minerals, but the cereals flourish abundantly. It contains 
vast forests of fir, pine and hemlock. 
California.-Population (1880), 864,694; square miles, 188,981. Climate variable, 
on account of extent of territory along the Pacific coast. Temperature ranges from 50° 
below in the north to 70° above at the south. 
These States and Territories help to make up the great Northwest of our country. 
Part of this immense region is traversed by our highest mountains and watered by 
rapid rivers. Much of it is prairie. The purest air in the world is abundant, and many 
of the habitations, particularly in the early times, were built on posts some distance 
from the ground. There is not a sewer within a hundred miles of some of these houses, 
and yet diphtheria is found. To the physicians in this great country I addressed a com- 
munication with the following questions :-* 
1. Does diphtheria occur frequently in your vicinity? 
2. What season of the year to the greatest extent? 
3. How far are you from any sewers ? 
4. Have you ever attended cases exceedingly remote from any possible source of 
infection? 
5. Have cases occurred in your practice in habitations raised from the ground so that 
no possible decomposing material under the house could act as a cause ? 442 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
6. Have cases occurred in your practice among the mountains, where the water 
supply is from pure springs or running brooks, where pollution from cesspools, water- 
closets or sewers was absolutely impossible ? 
7. Does proximity to barns or stables seem to predispose to the disease ? 
From among many who have kindly answered my communication, I select the fol- 
lowing as having some bearing on the questions involved :- 
Dr. Hulburd says, "our cases are almost without exception traced to some infected 
person or clothing. " He also gives another cause, which I think demands attention, 
that is, railroad cars as a means of conveying the contagion from one place to another, 
and as the place where the contagion may be taken into the systems of little people who 
are riding in the coaches. 
Dr. Spalding says that he passed through a severe epidemic with great fatality two 
years ago. " Our drinking water is free from all organic matter, and the habitations 
are upon high ground." 
Dr. Cushman says that cases appear sporadically, and then another case appearing 
miles away with no visible connection. ' ' Cases occurring in sod houses and houses 
situated on low ground seem more virulent." • 
Dr. Spooner, whose experience has been great, according to the testimony of others, 
answers my questions very fully, to such an extent that I produce nearly his entire 
letter :- 
Lake Prairie, Kingsbury County, Dakota, July 14th, 1887. 
Dear Doctor :- 
I am pleased to receive your letter of inquiry, and will endeavor to answer to the best of my 
ability. 
Query 1. We have cases of diphtheria in almost every month in the year. Since May 9th 
last, there have occurred in my practice in this vicinity eight eases. In the practice of others, 
four cases, and two cases that were undoubtedly diphtheria that were here, making fourteen cases. 
Two of them undoubtedly contracted the disease in transit from Norway, as one of the same 
family, a babe, died on shipboard from the same disease, if the statements of the parents are to 
be relied on. Five of my cases contracted the disease after coming to Dakota. So the disease, 
so far as we are able to ascertain, really originated here in one-half these cases only. In the 
four treated by others the origin of the cases is unknown. In the three remaining cases treated 
by myself, one visited a family where a patient had had the disease and was supposed to be con- 
valescent ; but that was the only possible source of infection, so far as I could gather from care- 
fully questioning the patient and friends. The remaining two cases of mine were patients who 
had had the disease before; origin at this time unknown. 
Query 2. I cannot say positively, but the majority of cases have occurred from January to 
September in this territory, in my practice. 
Query 3. We are forty miles from any sewers ; so far that it does not enter into the considera- 
tion of this question at all. We may say, perhaps, that a lack of proper drainage does furnish 
suitable conditions for either the development or the propagation of the diphtheria germ. 
Query 4. I have attended cases where it was impossible to decide the cause of the disease ; 
and, as far as being remote from any "possible source," it would be exceedingly difficult to 
decide, but I can say they were remote from sewers ; in fact, all cases coming under my observa- 
tion have been those where the sewerage did not enter into the consideration of the case at all. 
Query 5. In a number of instances the cellars have been perfectly clean and free from decay- 
ing vegetables. In at least six or seven instances of separate families it has been the case that 
there has been no possible source of infection from the presence of decomposing material under 
the house. 
Query 6. I have never practiced in mountainous districts, but some of my most violent and 
malignant cases have occurred on the highest points of land in the country. The cause, to my 
mind, was evident, t.e., an unclean cistern, with no attention to hygiene indoors or out. 
Query 7. My opinion is that proximity to barns and stables enhances the liability to the 
disease. I cannot say it causes it, but believe, the diphtheria germs being present as the prime SECTION X DISEASES OF CHILDREN. 
443 
factor, these other conditions are potent factors in the propagation of the disease and in the con- 
tinuation of it. 
In Dakota my practice has been on the prairie exclusively, as there is nothing but prairie 
here. Our prairie has scattered all over it ponds of water during a wet, or moderately wet, season. 
We are in close proximity to a number of lakes, which are really the head waters of the Ver- 
million, a stream one hundred miles in length, a tributary of the Missouri. We are on a point 
of land which has nearly the greatest elevation in Southern Dakota, unless it be the Washington 
Hills. The surface is undulating. Winds prevail from the south and southwest. The soil is a 
black sandy loam ; underlying this a yellow clay, except in the vicinity of the lakes the clay is 
shallow and more sand appears in the soil. The atmosphere contains less moisture than in Iowa 
or Minnesota; is what is termed a dry atmosphere. 
The wells in this vicinity are generally dug through the loam, and the water is found in either 
sand and gravel or clay, at a depth varying from eight or ten feet to thirty. The majority of 
wells average about twelve feet. 
Dr. Kreychie says that he has seen cases in houses where potatoes and other vegeta- 
bles were stored under the building. Several gentlemen seem to think that decomposing 
material, such as vegetables, especially with moisture, predispose to the disease. Two 
or three children will die in the same house within a very short period. Indeed, the 
virulency appears quite as terrible as in our large cities. The same gentleman narrates 
the history of a family of five persons living in a sod shanty with filthy surroundings, 
a cesspool and a lot of manure in front of the shanty. Three children were taken with 
the disease, and all died within the space of about ten days. Some miles from his home 
there live a few families on the banks of a sluggish stream of water that flows only in 
the spring. There has not been a spring since he settled there that some of those 
families have not had a case of severe diphtheria occurring. 
Dr. Kelly has attended cases of malignant diphtheria remote from sewers and all 
possible sources of infection. He attended one case five miles from any other habitation. 
He believes proximity to stables where there is a good deal of filth seems to predispose 
to the disease. 
Dr. Watkins says diphtheria is rare in Wyoming; that he has seen only one case in 
eight years, and that of a very virulent type. He thinks that was caused by the child's 
stirring up the town dump of manure. 
Dr. Hazlett says that in one epidemic in his county, in a town on the high prairie, he 
had a number of cases, many of which died in spite of all that could be done. In one 
of his families, where all possible pains had been taken in regard to cleanliness and to 
escape any effect of decomposition, the house standing on raised ground and some dis- 
tance from barns, fatal cases occurred in his practice. 
Dr. Ormsby writes that he has found diphtheria in houses miles from any others, at 
the mouth of a canyon, where the purest of mountain air prevailed and no possible 
chance for decomposition existing. He does not see how sewer gas or decaying vegeta- 
bles can have anything to do with the disease. 
Dr. Gregor says that the epidemic of 1882 was particularly fatal in a little settle- 
ment near the top of the mountain, at an elevation of 9000 feet ; this settlement 
consisted of probably a dozen houses built around what used to be a small lake, but at 
that time dry. The water had been drained off from the lake by a mine below. The 
water used by these people, however, for household purposes, is perfectly pure, coming 
from water-courses from above, and where it was not possible that contamination 
existed. 
Dr. Kahler says that it occurs frequently in elevated situations where no possible 
decomposing material existed. It takes place frequently in mountainous districts 
where the water is pure and no cesspools or water-closets are present. 
Dr. Dubois, 290 miles from a railroad, in a vicinity where there are no sewers, has 444 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
passed through one epidemic of diphtheria. Water supplied from springs, and the 
climate is particularly unfavorable to the conditions usually producing this disease. 
Dr. Croweler says that the worst case he ever saw was in habitations upon the sandy 
soil in the hills and fifteen miles away from any point of infection. He knows from 
experience that it will and can exist in all its malignancy where there are no sewers. 
Dr. Frank H. Payne says: " I have had considerable experience with diphtheria, 
especially during the winter of 1885-6, when about seventy cases occurred in my prac- 
tice. I found that the disease occurred under every condition and circumstance of life; 
sometimes as divergingly different as could possibly be. In miserable, filthy hovels, 
with poor sewerage and every condition favorable for its propagation, and again in well- 
ventilated, well-sewered houses where disinfection is constantly practiced and cleanli- 
ness observed. 
' ' I have had isolated cases in the mountains where no sewers existed and every con- 
dition seemed favorable to health. But I must confess that it is very difficult to stamp 
out the disease when it exists in an unfavorable, bad sewered locality. Such conditions 
seem to favor its spread, and I am also inclined to believe have some influence upon the 
disease as to its virulence. 
" In a region swept by the fumes from an acid factory (sulphuric acid) I have never 
had cases except once, when they were directly traceable to exposure to a virulent form 
of the disease while in the city. ' ' 
Dr. Tyrrell says that, inasmuch as he is a strong believer in the specific cause of 
diphtheria, he thinks that sewer gas has nothing to do with it. His belief is, no germs, 
no diphtheria. 
Everything, however, points to the germ theory as the cause of this disease. How- 
ever much we may try to avoid accepting the theory, there is coming to be such a mass 
of evidence in favor of it that it is almost irresistible. 
CONCLUSIONS. 
1. Diphtheria occurs in the mountains and prairies of the great new northwest with 
the same malignancy as in cities. 
2. Diphtheria takes place with equal virulence in vicinities remote from sewers. 
3. Diphtheria once present, the inhabitants in damp sod houses, those living over 
cellars containing decomposing vegetables and in proximity to manure heaps and poorly 
constructed sewers, seem to be in surroundings which tend to increase the severity of 
the malady. 
4. The fact is again demonstrated, although developed incidentally, that the conta- 
gious element may be carried or transported thousands of miles in a manner difficult to 
understand. « 
5. Testimony is abundant that the poison may be transported by means of cars and 
steamers. This fact calls for increasing watchfulness and more efficient means of disin- 
fection than have been heretofore practiced by our railroad companies. 
6. To such a degree is this terrible disease contagious, a few in the profession refus- 
ing to acknowledge it, and the majority of the people persistently refusing to isolate 
their children, it appears to me that the only method by which we can prevent the 
spread of diphtheria is by the enactment of laws compelling the people to assume some 
responsibility in regard to contagious diseases. 
DISCUSSION. 
Dr. F. E. Waxham, of Chicago, said:-I believe that diphtheria is due to the 
absence of sewers rather than to their presence. It is true that in our large and 
crowded cities we meet with the disease far more frequently among the poor, who SECTION X-DISEASES OF CHILDREN. 
445 
live in districts without sewers, than among those living in well-sewered districts. 
That the disease is contagious there is no question, and that filth, decomposing 
vegetable matter, impure air and bad hygienic conditions are important factors in its 
production, I cannot doubt. Recently it was my privilege to attend five children 
with diphtheria in a house consisting of a cellar and two flats. There were three 
children in one family and two in the other. In the cellar was found a large quan- 
tity of decomposed vegetable matter around which the children had been playing 
every day. 
Absolute cleanliness, which means disinfection as well, is our great remedy in 
preventing this disease. 
Remarks by the President.-The interesting and instructive paper of Dr. 
Earle opens for discussion a subject of the greatest importance to the public as well 
as physicians. That is, how to prevent the spread of diphtheria. His statistics 
show that it desolates families in salubrious rural localities where there is no impurity 
in the air or water. They demonstrate the fact of its extreme contagiousness from 
person to person and through infected articles, either of wearing or merchandise. 
On the other hand, we in the cities have abundant and melancholy proof of the 
causative relation of foul air, whether arising from the sewers or stagnant filth, to 
diphtheria. Dr. Sternberg, in his recent prize essay, published by the American 
Public Health Association, remarks as follows : "It seems extremely probable that 
the diphtheritic poison-germ-is capable of increase, independently of the sick, in 
damp, foul places, such as sewers, damp cellars, and especially under old houses in 
which the floors come near the surface of the ground, leaving a damp, ill-ventilated 
space. At all events the disease often clings to such houses, in spite of the applica- 
tion of the usual means of disinfection. There is no doubt as to the influence of bad. 
hygienic conditions in maintaining the infection when the disease has been introduced, 
and it is possible that such conditions may, in certain cases, originate it. ' ' These 
views, as regards the causative relation of foul air to diphtheria, are abundantly sus- 
tained by clinical observations in the cities where diphtheria is established. Thus, 
in New York, prior to 1850, although foul sewers and" insanitary conditions existed, 
there was no diphtheria ; but in the decade following 1850 diphtheria was intro- 
duced ; its germ found its way into the sewers, where, in the filth underground, it 
obtained a nidus favorable for its development, and for many years, in every street 'n 
this city, wherever sewer gas escapes into the houses children fall victims to this 
disease. ' ' Sanitary plumbing, ' ' although it probably has diminished the number of 
cases, has failed to prevent the occurrence of diphtheria. 
Dr. Earle recommends legal enactments to check the spread of diphtheria, and 
certainly the most stringent enactments should be passed in the face of a pestilence 
that is desolating so many of our families. Still, I think that the disease is beyond 
the control of law makers. One of the most common ways in which diphtheria is 
propagated is by walking patients. Children with slight diphtheritic sore throat go 
to the dispensaries and sit among other children, to the schools and infect a whole 
school room, and to the doctor's office and expose his children and other children who 
may be waiting. I was once summoned by a little girl from my office to see her 
brother, who had diphtheria. It occurred to me to examine her throat. She was 
in the street with her playmates. She did not complain and seemed well, but a 
diphtheritic patch was found upon her fauces. Physicians, whenever diphtheria 
occurs, have not only a professional but a deep personal interest in arresting its spread, 
for wherever it is established it desolates more physicians' families, from the peculiar 
manner in which they are exposed, than do all other contagious diseases together. 446 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The praiseworthy endeavor to prevent diphtheria by excluding affected children from 
the society of others is only partially successful, on account of the large number of 
mild, undetected and unsuspected cases. Children mildly affected and under no 
restraint communicate the disease, in numberless instances, to well children, who 
sicken, and their parents are ignorant of the time and mode of exposure. 
ON THE RATE OF GROWTH IN CHILDREN. 
DU DEGRÉ DE CROISSANCE DANS LES ENFANTS. 
ÜBER DEN GRAD DES WACHSTHUMS BEI KINDERN. 
Professor of Midwifery and the Diseases of Women and Children, University of Aberdeen, Scotland. 
BY WM. STEPHENSON, M.D., 
From the self-apparent truth that the presence of active growth and development is 
the distinguishing characteristic of childhood, little advance has been made in our 
knowledge of the facts of that growth, or of the influences, for good or for evil which 
such activity exerts. Nothing, as yet, is known of the clinical bearings of the relative 
height and weight of a child, and many important questions remain unsolved. 
What is the relative activity of growth one year with another? Is it a uniformly 
diminishing quantity from the first year of life onward, or are there periods of increasd 
action following upon others of comparative rest ? Children do grow more rapidly at 
times than at others, but do these times follow any law, or do they occur in irregular 
and uncertain spurts ? 
If a boy adds to his weight, in a certain year, double or treble the number of pounds 
which he does in another, is he, on account of this increase of cell activity, the more or 
the less able to bear a strain, such as school pressure or physical labor ? 
Again, what influence has the activity of growth on the predisposition to disease ? 
What effects in after life may arise from the process of growth being disturbed in the 
earlier years ? How far is this process swayed by the occurrence of temporary ailments 
and the variations in surrounding circumstances ? 
Here there is a comparatively unknown territory in Pediatrics-a field which cannot 
be explored by any one man, but requires the accumulation of the work of many 
observers in different countries, and extending over many years. 
The reason why our knowledge of the subject is so defective is, that till recently we 
did not possess the data necessary to furnish a basis of observation and a guide to the 
proper methods to be employed. The basis of observation required, is a reliable stand- 
ard of development and growth for each year of life, and the deduction therefrom of a proper 
method of comparing one child with another. By the exertions and labor of Professor 
Bowditch, in America, and of the Anthropological Committee of the British Associa- 
tion, we now possess material from both nations for forming such a standard. Each 
group of statistics-American and British-is in itself sufficiently large to supply reli- 
able results. Taken separately they act as checks, one on the other, in the elimination 
of accidental appearances, and in confirming the results where both agree. Taken 
together, the averages may confidently be accepted as representing A TYPICAL stand- 
ard for the English-speaking races. 
Unfortunately, the observations for the years under five are not sufficiently numerous 
to yield reliable results; they are, therefore, not included in this paper. The present 
investigation has also stopped at the eighteenth year, as the American statistics do not as SECTION X-DISEASES OF CHILDREN. 
447 
yet extend beyond. The observations on girls, especially the British, are not so numerous 
as could be desired; the results, therefore, should be accepted as so far tentative. 
In the tables appended will be found the averages of all the observations of the 
height and weight of American and British boys and girls for each year of age, which 
may, therefore, be regarded as the typical height and weight of the English-speaking races. 
From this is easily obtained- 
THE RELATIVE ACTIVITY OF GROWTH ONE YEAR WITH ANOTHER. 
The numbers are given in the tables, but a clearer conception of the relative growth, 
or the difference of one year with another, can be obtained from the graphic representa- 
tion given in the charts. The annual increase in weight is taken as the measure of the 
activity, and the actual number of pounds weight is used in preference to a percentage, 
as being equally serviceable and more ready of reference in after use when applying the 
standard to individual cases. 
The American measurements, it will be seen, correspond very closely with the 
British. The object at present is, however, not to compare the one race with the other 
Annual Increase in Weight in Boys. 
as to height and weight, but only as to time. The exact accordance of the periods of 
rise and fall in both nations, as shown in the charts, convincingly proves that the rela- 
tive rate of growth, one year with another, is dependent upon a distinct lato, and is not arbi- 
trary or uncertain as to time. 
The graphic line representing the annual increase in weight presents a definite 
curve, of a similar type in girls as in boys, but differing in the times of maxima and 
minima. In both a maximum activity occurs in the first year of life; it then rapidly 
falls to a minimum between the third and fourth years. After various changes a 
second maximum is reached, in girls in the thirteenth year and boys in the sixteenth. 
Thereafter it falls rapidly, but in girls more gradually than in boys. 
A secondary rise occurs, in the eighth year in girls and the tenth in boys, followed 
by a marked fall, in the ninth and eleventh years respectively. (See charts. ) 
These features are so constant, not only in the American and British statistics sepa- 
rately, but also in the various sections of society, such as the professional and artisan 
class, that they must be considered as facts, and not due to imperfections in the obser- 
vations. 
These curves of growth furnish a clearer conception than can otherwise be obtained 448 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of the activity of growth at different ages, and the differences which exist between 
male and female. They show how important it is that in all statistics the data should 
be given for each year, and not in quinquennial or decimal periods. They point out 
wherein the growth of males differs from that of females, and that, therefore, boys 
should not be compared with girls of the same age, but that, for example, the sixteenth 
year in boys corresponds with the thirteenth in girls, the eleventh with the ninth, and 
so on. We thus reach what may prove to be a general law, that as physiological periods 
differ in the female from the male, in man they are in the ratio of four to five. 
The well-marked retardation of growth in the tenth and eleventh years respectively, 
is a fact to which attention has not previously been drawn, but will doubtless be found 
to have important clinical bearings. So, also, with the striking peculiarity of the thir- 
teenth and the sixteenth years. Is a boy or girl less able, during this period of rapid 
growth, to bear the strain of school work ? At first sight one is disposed to think that 
such would be the case, but there are grounds to doubt this; the question is one which 
has still to be worked out. 
The critical or trying character of the period known as puberty has always been 
associated with the idea that it was dependent upon the development of the generative 
Annual Increase in Weight in Cirls. 
organs. The sexual development has, however, hardly begun, and the charts show 
that puberty more properly coincides with the demand made on the system to meet the 
increased activity of growth of the body, which is to take place before the reproductive 
function is called into action. 
•Having now obtained a typical standard of the height and. weight for each year of 
age, the question arises, How are individual cases and the statistics of the different 
countries and classes of society to be compared with this standard ? The want of a 
proper method of comparison has hindered the practical outcome of the extensive 
researches that have been made. The subject is complicated by there being three 
factors-age, height and weight. The ratio of weight to height increases with age in 
a proportion easily calculated. But children of the same age vary considerably in 
height, and one child may be equally well developed as to weight with another of the 
same age who is six inches taller. Some method, therefore, is required, whereby we 
may calculate the proportional weight to the varying height at each age. The follow- 
ing law has been deduced from an analysis of the tables :- 
Let H = height, W = weight, N = age, and introduce a fourth term, m = a 
standard number which can be readily found for each year of age. The law may now SECTION X-DISEASES OF CHILDREN. 
449 
be stated as follows: m - n varies directly as the square of the height and inversely as the 
H2 
weight, or by the formula m - n - 
The tables supply the standard H and W for each year, so the value of m can be 
H2 
readily found for each age. Then by the formula m_n = W, we can obtain the typi- 
cal weight for each inch of stature for the respective years. 
Tables HI and IV have in this way been calculated, and enable us readily to com- 
pare any sets of observations, or determine in individual cases whether the weight is 
duly proportioned to the height. 
The reliability and value of these tables can be tested by a comparison therewith of 
the statistics of the various classes of society.* The results may be stated shortly as 
follows :- 
The English statistics are divided into four classes :- 
1. The Professional Class (Town and Country). Here the heights for the several 
years exceed the standard by 1J to 2 inches, but this is accompanied by a deficiency in 
weight of from three to six pounds, the highest number occurring from the twelfth 
to the fifteenth year inclusive. 
2. The Commercial Class (Towns'). The heights do not vary from the standard more 
than a fractional part of an inch, the difference, however, being on the plus side. The 
weights, as in the former class, again show a deficiency, but to a lesser extent, viz., 
from one to four pounds. The larger number here also occurs from the thirteenth 
to the fifteenth year inclusive. 
3. The Artisan Class (Towns). Here the stature is under the standard by 1 to 1.8 
inches, but the weights are exactly proportional until after the thirteenth year. 
Thereafter they fall short by one to four pounds. 
4. The Labor Class (Country). The stature here, like the artisans in towns, is below 
the standard. The more favorable circumstances for the promotion of growth is shown 
in the constant excess of their weight over the standard, of from one to four pounds. 
The variations in these cases are instructive and interesting. What may be termed 
the advantages of life, or affluence, tends to a relative increase in height, but do not 
promote weight till after the activity of growth in height is completed. The less 
favorable circumstances which surround the laboring classes diminishes their stature, 
but influences less the increase of weight. The fall in relative weight after the 13th 
year in the town artisan class indicates the influence of occupation, as that is the age 
at which they begin their trades. 
The maximum efficiency in weight in the more favored classes, i. e., the professional 
and commercial, occurs, as has been noted, from the twelfth to the fifteenth years. In 
the latter it falls in the sixteenth year from 4.6 to 1 pound, at which it continues; in 
the former the fall is from 6} to-5 pounds only, at which it continues for the next three 
years. These facts seem to point to an educational influence or school pressure. In 
the commercial class boys leave school at about 15, and thereafter the defect diminishes, 
whereas, in the professional class education is carried on to 18, and further, and its 
influence is marked by the continuance of the depressing effect in a high degree up to 
that year. 
The American statistics at our command permit of division into two classes: the 
"American born''and the "Anglo-American." They cannot properly be compared 
with the English divisions, but the results are interesting. 
The boys "American born" accord with the standard very closely, varying only a 
small fractional part of an inch in stature throughout. In weight there is a tendency 
to be under the standard, but not to the extent of a pound, until the thirteenth year, 
Vol. 111-29 
* Trans. Brit. Ass., 1881, p. 243. 450 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
■when the increased activity of growth which then occurs is well met by an excess of 
three and four pounds in the fifteenth and sixteenth years. In the seventeenth and 
eighteenth years they are one and two pounds light. 
In the Anglo-Americans a difference is perceptible. They show from the sixth to the 
ninth years, inclusive, the same tendency to exceed in weight which is noticed in the 
English artisan class, but not the corresponding deficiency in height. After the tenth 
year this excess disappears, and thereafter they accord closely in weight with the 
standard. 
Among girls " American bom " the standard is kept to a fractional degree through- 
out. The statistics of English girls, as yet obtained, manifest the tendency to excess 
in weight in the years before 12, and the falling short after that period, which charac- 
terised the artisan class of English boys, a circumstance which points to the prob- 
ability that the statistics have chiefly been derived from the less favored class of society. 
These remarks apply to the total numbers and not to individuals of each class. 
Individual cases may in like manner be examined. Thus, a boy seven years old is 
49 inches in stature and 61 pounds in weight. By reference to table in he is found to be 
fully three inches above the standard in height, and four pounds heavier than the pro- 
portional weight, therefore, a well-developed youth. His sister, on the other hand, 
who is 12 years old, 53 inches in height and 64 pounds in weight, is two inches under 
the standard and six pounds too light for her stature. 
In the selection of youths for the public services this method of comparison will be 
found of great and ready service. The results of observations have yet to be compared 
with those of clinical experience, and enough has been given to show that the subject 
of this paper opens up a very large field for future research. 
TABLE I.-TYPICAL STANDARD OF GROWTH. 
AVERAGES OF COMBINED OBSERVATIONS OF HEIGHT AND WEIGHT OF AMERICAN 
AND BRITISH BOYS. 
Age. 
Height. 
Inches. 
Gain 
in 
Height. 
Weight. 
Pounds. 
Gain 
in 
Weight. 
Ratio. 
W 
H 
Ratio. 
H 
W 
5 
41.30 
40.49 
.98 
1.02 
6 
43.88 
2.58 
44.79 
4.30 
1.02 
.98 
7 
45.86 
1.98 
49.39 
4.60 
1.07 
.92 
8 
47.41 
1.55 
54.41 
5.02 
1.14 
.87 
9 
49.69 
2.28 
59.82 
5.41 
1.20 
.83 
10 
51.76 
2.07 
66.40 
6.58 
1.28 
.77 
11 
53.47 
1.71 
71.09 
4.69 
1.32 
.75 
12 
55.05 
1.58 
76.81 
5.72 
1.39 
.71 
13 
57 06 
2.01 
83.72 
6.91 
1.46 
.68 
14 
59.60 
2.54 
93.46 
9 74 
1.56 
.63 
15 
62.27 
2.67 
104.90 
11.44 
1.68 
.59 
16 
64.66 
2.39 
120.00 
15.10 
1.85 
.53 
17 
66.20 
1.54 
129.19 
9.19 
1.95 
.51 
18 
66.81 
.61 
134.97 
5.78 
2.02 
.42 SECTION X DISEASES OF CHILDREN. 
451 
TABLE II.-TYPICAL STANDARD OF GROWTH. 
AVERAGES OF COMBINED OBSERVATIONS OF HEIGHT AND WEIGHT OF AMERICAN AND 
BRITISH GIRLS. 
Age. 
Height. 
Inches. 
Gain 
in 
Height. 
Weight. 
Pounds. 
Gain 
in 
Weight. 
Ratio. 
W 
H 
Ratio. 
H 
W 
5 
41.05 
39.63 
.96 
1.03 
6 
42.99 
194 
42.84 
3.21 
.99 
1.00 
7 
44.98 
1.99 
47.08 
4.24 
1.03 
.96 
8 
47.09 
2.11 
52.12 
5.04 
1.10 
.90 
9 
49.05 
1.96 
56.28 
4.16 
1.14 
.87 
10 
51.19 
2.14 
62.17 
5.89 
1.21 
.82 
11 
53.26 
2 07 
68.47 
6.30 
1.28 
.77 
12 
55 77 
2.51 
77 35 
8.88 
1.38 
.72 
13 
57.96 
2.19 
87.82 
10.47 
1.51 
.65 
14 
59.87 
1.91 
97.56 
9.74 
1.62 
.61 
15 
61.01 
1.14 
105.44 
7.88 
1 72 
.57 
16 
61.67 
.66 
112.36 
6.92 
1.82 
.54 
17 
62.22 
.55 
115.21 
2.85 
1.85 
.54 
18 
62.19 
116.43 
1.22 
1.87 
TABLE III. 
STANDARD WEIGHT, IN POUNDS, FOR EACH INCH IN HEIGHT, IN BOYS FROM 6 TO 18 
H« 
YEARS OF AGE. CALCULATED BY FORMULA, rj-= W* 
' M-N 
Inches. 
Age. 
Inches. 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
40 
37 
37 
64 
64 
50 
41 
39 
39 
40 
41 
66 
66 
68 
51 
42 
41 
41 
42 
43 
43 
69 
69 
71 
52 
43 
43 
43 
44 
45 
45 
46 
72 
72 
73 
53 
44 
45 
45 
46 
47 
47 
48 
74 
74 
76 
78 
54 
45 
47 
47 
48 
49 
49 
50 
50 
77 
77 
79 
81 
55 
46 
49 
50 
51 
51 
52 
52 
80 
80 
82 
84 
89 
56 
47 
51 
52 
53 
53 
55 
55 
83 
83 
85 
87 
92 
57 
48 
53 
54 
56 
56 
57 
57 
86 
86 
88 
91 
96 
99 
58 
49 
57 
58 
58 
60 
60 
89 
89 
91 
94 
99 
102 
106 
59 
50 
59 
61 
61 
62 
62 
92 
92 
94 
97 
103 
106 
109 
60 
51 
63 
63 
65 
65 
95 
95 
98 
100 
106 
109 
113 
61 
52 
66 
66 
67 
67 
98 
101 
104 
109 
113 
116 
62 
53 
68 
68 
70 
70 
101 
104 
107 
113 
116 
120 
63 
54 
71 
71 
72 
72 
105 
107 
110 
117 
120 
124 
64 
55 
73 
75 
75 
111 
114 
120 
124 
128 
65 
56 
78 
78 
114 
117 
124 
128 
132 
66 
57 
81 
81 
118 
121 
128 
132 
136 
67 
58 
84 
.84 
121 
125 
132 
136 
140 
68 
59 
87 
128 
136 
140 
144 
69 
60 
132 
140 
144 
148 
70 
61 
136 
144 
148 
152 
71 
*M -= 
48 
49 
49 
49 
50 
50 
51 
51 
52 
52 
52 
51 
51 
51 
N = Age. 
The dark line across each column indicates the average height and weight for the 
respective years. 452 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
STANDARD WEIGHT, IN POUNDS, FOR EACH INCH IN HEIGHT, IN GIRLS FROM 5 TO 18 
YEARS OF AGE. CALCULATED BY FORMULA -r 2 = W.* 
M-N 
TABLE IV. 
Inches. 
Age. 
Inches. 
5 
6 
7 
8 
9 
10 
11 
12 
13 
14 
15 
16 
17 
18 
38 
33 
48 
39 
35 
35 
35 
60 
49 
40 
37 
37 
37 
62 
65 
50 
41 
39 
39 
39 
40 
65 
68 
51 
42 
41 
41 
41 
42 
42 
67 
71 
52 
43 
43 
43 
43 
44 
44 
44 
70 
74 
78 
53 
44 
45 
45 
45 
46 
46 
46 
73 
76 
81 
83 
54 
45 
47 
47 
47 
48 
48 
48 
75 
79 
84 
86 
55 
46 
49 
49 
50 
50 
50 
51 
78 
82 
87 
89 
92 
56 
47 
51 
51 
52 
52 
52 
53 
81 
85 
90 
92 
95 
98 
57 
48 
53 
54 
54 
54 
56 
84 
88 
93 
96 
99 
102 
102 
58 
49 
55 
57 
57 
57 
58 
87 
91 
96 
99 
102 
105 
105 
59 
50 
59 
59 
59 
61 
90 
94 
100 
102 
105 
109 
109 
60 
51 
62 
62 
62 
63 
97 
103 
106 
109 
112 
112 
61 
52 
64 
64 
64 
66 
101 
106 
109 
113 
116 
116 
62 
53 
66 
66 
68 
104 
110 
113 
116 
120 
120 
63 
54 
69 
69 
71 
107 
113 
117 
120 
124 
124 
64 
55 
72 
73 
117 
120 
124 
128 
128 
65 
56 
74 
76 
121 
124 
128 
132 
132 
66 
57 
77 
79 
128 
132 
136 
136 
67 
58 
82 
136 
140 
140 
68 
*M - 
48 
49 
50 
50 
51 
52 
52 
52 
51 
50 
50 
50 
50 
51 
NT = Age. 
The dark line across each column indicates the average height and weight for the 
respective years. 
DE L'IRRITATION CÉRÉBRALE CHEZ LES JEUNES ENFANTS, ET 
SURTOUT CHEZ LES ENFANTS À LA MAMELLE. DES DAN- 
GERS AUXQUELS ELLE EXPOSE LES BEBES. DE SA 
CURABILITÉ ET DE SON TRAITEMENT. 
ON CEREBRAL IRRITATION IN YOUNG CHILDREN, ESPECIALLY IN CHILDREN 
AT THE BREAST. THE DANGERS TO WHICH IT EXPOSES THE BABIES. 
ITS CURABILITY AND TREATMENT. 
ÜBER HIRNREIZ BEI JUNGEN KINDERN, HAUPTSÄCHLICH BEI SÄUGLINGEN. DIE GE- 
FAHREN, DENEN ER DIESELBEN AUSSETZT. SEINE HEILBARKEIT 
UND BEHANDLUNG. 
PAR LE DOCTEUR JULES SIMON. 
Médecin de l'Hôpital des Enfants, à Paris. 
Je me propose, dans la très-courte communication que j'ai l'honneur de présenter à 
la Section des maladies des enfants, d'attirer l'attention des praticiens sur un état 
névropathique spécial Virritation cérébrale des jeunes enfants et surtout des enfants à la 
mamelle qui me parait être, non seulement sous la dépendance de l'hérédité, de l'al- SECTION X-DISEASES OF CHILDREN. 
453 
coolisme, et de la syphilis des parents, mais encore sous l'empire des excitations et des 
écarts de régime et d'hygiène auxquels on abandonne les bébés. 
Cet ébranlement nerveux, qui n'est pas intermittent comme les signes d'un tempé- 
rament nerveux, qui ne s'accompagne ni de fièvre, ni de paralysie, ni de contracture 
comme dans la lésion du système nerveux, est caractérisé par une excitation permanente 
de l'encéphale, des sens, et des actions réflexes. 
Capable de saisir l'enfant dès le berceau, il prépare le terrain au développement de 
la sclérose, de la méningite, et de l'épilepsie. 
Quand elle frappe les bébés, cette irritation maladive le rend excitable par toutes 
les sensations. Le bruit, la lumière l'agitent au suprême degré. Le sommeil est léger 
fréquemment interrompu ; l'appétit capricieux, le développement lent, irrégulier, et 
les actions réflexes exagérées au point que des vomissements, des soubresauts, des 
convulsions éclamptiques se produisent au moindre prétexte. L'intelligence parait vive, 
et, chez des enfants de six mois, le visage, la mimique expriment des sentiments au- 
dessus de leur âge, mais sous coordination ensuite. 
Doué, parfois, d'une précocité effrayante, le bébé irrité cherche à traduire la 
crainte, la joie, l'affection, tout en étant animé de mouvement perpétuels. Son 
corps, ses membres s'agitent sans cesse, sans laisser à l'enfant le calme, la certitude 
du nouveau né bien équilibré. Il semble en proie à des excitations internes, per- 
pétuelles, et il subit des actions réflexes hors de proportion avec la cause apparente 
qui les a fait naître. 
Quand l'enfant a dépassé deux à trois ans, il est plus facile encore d'analyser ces 
phénomènes étranges que les gens du monde attribuent à une origine privilégiée, ou à 
l'évolution dentaire. 
L'enfant remue sans trêve en repos, le regard inquiet, le visage indifférent. Il est 
en quête de connaître tous les objets qu'il vient de toucher déjà, et de voir avec une 
sorte de curiosité, mais dont il a oublié à l'instant les caractères qu'il cherche de nou- 
veau à retenir. La mémoire est presque nulle, le langage discordant, le caractère irri- 
table, et l'intelligence qui parait vive par certains côtés, n'est capable ni d'application 
ni de développement. Aussi, même quand elle se manifeste par des signes indéniables, 
a-t-elle toujours de la tendance à s'amoindrir avec le temps. 
Cette irritation cérébrale du nouveau-né et de l'enfant plus avancé en âge peut 
apparaître dès les premiers mois de l'existence ; elle se déroule ainsi pendant plusieurs 
années avec des périodes d'accalmies ou d'aggravation, et se termine vers l'âge de cinq 
ans, ou par la guérison, ou le plus souvent par la sclérose cérébrale, l'épilepsie, ou la 
méningite. 
L'hérédité, l'alcoolisme, la syphilis des parents en sont les causes les plus fréquentes. 
Je possèdeisur cette question des documents absolument certains, mais il est une autre 
cause toute moderne, toute contemporaine que je tiens à mettre en évidence. C'est le 
déplorable élevage des enfants à la mamelle. Au lieu de les laisser dans l'isolement de 
la nourricerie, ou en fait un objet de distraction, on les excite par le bruit, le chant, les 
lumières, et quelquefois aussi par des boissons excitantes, (café, thé, spiritueux) qu'ils 
prennent directement à la table commune ou avec le lait de la nourrice mercenaire. 
L'agitation fébrile qui se répand autour du berceau de l'enfant, dans les sociétés 
modernes, se répercute dans ces cellules cérébrales, y communique une vibration con- 
tinue, et traduit un ébranlement maladif qu'il est malaisé de calmer par la suite. Le 
médecin a fort à faire quand il cherche à s'opposer à ces pratiques déplorables. Les 
efforts se heurtent aux habitudes contractées dans la lutte pour la vie. 
Son devoir est cependant d'instituer une hygiène spéciale et sévère, et un traitement 
anti-nerveux. 
Dès les premiers symptômes il faut s'appliquer à supprimer toutes les sources d'ex- 
citation ! Le bruit, la lumière, les réunions de famille, les aliments excitants. La 454 
NINTH' INTERNATIONAL MEDICAL CONGRESS. 
rie an grand air, lourd des grandes villes, du bord de la mer contribuera à ramener le 
calme dans ces cervelles irritées. 
A cette médication, on ajoutera l'emploi du bromure à la dose de 0.10 à 0.17 centi- 
gramme chez les enfants au dessous d'un an; à celle de 0.30 centigramme chez l'enfant 
d'un an ; à celle de 0.60 entre un et de deux ans. À partir de cet âge, c'est avec un 
gramme et plus qu'il faut opérer. À condition toutefois de suspendre le médicament 
au bout de trois jours, pour le reprendre trois jours après. 
Grâce à cette hygiène, et à ce traitement bromuré, aidé des laxatifs où arrêtera 
quelquefois une disposition fâcheuse à contracter des névroses, et des lésions céré- 
brales. 
En résumé, mon but a été de démontrer qu'il existe chez l'enfant, et même chez 
l'enfant à la mamelle un état névropathique qui précède les altérations du système ner- 
veux, et qui peut être souvent mis sur le compte de l'hérédité, de l'alcoolisme et de la 
syphilis, mais qui peut prendre la source dans le genre de vie de la famille moderne, et 
dans l'inobservation des lois les plus élémentaires de l'alimentation des nouveau-nés 
dont le développement régulier exige le calme, et l'absence d'excitation du cerveau, 
des sens, du système nerveux en général. 
[Abstract.] 
CEREBRAL IRRITATION IN YOUNG CHILDREN, AND ESPECIALLY 
IN INFANTS AT THE BREAST. 
BY DR. JULES SIMON, 
Physician to the Hôpital des Enfants Malades, Paris, France. 
I propose, in the very short communication which I have the honor to present tn 
the Section of Diseases of Children, to draw the attention of practitioners to a special 
neuropathic state (cerebral irritation) of young children, and particularly of infants at 
the breast, which appears to me to be not only due to heredity, alcoholism or syphilis 
of the parents, but, in a still greater degree, to be caused by nervous excitation and the 
absence of proper regimen and hygiene. 
This nervous disorder, which is not intermittent, like the symptoms of a nervous 
temperament, which is accompanied by neither fever, paralysis nor contraction, such 
as occurs in injuries of the nervous system, is characterized by permanent excitement 
of the brain, the senses and reflex actions. Commencing in the child even in early 
infancy, it prepares the way for the development of sclerosis, meningitis or epilepsy. 
When it seizes the infant, this unhealthy irritation makes it excitable to all sensations ; 
noise and light agitate it to a supreme degree ; the sleep is light and frequently inter- 
rupted ; the appetite is capricious ; the development slow and irregular, and reflex 
actions are exaggerated to the point of vomiting, of subsu] tus, of eclamptic convulsions. 
These reflex actions are produced by the slightest exciting causes. The intelligence 
seems active, and in infants of six months the face has the expression of sentiments 
beyond its age, but without coordination. In short, endowed sometimes with an SECTION X DISEASES OF CHILDREN. 
455 
alarming precocity, the excited infant tries to express its fear, its joy, its affection, and 
its endeavor is attended by perpetual movement. The body and limbs are agitated 
without ceasing, not allowing the infant the rest and calmness which characterize the 
healthy equilibrium of the new-born. It seems a prey to extreme and constant excite- 
ment, and suffers reflex action out of proportion to the apparent cause producing it. 
When the child has passed beyond the second or third year, it is more easy to 
analyze these strange phenomena, which the laity generally attribute to a special origin 
(origine privilégiée) or to dental irritation. The child moves without respite in sleep ; 
the look is inquiet, the countenance indifferent. It is eager to investigate the objects 
which it has already handled, and views them with a sort of curiosity, but forgets their 
characters in the instant that it seeks for something new. The memory is almost nil, 
the language discördant, the character irritable, and the intelligence, which seems bright 
in certain directions, is capable neither of application nor development. Even when 
it manifests itself by undeniable signs, it always has a tendency to grow less by time. 
This cerebral irritation of early life may appear in the first months of existence ; it 
can also develop itself during several years, with periods of arrest and exacerbation, 
and it terminates toward the age of five years in recovery, or, more often, by cerebral 
sclerosis, epilepsy or meningitis. Heredity, alcoholism and syphilis of parents are the 
most common causes. I possess on this point statistics absolutely certain ; but there is 
another cause, entirely recent, entirely cotemporaneous with the child, which I desire 
to notice. It is the deplorable management of children at the breast. Instead of 
leaving them in the quietude of the nursery, they are distracted and excited by loud 
noises, as singing, bright lights, and sometimes by exciting drinks, as tea, coffee and 
spirits, administered undiluted or mixed with the milk of the nurse. The feverish 
excitement which surrounds the cradle of the infant in modern society reflects itself in 
the cerebral cells, produces a continuous vibration, and causes an unhealthy disturb- 
ance, which, in the end, is with difficulty overcome. The physician has much to do 
when he endeavors to oppose these deplorable practices. His efforts are opposed to 
habits contracted during the life-work of the nurse. It is his duty, nevertheless, to 
secure a special and strict hygiene and a treatment anti-nervous. From the first symp- 
toms it is necessary to endeavor to suppress all the sources of excitement-noise, light, 
family gatherings and stimulating nutriment. Life in the open air, at a distance from 
the great cities, at the seashore, contributes to restore tranquillity to the irritated brain. 
To this treatment may be added the use of bromides, in the dose of 10 to 15 centi- 
grammes (1| to 2| grains) for a child under one year, 30 centigrammes (4| grains) for 
a child of one year, and 60 centigrammes (9 grains) for a child between the ages of 
one and two years. For children above this age we may prescribe a gramme (15 grains) 
or more, on condition always that the medicine be suspended after three days, to be 
resumed three days subsequently. 
Thanks to this hygiene and to the bromide treatment, aided by laxatives, we are 
enabled, sometimes, to check the dangerous predisposition to contract the neuroses and 
cerebral lesions. 
To recapitulate : my object has been to show that there exists in the child, and even 
in the infant at the breast, a nervous state, which precedes anatomical alterations in 
the nervous system, and which can often be attributed to heredity, alcoholism or to 
syphilis, but which may also originate in the mode of life of modern society and in dis- 
regard of the most elementary laws relating to the nutrition of the infant, whose normal 
development requires quietude and the absence of excitement of the brain, the senses and 
the general-nervous system. 
DISCUSSION. 
Dr. S. H. Charlton, of Indiana, said :-Although agreeing with the opinion 
of the distinguished French physician whose paper we have listened to, that cerebral 456 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
irritation in the infant may result from heredity, particularly from alcoholism or 
syphilis in the parent, I am of opinion that the anti-hygienic conditions which sur- 
round the child are the common exciting causes. An indigestible and irritating diet, 
prolonged atmospheric heat, noise and excitement, the lack of sufficient sleep, may 
be mentioned among the causes which disturb the nervous system and produce cere- 
bral irritation, even when there is no history of syphilis or alcoholism in the parents. 
According to my observations, cerebral irritation of the infant is more common in 
midsummer, when the air is impure from the presence of marsh miasm and noxious 
vapors, than at other seasons of the year. 
Remarks by the President.-The paper by M. Simon, to which we have 
listened, relates to a matter of great importance, and one which is not understood by 
a large proportion of experienced physicians. That the state which the writer desig- 
nates cerebral irritation is common in the infant all will admit. Fretful, wakeful 
infants, with limbs constantly in motion when not asleep, tremulous and excited by 
sudden noises or the approach of a stranger, having sudden jerking or twitching of 
the muscles, premonitory of eclampsia, from slight causes-such infants are often met 
in the American household. Frequently, indeed, in such infants eclampsia occurs 
from slight exciting causes. The old explanation of the etiology of these nervous 
symptoms, that they are due to dentition or the presence of worms, though it may 
satisfy the mother or nurse, has been long discarded by intelligent physicians. The 
gum lancet and vermifuges do harm to the great majority of these infants, increasing 
the cerebral excitement, and they are no longer employed by intelligent physicians. 
I accept M. Simon's opinion, that the cause of the cerebral irritation may be inherited. 
I think that it may sometimes be traced back to alcoholism, syphilis, privations, 
great mental worriment or excitement, or irregularities in the parents; but more 
frequently the cause of the cerebral excitement exists in the present bad management 
of the infant. The habits of modern society interfere with the necessary quietude 
of the nursery, and irregularities in the nursing or feeding or sleep are quite sufficient 
to cause cerebral irritation in the delicate organism of the infant. 
The fact, mentioned by M. Simon, that cerebral irritation in the infant, attended 
at first by no structural lesions, may, if it continue, end in grave central disease, as 
sclerosis or meningitis, should be known in every household. For many years, when 
called to a patient exhibiting the symptoms so clearly and forcibly described by JM. 
Simon, I have been in the habit of prescribing one of the bromides, usually that of 
potassium, and I am sure that I have averted many times, by the use of this agent, 
eclampsia, if not more serious disease. In all those cases of cerebral excitement or 
irritation, the bromide, with hygienic measures, has seemed to me to be the sovereign 
remedy. It will relieve cerebral irritation, when not dependent on organic disease, 
as quickly and surely as quinine relieves the diseases due to marsh miasm, but it is 
occasionally best to use, in addition, cool lotions to the head and a warm foot bath. 
It has been my practice to prescribe two to three grains of the bromide of potassium 
to an infant of six months, and four grains to one of twelve months, evSry two to 
four hours, until the symptoms abated. The larger dose employed by M. Simon is 
to be noted, but I presume he does not administer it so often. His recommendation 
to employ it in periods of three days, with intervals of three days, is, I presume, to 
avoid bromism. If the views expressed by M. Simon were widely disseminated, and 
the measures recommended by him generally followed, the nervous diseases in early 
life would certainly be less frequent. SECTION X-DISEASES OF CHILDREN. 
457 
LA DILATATION PRÉPUTIALE. L'IGNIPUNCTURE DES 
AMYGDALES. 
PREPUTIAL DILATATION. IGNIPUNCTURE OF TUE TONSILS. 
DIE DEHNUNG DER VORHAUT. DIE IGNIPUNKTUR DER MANDELN. 
PAR LE DOCTEUR DE SAINT-GERMAIN. 
Chirurgien de l'Hôpital des Enfants, Paris, France. 
Si l'on, doit accorder un grand mérite au chirurgien qui invente une opération, on 
ne saurait refuser un très-petit mérite à celui qui en supprime deux du manuel chirurgi- 
cal pour leur substituer deux procédés moins dangereux, tout aussi sûrs et d'une exécu- 
tion plus facile. 
C'est à ce titre que j'ai l'honnenr de présenter au Congrès l'exposé de ma pratique 
pour ce qui touche à la dilatation préputiale et à l'ignipuncture des amygdales. 
La circoncision m'ayant parfois donné des accidents tels que hémorrhagie difficile à 
arrêter, gangrène partielle, diphthérie de la plaie, j'y ai à peu près complètement 
renoncé, et la réserve pour les cas vie la dilatation est impraticable, (ces cas sont dans la 
proportion de un sur 300.) 
Je n'emploie que la dilatation. Cette opération imaginée par Nélaton, reprise depuis 
par la plupart des chirurgiens consiste dans l'introduction, dans l'orifice préputial 
d'une dilatation à deux, et non à trois branches comme le pratiquait Nélaton, et dans la 
divulsion graduelle lente de l'orifice. 
Cette opération qui se complète par le décollement des adhérences à l'aide de la 
sonde canelée et par le massage quotidien obtenu par le décalottement du gland et son 
recalottement m'a donné les résultats les plus satisfaisants et les plus durables. Quant 
à l'ignipuncture des amygdales, elle est destinée à remplacer avec avantage l'amygda- 
lotomie. Ces accidents de l'amygdalotomie peuvent être mortels, et pour ne citer que 
l'hémorrhagie incoercible, l'envahissement de la plaie par la diphthérie, on voit que 
cette opération n'est pas aussi anodine qu'on pourrait le croire. 
Krishaber avait déjà essayé de lui substituer la cautérisation à l'aide du thermo- 
cautère ; mais son mode de procédé tout superficiel éternisait, pour ainsi dire, la durée 
du traitement. 
Aussi, ai-je imaginé d'introduire à l'aide du bâillon de Smith modifié, le thermo- 
cautère en forme de chrochet pointu, et l'enfermant dans chaque tonsille à un centi- 
mètre environ. 
Cette opération répétée tous les huit jours, comprend de deux à quatre séances ; au 
bout de ce temps on voit les tonsilles évidées, ratatinées ne plus présenter qu'un petit 
moignon insignifiant. Je n'ai jamais eu d'accidents par ce procédé, et je ne compte 
que des succès. Si, en conséquence, on considère la fréquence des deux opérations sus- 
dites, ainsi que le nombre de guérisons obtenues, sans que le malade ait couru le 
moindre danger, on est en droit de se demander si la double substitution adoptée n'est 
pas un progrès chirurgical appréciable. 458 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
[Abstract.] 
PREPUTIAL DILATATION. IGNIPUNCTURE OF THE TONSILS. 
DOCTOR DE SAINT-GERMAIN, 
Surgeon to the Hôpital des Enfants, Paris, France. 
Since we accord great merit to a surgeon who invents an operation, we cannot refuse 
a little merit to him who substitutes for two surgical operations, two methods of treat- 
ment less dangerous, quite as sure, and more easy of performance. 
In virtue of this right, I have the honor to present to the Congress an account of 
my practice relating to preputial dilatation, and ignipuncture of the tonsils. 
PREPUTIAL DILATATION. 
Since circumcision is sometimes followed by accidents, such as hemorrhage, diffi- 
cult to control, partial gangrene, diphtheria of the wound, I have almost entirely given 
it up, and reserve it for those casés in which dilatation is impracticable (these cases 
are in the proportion of one in 300). 
I employ only dilatation. This operation, devised by Nélaton, and since adopted 
by the majority of surgeons, consists in the introduction into the preputial orifice of a 
dilator of two branches, and not three, as practiced by Nélaton, and in the gradual and 
slow dilatation of the orifice. 
This operation, which is completed by separating the adhesions by the aid of a 
grooved director, and by daily movement of the prepuce, by which the glans is alternately 
uncovered and covered, has given me the most satisfactory and durable results. 
IGNIPUNCTURE OF THE TONSILS. 
As to ignipuncture of the tonsils, it is destined to replace with advantage tonsil- 
lotomy. The accidents of tonsillotomy may be fatal. Not to cite uncontrollable hemor- 
rhage, the occasional invasion of the wound by diphtheria makes it clear that the 
operation is not so harmless as we may have thought. 
Krishaber had already endeavored to substitute in place of this operation cauter- 
ization by the aid of the thermo-cautery, but his mode of proceeding, too superfi- 
cial, rendered his treatment, so to speak, perpetual. Therefore, it occurred to me to 
introduce, by the aid of the modified Smith's gag, the thermo-cautery in the shape of 
a pointed hook, and thrust into each tonsil to the depth of about a centimetre. 
This operation, repeated every eight days, requires from two to four sittings. At 
the end of this time the tonsil will be found evacuated and shriveled up, presenting 
only a little insignificant stump. I have never had any accident from this process, and 
I only enumerate successes. 
If, consequently, one considers the frequency of the two operations mentioned 
above, and also the number of cures obtained, without the patient incurring the slightest 
danger, he has the right to ask if the double substitution adopted is not an appreciable 
surgical improvement. 
DISCUSSION. 
Remarks by the President.-Of two operations for the relief of the same 
ailment, the one that is attended with less pain, less mutilation of parts, less liability to 
accidents or complications is, of course, to be preferred if the result be equally good. SECTION X-DISEASES OF CHILDREN. 
459 
That circumcision has resulted disastrously in not a few instances is well known. 
Ordinarily a simple and safe operation, it may result badly through carelessness or 
untoward circumstances. In a recent number of the British Medical Journal, Mr. 
Phillips states that a child of thirteen months was circumcised ; the same instru- 
ments being used that were employed a few hours previously for tracheotomy in a 
case of diphtheritic croup. Four days later the pseudo-membrane appeared 
upon the prepuce, producing much infiltration and oedema, and retention of urine. 
In the Liverpool Med.-Chir. Jour., January, 1887, Dr. E. Zula Greves relates that 
a boy, who had been circumcised for phimosis, was admitted into the Liverpool 
Infirmary with an unhealthy-looking prepuce that had not healed after the opera- 
tion. Weak and anæmic at the time of admission, he continued to sink, and died of 
cardiac failure. The wound and subjacent tissues were infiltrated with micrococci, 
like those in the pharyngeal pseudo-membrane. The fact that hemorrhage, diph- 
theria, and other forms of blood contamination, may result from circumcision, even 
if it be through carelessness, constitutes an argument against the operation, as Saint- 
Germain has said. An important part of the treatment of phimosis, without which 
it is incomplete and unsuccessful, is the removal of the preputial mucous mem- 
brane from the surface of the glans, and the washing away of the smegma, which, 
acting us a foreign substance, produces a low grade of inflammation, a balanitis. 
The removal of this smegma and inflammation is essential to recovery, and, accord- 
ing to my observations, the agglutinated mucous surfaces can be more readily sepa- 
rated if the foreskin remain attached to the mucous layer underneath; in other 
words, if dilatation be practiced rather than circumcision. 
The foreskin in its normal state is very distensible. It can be slowly stretched at 
one or two sittings, so as to slip over the glans, even when the orifice was previously a 
pinhole. Saint-Germain says that circumcision is not required for phimosis in more 
than one case in three hundred; dilatation being employed instead. Our experi- 
ences in the Out-door Department at Bellevue correspond with his, although we 
have not preserved statistics. I have employed for dilating the prepuce, with the 
best results, the long, slender forceps used for removing foreign substances from the 
ear. When closed, these forceps are blunt-pointed and scarcely larger than a probe. 
The foreskin being drawn forward from the glans and the point of the forceps 
pressed into the orifice, and the child firmly held in a horizontal position, dilatation can 
be accomplished in a few minutes, without apparently much pain, by gradually and 
slowly separating the blades. When the dilatation is sufficient, the next step is the 
retraction of the prepuce, which can be best accomplished by the fingers, dry, not 
oiled ; but the two preputial surfaces are so agglutinated that I have in most instances 
employed a probe, grooved director, or similar instrument, to facilitate their separation. 
Dr. Holgate, sixteen years physician to the class of children's diseases in the 
Out-door Department at Bellevue, states that he has treated hundreds of children 
with narrow prepuce and preputial adhesions, in which symptoms were so pro- 
nounced that surgical interference was required, and in no instance has he found it 
necessary to circumcise or use the knife, even when the entire prepuce was adherent. 
He uses no instrument but the probe. The patient being firmly held in a reclining 
position, the prepuce is pressed backward by the thumb and forefinger of each hand 
until the glans begins to protrude. The adhesions are then separated by the blunt 
end of an ordinary silver probe, which is carried in a circular direction around the 
glans. By the backward pressure of the foreskin the glans protrudes more and more 
and is soon uncovered. The parts are then oiled, the smegma removed, and the 
foreskin returned. Every day or second day during the ensuing week the glans is 460 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
uncovered, oiled, and the foreskin replaced. The first operation, Dr. Holgate says, 
does not occupy more than three minutes. We have, therefore, in the children's 
class in the out-door department pursued essentially the same treatment of phimosis 
as that recommended by Saint-Germain. 
Dr. A. D. Rockwell, of New York, the celebrated electro-therapeutist, has 
kindly consented to add the following remarks on Saint-Germain's paper relating to 
ignipuncture of the tonsils:- 
The author's description of his method of ignipuncture of the tonsils is too 
brief and vague to render possible any satisfactory discussion of the subject. 
I take it, however, that the idea intended to be conveyed is, that the two 
hooks (platinum, of course, although the kind is not mentioned), after having been 
thrust into both tonsils, are attached to a galvano-cautery apparatus, and then heated 
to a white heat. From personal experience I cannot speak of this method in its 
application to the tonsils, but only as I have attempted it in small external growths, 
and from the common knowledge that we all possess as to the destructive powers of 
heat. Its action upon these various external growths, vascular and non-vascular, in 
causing them to wither and shrivel away, renders the statement of Saint-Germain 
in regard to its effects upon enlarged tonsils sufficiently plausible, and coming from 
such a reliable source, the operation ought to be well tested. Especially is this the 
case when we consider certain positive advantages that the galvano-cautery possesses 
over the knife, in that it saves all, or nearly all, hemorrhage, leaving but little pain 
after the operation, besides being less liable to be followed by pyæmia. 
We might expect that ordinary electro-puncture would prove of sendee in 
reducing enlarged tonsils, not only through the actual disintegration of tissue that 
takes place, but through that well-known process of absorption that is set up and 
continues for a long time after the cessation of the electrolytic action. It is doubt- 
ful, however, whether children could be induced to tolerate its use, since it is very 
painful, and each seance would have to be five or six minutes in duration in order to 
obtain effects. 
Ignipuncture, on the contrary, is almost instantaneous in its action, and causes 
much less pain. 
If further experience is favorable to the feasibility of the operation so far as it 
relates to the readiness with which it can be performed on children, and its efficiency 
in reducing the hypertrophied tonsils, the two advantages it possesses over tonsillot- 
omy, viz., freedom from possible hemorrhage and far better healing, are of no small 
importance. 
Remarks by Dr. Robert Newman.-I have had some experience in treating 
enlarged tonsils by thermo-cautery, and the result has been satisfactory. Success in 
treating the hypertrophied prostate by this agent led to the belief that enlargement 
of the tonsil might be reduced by the same treatment, since there is similarity in 
the structure of the two organs. The approval of so high an authority as Saint- 
Germain increases the confidence in the operation. My experience has shown that a 
child of a tender age will go through the operation without flinching and without 
complaint of pain, and he opens his mouth and submits to subsequent operations 
with more confidence than at first. 
The instrument used by me has the shape of a catheter, of smooth, polished metal, 
with a short curve. At the end beyond the curve is a fenestrum containing the 
platinum wire to be heated. The other straight end of the instrument, forming the 
handle, contains two distinct metal pins for connection with the electrode cords of SECTION X DISEASES OF CHILDREN. 
461 
the galvano-cautery battery. The current breaker is attached to the handle, 
and by pressing it down by the finger electricity is evolved and the burner 
instantaneously heated, giving a sudden light which illuminates the fauces. A 
white film forms upon the tonsil. With this superficial cauterization the operation 
may be repeated in two or three days. In one case I did it on the following day. 
With the deeper cauterization performed by the instrument of Saint-Germain, of 
course longer intervals between the operations are required. The deeper and more 
effective burning of the tonsil by Saint-Germain would require intervals of a week. 
This treatment diminishes the tonsils until they return to their normal size, without, 
so far as I know, any ill effect in any case in which it has been practiced. My 
experience leads me to agree fully with the opinion of Saint-Germain. 
ON THE DELETERIOUS RESULTS OF A NARROW PREPUCE AND 
PREPUTIAL ADHESIONS. 
SUR LES RESULTATS DÉLÉTÈRES D'UN PRÉPUCE ETROIT ET DES ADHÉ- 
RENCES PREPUTIALES. 
DIE SCHÄDLICHEN FOLGEN EINER ENGEN VORHAUT UND DER PRÄPUTIALEN 
ADHÄSIONEN. 
LEWIS A. SAYRE, M.D., 
Professor of Orthopædic Surgery in Bellevue Hospital Medical College, New York. 
In 1870 I published my first paper on this subject in the Transactions of the Amer- 
ican Medical Association, under the title of " Partial Paralysis from Reflex Irritation 
Caused by Congenital Phimosis and Adherent Prepuce, ' ' illustrated by cases. 
This paper produced a marked impression on the profession, and was extensively 
commented on by various medical journals both at home and abroad. 
D. Campbell Black, M.D., F.R.C.S., Edinburgh, in his very valuable work "On the 
Functional Diseases of the Renal, Urinary and Reproductive Organs," published in 
1872, quotes very extensively from this paper, and concludes by saying, on page 213: 
" I offer no apology for thus giving considerable prominence to the foregoing cases. I 
attach to them immense importance as disclosing, possibly, a frequent source of infan- 
tile paralysis, and the numerous indications of nervous irritability in childhood, while, 
as far as known to me, Dr. Sayre's cases are unique in medical literature. ' ' 
I, therefore, feel that I can justly claim to have been the first to draw the attention 
of the profession to this important subject.* 
In 1875 I published a more elaborate paper on the same subject in the Transactions 
of the American Medical Association for that year, entitled, ' ' Spinal Anæmia, with 
Partial Paralysis and Want of Coordination, from Irritation of the Genital Organs." 
This paper was also illustrated by a number of cases which had been relieved of 
* I have recently been informed that Mr. Stanley published on this subject in the Medico- 
Chirurgical Transactions, Vol. xvm, p. 260, 1833. But on referring to his paper I find he reports 
some cases of reflex paralysis from abscess of kidney, which had been supposed to depend on dis- 
ease of the vertebrae and spinal cord, but which were found healthy on post-mortem examination, 
and I find no ease reported from congenital phimosis. 462 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
their paralysis, and various other nervous symptoms, including want of coordinating 
power, etc., by simply removing the constriction from the glans penis, and the retained 
and concrete smegma from behind the corona, and so arranging the prepuce that it could 
glide easily to and fro over the glans without any constriction, thus permitting the 
parts to be kept perfectly clean, and thereby removing one great source of irritation. 
In this proper arrangement of the prepuce, it became necessary in some cases to per- 
form circumcision, or an actual removal of a small portion of the prepuce, and in some 
cases to dissect it from its attachments to the glans, which were not simply by aggluti- 
nation, which is the normal condition, but the attachments were by actual adhesion, an 
abnormal condition, and entirely different from the normal agglutination. Unless there 
is a great redundancy of the prepuce with constriction of the elongation there is no 
occasion to remove any of the tissue; but in the great majority of the cases the object 
to be obtained can be easily accomplished by simply passing a grooved director into the 
narrow orifice of the prepuce, gliding it between it and the glans, with the groove 
toward the prepuce, and pressing it with the thumb and finger as far back as possible, 
glide into the groove a pointed curved bistoury, and divide the contracted tissue suffi- 
ciently to enable you to tear it back and uncover the glans; then a slight nick with the 
scissors or bistoury, through the thickened fold of the edge of the frenum ; after 
which you can, with the thumbs and forefingers of the two hands, easily tear down 
the frenum and other adhesions so as to expose the entire glans, and in the sulcus 
behind the corona will often be found a hardened smegma, sometimes containing chalky 
concretions, which have been one of the sources of the irritation, and which can 
be readily wiped away; the whole operation can thus be completed without the sacrifice 
of any tissue, and with very little loss of blood. 
In some cases it may be advisable to take a stitch on either side of the incision, 
between the integument and mucous membrane; in others no stitching is required; but 
in either case the foreskin is carried well back, uncovering the glans, and a little styptic 
cotton, or a rag wet in persulphate of iron, is wound around the wound and left in situ 
for eight or ten days, when the wound will be entirely healed, and the organ in a nor- 
mal condition, with the glans partially covered with its prepuce, but which can be 
easily uncovered, as it should be, and not mutilated and disfigured, as I have frequently 
seen it, by a too free removal of the prepuce, thus leaving the glans entirely unpro- 
tected. 
While, therefore, I may be responsible for bringing this subject so prominently 
before the profession, I wish to raise my voice in protest against this unjustifiable muti- 
lation, as well as against the indiscriminate performance of the operation in cases where 
it can be of no avail. 
This unnecessary mutilation in some cases, and the unwise and injudicious promises 
of great relief in others, where it can do no good, is likely to bring the operation into 
disrepute, and thus deprive the cases that might be benefited by its performance of 
receiving that relief which in many cases it certainly will afford. 
While some over-zealous advocates have recommended and performed the operation 
of circumcision in all cases of infantile paralysis, even those dependent on some central 
lesion of either the brain or spinal cord, where it can do no good, others have gone to 
the opposite extreme, and deny the existence of a paralysis, or even muscular incoor- 
dination from reflex genital irritation. 
The object of this paper is to harmonize these two extremes, and show that there 
are some cases of very anomalous and extraordinary nervous manifestations entirely 
dependent upon some irritation of the genital organs, in which an operation is not only 
justifiable, but absolutely demanded, and that in many instances the relief from all the 
strange symptoms has not only been immediate, but permanent after the operation, 
without any other medical or surgical treatment. SECTION X DISEASES OF CHILDREN. 
463 
While I am convinced that the observation just made is absolutely correct, I am also 
equally well convinced that any attempt to relieve a nervous disturbance by an opera- 
tion on the genital organs, when the cause of that nervous difficulty was some organic 
change in the brain or spinal cord, would result in no benefit whatever, and in such 
cases an operation is unjustifiable and should be condemned. 
I shall not in this paper refer to any of the numerous cases that have been under 
my own personal observation and treatment for the past 15 years, although they have 
been numerous and many of them exceedingly interesting, fully corroborating all the 
statements made in my two original papers, but I shall take only a few of the cases for 
illustration from the numerous reports that have been made to me by various physicians 
and surgeons in different parts of the country, thus showing that other competent 
observers have arrived at similar conclusions with myself, and have had the same satis- 
factory results in practice, when they have operated upon properly selected cases. 
The first case is from the distinguished Professor of Surgery in Jefferson Medical 
College, and is a beautiful illustration of the rapid improvement that sometimes 
occurs :- 
1112 Walnut St., Philadelphia, February 7th, 1882. 
Dear Sayre :- 
The case to which Lewis* heard me allude in my clinic last December, was that of a child 
two years of age, whose gait simulated that of locomotor ataxia, being uncertain, precipitate, 
irregular and jerking. There was no paralysis of any muscles ; but the trouble seemed to be due 
to defective coordinating power over the muscles. On the second day after removing a con- 
tracted and adherent prepuce, the trouble had entirely disappeared and I found my little patient 
running about the room. Yours truly, 
S. W. Gross. 
The following case from Dr. A. R. Mott, Jr., Resident Physician of Randall's 
Island, is a good illustration of the injurious effects upon the nervous system by 
girdling or strangulation of the glans penis, and the immediate relief afforded by the 
removal of the same. 
The results are the same upon the nervous system whether the partial strangulation 
is from an adherent and contracted prepuce, or from a string tied around the organ. 
Randall's Island, January 18th, 1880. 
Dear Doctor :- 
I have been unable to find the report of the case of which I spoke to you on Friday, but 
know it was made in the Hospital Gazette of January, 1879. 
The following, however, is an outline of the history, taken from the case book of the Work- 
house Hospital on Blackwell's Island, of which I was at the time House Physician. 
Very respectfully, A. R. Mott, Jr., m.d. 
To Lewis A. Sayre. 
Case.-Ino English, age forty-six, native of England, widower, clerk; admitted to Work- 
house Hospital (B. I.) Dec. 23d, 1878. Patient had been at work for a week, as a prisoner. On 
the 23d was noticed to be restless and uneasy, and finally, in the evening, he fell from his bunk in 
a fit. During the next forty-eight hours he had several (eight or nine) convulsions, and during 
the intervals lay in a semi-comatose condition, showing no consciousness except to stir a limb 
when pinched. Pulse 120, temperature 101J°, respiration 18-swallowed nothing and passed 
fæces in bed. Continued in this condition to evening of December 25th (temperature having 
fallen to 100), when a string was discovered passed twice around the penis behind the corona and 
tied, the long prepuce serving to conceal it from observation. While not sufficiently tight to 
occlude the urethral canal, still a firm indurated band remained after the string was cut, and did 
not disappear for four or five days. 
* My son, who had been present at his lecture. 464 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Within one hour after the removal of the string the man sat up and asked for milk, and from 
this time remained perfectly well (was under observation for three months). 
He declared that he remembered nothing that had taken place during the past three days- 
had never had "fits," denied venereal, was moderately addicted to drink, but had led a "virtu- 
ous life since the death of his wife, two years before." 
Though seemingly healthy, there was nothing to indicate incorruptible virtue or veracity. 
The following case from Dr. James S. Green, a very distinguished physician of 
Elizabeth, N. J., is exceedingly interesting as showing how rapidly in some instances 
cases of almost complete paralysis are at once restored to nearly full muscular power. 
342 Union Avenue, Elizabeth, New Jersey. 
My Dear Doctor :-Of a number of cases of reflex paralysis upon which I have operated and 
performed circumcision, I desire to send you the account of one demonstrating remarkably the 
rapid curative effect of the operation. Some time in April last a boy, fourteen years of age, was 
brought to me, supposed by his friends to be suffering from chorea. 
There was intense hyperæsthesia of the skin of the whole body, very marked want of coordi- 
nation of motion in the arms and hands and great difficulty in walking. 
The youth was so uncertain in his gait and had fallen so frequently, that he was afraid to 
attempt the act alone. He had been suffering in this way for three years, becoming gradually 
worse, and was mentally below the average of boys of his age. 
Having taken medicine in large quantity and sugar of milk adulterated infinitesimally for 
a long while, his attendants were surprised, after I examined his penis, with my opinion that 
circumcision would cure him. The operation was performed that afternoon ; the next morning 
the boy was relieved of his hyperæsthesia, and in forty-eight hours he recovered entirely the use 
of his limbs. 
He is now at school, which he had not been able to attend in three years, and was so altered 
in appearance when I met him on the street last week that I scarcely knew him. I have the 
notes of a number of other similar cases, less striking in their features and rapidity of cure, 
but all demonstrating the -.orrectness of the views you hold of the pathology of the disease. 
Very truly yours, 
Dr. Lewis A. Sayre. James S. Green. 
The next case is one of paralysis, and reported to me by Dr. Wirthington, of Liver- 
more, Pa. 
PARALYSIS FROM PHIMOSIS. 
Livermore, Pa., Dec. 19th, 1881. 
Dr. Lewis Sayre :-I have often thought of giving you the history of a case of paralysis 
from congenital phimosis, being a parallel to your " Pee-Pee Case " (page 14).* 
After reaching the house I found a beautiful boy (except he looked pale and worn out) of 
whom it was said he never was sick. 
He was three years old and had been paralyzed in his lower extremities for six months pre- 
vious to my seeing him. The doctor who had attended him had used all the ordinary drugs 
given in such cases, and in full accord with his diagnosis. Meeting the father of the boy one 
day, he asked me for an opinion as to the cure of the child. Of course he had stated the fact of 
his boy being paralyzed. Not feeling at liberty to venture an Opinion, I was asked to see him. 
The " Pee-Pee Case " made it an easy matter to diagnosticate, and I told the father, accordingly, that 
his child could be cured, and that he would require no medicine.. After the parents and grand- 
mother had held their consultation, I was called to take the case. The next day, October 1st, 
1878, I operated on the boy, after first putting him fully under the influence of ether. 
The prepuce was adherent almost all the way around the glans penis. 
Behind the corona was a solid cake of sebaceous matter. I never gave a single drop of medi- 
cine, and the case made a happy and rapid recovery. Before the sore was completely well, all 
symptoms of paralysis had disappeared. I am respectfully yours, 
F. J. Wirthington, m. d. 
* Referring to case reported in my Lectures on Orthopædic Surgery. SECTION X-DISEASES OF CHILDREN. 
465 
As I was anxious to know the ultimate result in this case, I wrote to the Doctor in 
about two months, and received the following reply :- 
Livermore, Pa., February, 24th, 1882. 
Dr. L. A. Sayre:- 
Dear Sir:-I have given you the history of that child so far as I know, except one fact ; the 
father tells me to-day that when the child was born he was considered the biggest and finest boy 
that had been born in the community for a long time. At the age of about two years he began 
to be contrary, fretful and peevish, etc., and would fall down without the slightest cause. This state 
of things went on for some time, until an M. D. was called in, who told them their child was para- 
lyzed, and treated him with the usual nerve tonics and with electricity. Notwithstanding all 
this, the boy went steadily down, and the paralysis continued until I saw him, October 1st, 1878, 
when he was unable to walk. He was pale, lean and anæmic. The doctor who had examined 
him could find nothing which he thought caused the paralysis. I operated on this boy October 
1st, 1877, and before the wound that I had made was healed, my little paralyzed patient could 
walk. He can walk, and has run and jumped ever since. He is hearty, and is the very picture 
of health. 
I believe he began to improve as soon as he was operated upon, from the fact of his having 
passed his water in a round, full stream, a thing he had not done for months. It dribbled away, 
while he cried all the time. 
He never took a particle of medicine, and has not to this day, February 24th, 1882. He is 
well, and has never had a sign of paralysis since. 
Very respectfully yours, 
F. J. WlRTHINGTON. 
The following case from Dr. Leech, of Indiana, is interesting as illustrating the 
various nervous disturbances that can be caused by genital irritation, and the imme- 
diate relief afforded by a proper operation. 
LEECH'S case of phimosis. 
Attica, Fountain Co., Ind., August 31st, 1875. 
Dear Doctor :- 
I send you the following report of a case, as you requested the members of the American Med- 
ical Association to do :- % 
Mr. John Maguire and wife, of our town, have but one child, a boy of fourteen months, who 
has been the terror of all that part of town for six months, as he cried constantly, except when 
asleep or nursed by his mother. He would lay perfectly still and squall, not showing any dis- 
position to sit up, nor did he like to be raised up. He was very nervous, and would have times 
when his limbs would be rigid. This state of things grew worse until Wednesday last, August 
25th, when the family physician was called in, and found the child with fever and suffering from 
great nervous excitement. He pronounced it a case of remittent fever, and gave medicine 
accordingly, but to no purpose, as the fever and excitement increased, and the child had spasms 
frequently, and particularly when his bladder needed emptying. At that time the child would 
strain and cry, giving evidence of great suffering, and had a tendency to prolapse of rectum. It 
would have several spasms at these times, which would come on rapidly, and they grew more 
severe at each succeeding time. Late Saturday night, August 28th, in the absence of the 
family physician, I saw the child, and found paralysis of the lower half of the body, not very 
marked, but sufficiently to be easily diagnosticated, and spinal irritation. I at once examined 
the penis, hoping to find a case of phimosis, and, sure enough, I did. I had the family physi- 
cian called as soon as possible, and before leaving the house that night I introduced a small 
groove director into the prepuce and laid it open with a bistoury. This exposed the glans penis 
enclosed in a sheath of mucous membrane, the latter agglutinated to the gland so tightly that I 
had to use a sharp instrument to get under it, and even after I got a place started, I could hardly 
separate the two. I persevered, and finally exposed behind the corona glandis a roll of sebaceous 
matter, of a cheesy consistence and about the size of a cotton shoe string, and extending almost 
around the penis. I removed this, and after making a free incision of the deep mucous mem- 
Vol. 111-30 466 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
brane, I washed away the remaining débris and applied water dressings, and left the child in a 
few minutes almost asleep, not nearly so nervous, and seemingly in a condition of general well 
feeling. I used no internal remedies, and now, three days later, the child has made marked im- 
provement, and bids fair to make a rapid and complete recovery. The glans, while in the grasp 
of the mucous membrane, was about one-third its natural size, and I think the contracted scar 
tissue, the result of inflammation, was the cause of the whole trouble. 
If you desire, will report the progress of the case. 
Very truly yours, 
Dr. L. A. Sayre. T. F. Leech, m.d. 
Attica, Fountain Co., Ind., December 1st, 1875. 
Dear Doctor:- 
The boy I wrote you about in August last has remained perfectly well ever since the opera- 
tion. Has had no spasms or other nervous disturbance, and runs and jumps as active as any boy 
of his age. Very truly yours, 
T. F. Leech, m.d.* 
The following interesting case of phimosis, with reflex effects, chorea, etc, is from 
J. H. Pooley, M. D., Columbus, Ohio, Professor of Surgery, who writes :- 
Some years ago I was consulted with regard to a child about a year old, who presented some 
curious nervous symptoms. He was a large, finely developed boy, and until three months or so 
before my seeing him had always been in perfect health. 
His condition was one of localized chorea, manifesting itself in constant convulsive move- 
ments of the head. They were nodding, or antero-posterior movements, alternating with lateral 
or shaking and twisting motions. By the time I saw the patient these convulsive movements 
had become almost constant during his waking hours ; there was no grimace or distortion of the 
features, no choreic movements of the extremities; indeed, the whole affection consisted in the 
nodding and shaking movements of the head referred to. These were almost incessant, some- 
times slow and almost rhythmical, then for a minute or two rapid and irregular, seeming to 
fatigue the little fellow, and accompanied by a fretful, whimpering cry. 
The child had been subjected to a variety of treatment, but without any benefit or effect of 
any kind. Upon the most careful examination of the patient and his history and antecedents, I 
*1 wrote to Dr. Leech in July, when I this paper, to learn the present condition 
of his patient ; but he did not receive my letter in time, and has just sent me the following 
letter, which seems of so much importance that I add it as a footnote. 
Judson, Park Co., Indiana. 
Mr Dear Doctor:- 
Your letter of July 14th last is just at hand, having lain in the Attica, Ind. P. 0. all this 
time. The case of phimosis you refer to was an interesting one, and the operation was a grand 
success. The boy is now almost a man, and helping his father in the express office ; and his 
father took great pride in telling me last summer, when I was in Attica, what a noble fellow he 
was, and how he owed his life to me, etc. 
The profession is under lasting obligations to you for originating this proceeding and bring- 
ing it before the world so prominently. I know you must often feel disgusted and amused to 
find how slow some surgeons are in finding it out. My experience with the operation would 
make a book worth reading. In the first place, I used to treat those cases as paralysis from den- 
tition, as Prof. Gross taught me, and I would apply the actual cautery to the lumbar region, etc. 
One case, Franklin Robinson, a banker's son in Clinton, Mo., had a balanitis come on, and I 
liberated his glans penis, wiped out the smegma, and cured my case of paralysis without know- 
ing why or how. 
This was in 1868, and your paper read at the Association in 1870 was a "light from heaven" 
to me ; in fact, I saw a great light ; and since then, the case you refer to is only one of many. 
Yours trulv. 
To Dr. L. A. Sayre. 
T. F. Leech, m.d. SECTION X DISEASES OF CHILDREN. 
467 
could not discover anything that seemed to throw any light upon the case, except a condition of 
well-marked phimosis. Acting upon this, I immediately circumcised him, and from the very 
day of the operation the spasmodic action began to diminish, and in two weeks he was entirely 
well, without any other treatment of any kind. There has been no return. 
This case was published in the Toledo Medical and Surgical Journal, January, 1883, 
and copied in Braithwaite1 s Quarterly Epitome of Medicine and Surgery, Part XIII, March, 
1883. 
Some years since, Dr. W. R. McMahon, of Huntington, Indiana, reported to me two 
cases of epilepsy caused by congenital phimosis, and that he had entirely relieved 
by operation As I was anxious to know whether the disease had returned, I wrote 
him again a few months ago, and received the following reply :- 
Huntington, Indiana, July 22d, 1887. 
Prof. L. A. Sayre, New York :- 
Dear Sir :-In answer to your letter concerning the cases of epilepsy caused by genital irri- 
tation, and which I relieved by operation on the penis, and of which I sent you a full account 
some years ago, I will say, that they never had an epileptic seizure since the adhesions were 
broken up. They are now young men of sixteen or seventeen years, and in good health. 
■ I have seen, one other case of congenital epilepsy in a boy of ten years, in which there was 
very firm preputial adhesions and a high grade of inflammation of the parts. I separated 
the adhesions (gave no medicine) six months ago, since which time he has not had a single 
convulsion. Yours very respectfully, 
Dr. W. R. McMahon. 
The following very instructive case of convulsions and paralysis from phimosis was 
operated upon with perfect success by Dr. I. D. Griffith, Kansas City, Mo. :- 
CONVULSIONS AND PARALYSIS FROM PHIMOSIS CURED BY CIRCUMCISION. 
Case.-In 1883 I received a letter from a very intelligent gentleman of Missouri, 
from which I make the following extract:- 
Our little boy is now two years and eight months old ; is a very large and fully developed 
child, with large head, but well formed; general health good; he is fat and full of life. About 
the middle of June, 1882, one night, when he was put to bed, we noticed he had a high fever, 
which we thought was the result of a couple of insect bites on each foot, which caused the feet and 
legs to be considerably inflamed. About 11 o'clock he was taken with a very hard convulsion, 
which lasted for thirty minutes or more ; we sent for our physician, and he thought the convul- 
sion was caused by a high state of nervous excitement (his nervous system being very highly 
developed) ; for four or five days the convulsions continued at intervals, having from three to 
six a day, after which he seemed perfectly well, until December 2d, 1882, when again, after a 
high fever, convulsions followed, but only had two, and was perfectly well again until February, 
1883, when he was again taken with convulsions, which continued for a week or more, at longer 
or shorter intervals. During this spell we had several physicians to see him, but could make no 
satisfactory diagnosis. They all thought he had too much brain, and it might be the result of 
some nervous derangement. All trouble, however, again passed off, and he was seemingly per- 
fectly well during the daytime (and right here I will say that he has always been exceedingly 
restless at night'), until in August, when he was again taken with convulsions (this time he had 
no preceding fever), which continued for several days. Our physician said the convulsions were 
the result of malarial poison, and put him on heroic doses of quinine, giving five-grain doses 
every three hours for a week. During this spell a new symptom manifested itself, viz. : paraly- 
sis of the hips and legs, rendering him unable to walk at all. The convulsions continued to come 
on at shorter and shorter intervals. Now, Doctor, I will, as nearly as I am able, describe the 
spasms: They have been variable, but mainly a jerking of the muscles; sometimes the face has 
gotten dark ; he has never foamed at the mouth ; breathing labored, pupil of the eye dilated, 468 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
though the eye was fixed, and usually the spasm would pass off with a cry, as if in pain, but 
often would pass off without any stupor, though sometimes he has gone to sleep just after a spasm. 
He sometimes would fall backward, and often fall over on his face. Spasms have not been pre- 
ceded by a shriek, as a rule, though sometimes he has cried out just as a spasm came on. He does 
not bite his tongue, as a rule, though he did it once. Can anything be done to relieve this ter- 
rible cloud hanging like a pall over us ? 
Let us hear immediately, and, if necessary, will bring him to you as soon as possible. 
With much respect, I am, in suspense, most truly yours, 
Geo. W. Halloway. 
I immediately wrote to Mr. Halloway, requesting him to ask his physician to care- 
fully examine the child's genitals, and if he found phimosis, to circumcise him at once. 
I received a letter from the father a few months after, stating that Dr. Griffith, of 
Kansas City, had circumcised his boy, with the most satisfactory results. He had 
entirely recovered from his paralysis, and had had only one convulsion since the 
operation, which the father thought was caused by indigestion. As I was anxious to 
know the permanency of the cure, I wrote to Mr. Halloway a few weeks since, and in 
response received the following letter from Dr. L. D. Griffith, of Kansas City:- 
Kansas City, Mo., July 29th, 1887. 
Dr. L. A. Sayre :- 
Dear Doctor.-Mr. Halloway was in to see me, and asked that I should write to you something 
of the history of his little boy from the time of the operation for phimosis. He, at the time I 
saw him first, was, I think, the most intensely nervous and restless young one I ever saw. 
The least noise was most distressingly startling to him, almost causing convulsions ; these last 
had become so frequent that his facial expression had become noticeably changed, and his mother 
seemed to be distressed whenever she looked at him. The day I operated (to give you an idea of 
the frequency) he had fifteen, and this was not unusual at all, as, whenever the least drop of 
urine would attempt to pass, priapism would immediately set up and a convulsion follow. From 
the moment of the operation (and, by the way, the foreskin was adherent all around, and a large 
roll of caseous matter just back of the corona) his convulsion ceased and he has had none since, 
with the exception of one, and this from eating half of a watermelon, or something which over- 
loaded his stomach. Now, his expression has changed and with it his entire disposition. He 
recovered from his paralysis almost immediately after the operation. 
I was called, not long since, to a neighboring town to see a little one with hip-joint disease, 
and with the opening up of the foreskin and dissecting it from the head of the penis, I removed 
the extension from the limb and the joint disease (?) disappeared. Beside these, I have seen ten 
other children suffering from convulsions relieved after I operated. 
Yours truly, 
J. D. Griffith. 
The following letter explains itself:- 
Mobile, Ala., 106 St. Francis St., May 29th, 1887. 
Prof. Louis A. Sayre, m.d., 285 Fifth Avenue, New York :- 
Dear Doctor.-Having read with much interest some articles of yours on reflex irritation, and 
one article on " Spinal Anaemia, with Partial Paralysis and Want of Coordination, from Irritation 
of the Genital Organs," permit me to thank you for this valuable contribution to our profession, 
and to ask your views as to my diagnosis and my proposed treatment of a case met with to-day 
in my practice. 
W. E- e, male, white, aged six years, parentage good ; very sallow, with black eyes and 
dark hair; head large, good intellect; teeth decayed; lower extremities atrophied; feet inverted, 
the right more than left; too much bending of knees backward when standing ; the feet can be 
easily abducted to normal position, and if done with child standing, will remain by weight of 
body ; can only walk short distance without falling ; when walking, the feet are turned inward, 
the knees project forward and inward so as nearly to touch, with legs divergent; the gait unsteady SECTION X-DISEASES OF CHILDREN. 
469 
and inability to move in a straight line. Penis very small, not larger than a child six months 
old, prepuce long, with orifice so small as scarcely to admit a silver probe of pocket case, and pre- 
ternatural redness of same. Frequent priapism, which has been observed since one year old ; 
only partial control of sphincter ani; in other words, is not able to resist evacuation of rectum for 
a minute when nature calls. This the mother has noticed " ever since child commenced sitting 
up." The height of child is three feet four inches. In catechising the mother, she says : At 
birth the child was large and well-developed ; when about nine or ten months old a weakness of 
neck was noticed, and he was not able to sit alone until eleven months old ; after he learned to 
crawl, he continued to do so until three years old, when he was first able to stand alone ; was four 
years old before he walked any. The atrophy of lower limbs first attracted attention in his 
efforts to walk. Appetite " not very good," very few things agree with him. Is this a case of 
" spinal anæmia with partial paralysis and want of coordination, from irritation of penis "? 
Such is my diagnosis. The treatment proposed-circumcision, nutritious diet, electricity, strych- 
nia, cod-liver oil, friction, phosphorus, and, in short, assist nature to build up ; an instrument to 
keep limbs in place while walking. Now, my dear Doctor, you have my case; I would send him 
to you, but the parents are not pecuniarily able to visit New York, and hence my letter to you 
for any suggestions you may favor me with. I have had very little experience in mechanical 
appliances, and you will do me a favor by specifying particularly on this subject. 
• I am very respectfully, yours, 
A. J. Reese, m.d. 
I immediately wrote to the Doctor, stating that I thought his diagnosis correct, and 
advised him to circumcise the child at once. 
As I was anxious to know the ultimate result of the case, I again wrote to the 
Doctor in June, 1887, and received the following reply:- 
Mobile, Ala., July 28th, 1887. 
Prof. Louis A. Sayre :- 
Dear Doctor:-Your letter of inquiry regarding a case about which I wrote you, May 
29th, 1877, has been received, and should have been answered more promptly, but unavoidable 
circumstances prevented. 
The case of which you speak, if I remember correctly (for I had the misfortune to lose my 
notes of about fifteen cases) was a boy, six years old. I operated, with remarkable results ; diges- 
tion improved rapidly, perfect control of sphincter muscle, coordination all right. Saw him not 
long since, in fine health; a little parrot toed, otherwise all right. I am glad, my dear Doctor, to 
have the opportunity to thank you for your valuable contributions to the healing art. Since the 
above mentioned case I have operated about 25 times for this class of troubles, and never with 
regret ; five cases within last few months, i. e.-1st. Pat. McM., aged two years and six months ; 
one of twins; blonde, with large brain; unable to walk; the lower extremities not developed as 
body and upper extremities. The mother said she thought he had gravel, as he complained 
whenever he made water, as if in pain, and was very nervous. I examined genitals; found adherent 
prepuce, except the portion immediately surrounding meatus. Circumcised; removed hardened 
smegma (which was very abundant) ; dressed with oil. This constituted treatment. The child 
was soon walking ; the limbs developed rapidly ; no more gravel. 2d. Circumcision in one case, 
of infantile onanism, the first and only case I have ever seen. There was adhered prepuce in this 
case. The mother insisted that I should avoid circumcision if possible. Broke up adhesion, 
removed smegma, and with oil and forceps dilated prepuce. Child improved but was not entirely 
cured. I circumcised and had no further trouble. 3d. Was called to child eight months old (by 
attending physician) of good parentage, whose case simulated hip disease of right side ; any 
motion of the limb gave great pain. My medical friend, having exhausted his resources and the 
child growing worse, sent for me ; on examination found adhered prepuce, small preputial orifice ; 
priapism when penis was bandied (which we generally find in these cases) ; the movement of limb 
producing considerable excitement and pain. Diagnosed genito-reflex trouble ; operated at 
once ; result, " hip disease " cured. Never has had any more trouble. 4th. A mulatto child, two 
months old ; healthy parents ; was brought to office for prescription. The legs permanently 
drawn up ; great pain whenever an attempt to forcibly extend them ; had been in this con- 470 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dition, the parents said, several weeks. No fever; nursed well ; otherwise well, so far as could 
be seen. Examined penis ; found prepuce adhered and opening small ; priapism as soon as 
handled. Circumcised and uncovered gland after Sayre's method ; child got well without fur- 
ther medication. 5th. Was consulted five weeks since with regard to ten-year old boy, of good 
parentage, who invariably wetted the bed at night. Examined penis and found firmly adhered 
prepuce; gave chloroform; circumcised; removed smegma. Is now entirely well, growing 
rapidly ; has never wetted the bed since. Mother says he is quite another boy. 
Now, my dear Doctor, I have written so hurriedly and imperfectly, that I fear you will not 
be able to make anything out of my brief notes. Some of my cases are exceedingly interesting, 
and results surprising to all parties concerned. I regret not being able to give a more minute 
detail. Again thanking you for getting me out of some ugly scrapes, and for the good done 
mankind, I am Yours truly, 
A. J. Reese. 
Office of Dus. Cross and Easley, Little Rock Ark., April 11th, 1876. 
Dr. Louis A. Sayre, New York :- 
Doctor:-Your paper in 1870, and report on the subject last spring in Louisville, have 
attracted my attention to your theory of " reflex irritation from congenital phimosis," and I have 
done circumcision as advised in several instances, and always with the happiest results. I sup- 
pose the subject is still of interest to you, and even at this late day venture to send you the last 
of my cases. 
In February last, Mrs. H. L., wife of a prominent citizen of this place, called me to see her 
little son, three years old. The child was of fair size and development, though very pale. He 
walked in a difficult, sprawling manner, and had habitually a dazed, wandering look, although 
when his attention was concentrated he was not wanting in intelligence. His mother said that 
he had suffered from trouble in the genital parts since he was six months old, that she had called 
their attention to it, but that none of her medical attendants had advised an operation. She 
described his condition as one of almost constant suffering. His rest at night was much dis- 
turbed, and he would often scream and start from his sleep. In urinating he appeared to suffer 
great pain, the water often coming guttatim. At such times the child would writhe and move 
about half bent, the tears frequently starting from his eyes. The prepuce was found elongated 
and very sensitive. The contraction corresponding to the meatus was so tight that an ordinary 
pocket probe would barely pass. The nature of the trouble was explained and consent to an 
operation immediately obtained. The prepuce was retrenched, the mucous membrane snipped, 
and found at all points closely attached to the glans. So firm were the adhesions that the mem- 
brane was literally dissected back. Hardened lumps of secretion were found almost encircling 
the corona. But little inconvenience resulted from the measure and the child began at once to 
improve. He is now vastly better in every respect, indeed, is one of the brightest and most 
promising little fellows of my acquaintance. I send this, not because of any connection of mine 
with the little procedure, but that I may say how largely we are indebted to you for putting us 
right on this interesting and important subject. 
Very truly yours, 
E. T. Easley. 
When apprised that I was writing to you, my friend, Dr. Dibrell, gave me the following 
memoranda, and the case is so graphic an illustration of the trouble in question that I think I 
need not apologize for sending it. 
In November, 1875, was called by Mr. 0. to see his child, eighteen months old. The little 
patient presented a wasted, cachectic appearance, with its legs and feet œdematous. The child had 
great difficulty in voiding its urine, and invariably cried when doing so. He could not walk, nor 
could he stand, unsupported, upon his feet; his legs, to use the expression of the family, "would 
fly from under him." These symptoms were progressively growing worse. An examination of 
the genitals showed an extremely elongated prepuce with congenital phimosis. Through the 
opening in the prepuce a No. 1 flexible catheter could with much difficulty be passed. This 
condition was to me a satisfactory solution of the whole difficulty, and I at once circumcised the 
child. Its restoration to health was very rapid, and without the aid of any therapeutic measures 
whatever. SECTION X DISEASES OF CHILDREN. 
471 
I have recently written to Dr. Easley to know the present condition of the patient, 
but up to the present time have received no reply. 
I could add many more cases from various physicians, similar to those here quoted ; 
but it would only be corroborative evidence and add undue length to my report, and I 
will therefore only quote one more letter, just received from a total stranger, since I 
finished writing my paper, as it is instructive in showing that when the operation is 
performed, it should always be done properly. I therefore add it to my report :- 
Frostburg, Md., Aug. 29th, 1887. 
Dr. L. A. Sayre:- 
Dear Sir:-I have just read in the Medical Record that you are to read a paper before the 
International Medical Congress, next Monday, on the deleterious results, in children, of a narrow 
prepuce and preputial adhesion, which brings to mind a case I treated about fifteen months ago, 
a brief account of which I will now give you. In the early part of June, 1886, I was at King- 
wood, W. Va., to see a case of talipes upon which I had operated a year previously, and was 
asked to see a boy eight years old, living in the country, three miles from Kingwood. The boy 
had always been unable to walk without support ; rubbed the knees together until the skin was 
thickened and quite horny ; the adductor muscles were hard and rigid, so that when the child 
was placed upon his back upon the table the knees could not be separated more than four inches; 
patient was well developed ; no atrophy of any of the muscles. 
He had been treated for "weak knees" by an intelligent physician, who had him wear some 
kind ot a splint for several months. 
As soon as I saw the case I was reminded of a case I saw in your Clinic at Bellevue, in the 
fall of 1885, it being a case sent to you from Cumberland, by Dr. " Tom " Healey. ■ 
I therefore examined its prepuce, and found it very much elongated and contracted, upon 
which I diagnosed it as a case of phimosis, producing reflex symptoms, and recommended cir- 
cumcision, to which its parents readily consented. The operation was done without any anæsthetic 
with no one to assist me but the father. One week later I heard from the boy, through his 
father, stating that he was very much improved in his locomotion, being able to walk to the gate, 
about one hundred yards from the house, without assistance. However, about two weeks later on 
he wrote me saying the prepuce was contracting again, and that he had been trying to keep it 
open with a husking knife, but could not dilate it sufficiently, and that the boy was not walking so 
well as before. This result, as you will know, was because I had not removed enough of the 
prepuce, but the improvement immediately following the operation and then, too, the relapse 
simultaneous with the secondary contraction, convinced me of the correctness of my diagnosis. I 
therefore telegraphed them to meet me at Tunnelton, about one hundred miles west of this place, 
it being their nearest point on the B. and 0., when I recircumcised him, whereupon he began to 
improve, and now walks quite well. 
I write this to you because I am indebted to you for my ability to appreciate and properly 
diagnose and treat the case. Very respectfully, 
C. C. Jacobs, m. d. 
Class of '86, Bellevue Hospital Medical College. 
APPENDIX. 
Since presenting this paper to the Congress, I have seen a most valuable article by 
Dr. G. L. Magruder, of Washington, D. C., describing twenty-five cases of various 
nervous disturbances which he had entirely relieved by circumcision or dilatation, 
without any medication whatever. In this paper he also gives a summary of the nervous 
supply of the parts, and reviews, in so thorough a manner, a variety of the abnormal 
phenomena which accompany various peripheral nervous irritations, that I have thought 
it worthy to be added as an appendix :- 
"The nervous supply to the genital organs is derived from the pudic nerve of the 
cerebro-spinal system and the pelvic plexus of the sympathetic system. The pudic nerve 
is a large branch of the sacral plexus, and gives off in its course the inferior hemorrhoidal 472 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nerve which supplies the external sphincter, integument around the anus, and termi- 
nates in the perineal and the dorsal nerve of the penis. The perineal nerve is distrib- 
uted by the cutaneous and muscular branches to the integument in front of the anus, 
the sphincter ani, the scrotum, and under part of the penis, the levator ani, transversus 
perinei, accelerator urinæ, erector penis, and compressor urethrae. The dorsal nerve of 
the penis accompanies the dorsal artery of the penis, and is distributed to the glans, 
prepuce, the upper surface and sides of the organ, and sends off branches to communi- 
cate with the sympathetic. 
' ' In the female, the pudic nerve terminates in the clitoris, labia majora, and perineum. 
The othei' branches of the sacral plexus are the muscular, the superior gluteal, and the 
great and small sciatic. These supply the integument of the perineum and the back 
part of the thigh and the whole of the leg, the pyriformis, obturator internus, the two 
gemelli, the quadratus femoris, the glutei, the tensor vaginæ femoris and the adductor 
magnus muscles. Branches from this plexus supply the hip joint, perforating the cap- 
sule, and also the knee joint. Connection with the sympathetic nerve is had immedi- 
ately through the large cavernous nerve, which, after joining with the dorsal branch of 
the pudic nerve passes forward to supply the corpus cavernosum and spongiosum. This 
larger cavernous nerve is derived from the inferior hypogastric or pelvic plexus. This 
plexus distributes branches to all the pelvic viscera, viz., rectum, bladder, and the 
vagina in the female. Filaments pass to the vas deferens, vesiculæ séminales and pros- 
tate gland in the male. The connection with the rest of the cerebro-spinal and sympa- 
thetic systems is intimate. 
' ' Reflex spasm and paralysis from diseases of the digestive canal, the ovaries, uterus 
and urinary organs have been frequently observed. Why cannot the same phenomena 
arise from genital irritations ? 
" Reflex paralyses are due, according to Romberg, Stanley, and Graves, to a suspension 
of the sensory influence of the fibres of the sympathetic system, and are motor spinal 
paralyses. Brown-Séquard attributes the origin to chronic irritation of the genito- 
urinary organs with secondary contraction of the vessels of the cord and atrophy of the 
corresponding parts. Levisson experimented by compressing the uterus, kidneys, intes- 
tine, or bladder of rabbits, and found reflex excitability abolished and a paralysis of the 
posterior limbs lasting until the irritation was removed. The paralysis was considered 
due to excessive irritation of the sensory fibres, thereby causing an arrest of the function 
of the motor-nerve centres. 
"Feinberg has observed in animals, after a coat of varnish, tremor, hyperæsthesia, 
partial anæsthesia, increased reflex action, spasm and paralysis. Examination disclosed 
a dilatation of the cutaneous vessels, of the capillaries of the lung and the ramifications 
of the vena porta, hyperæmia of the meninges and a dusky redness of the cervical cord. 
If the animals survive a certain length of time, proliferation of the neuroglia occurs with 
atrophy of the nerve tubes from compression. Rosenthal, quoting these observations, 
says: "Thus, the irritation of the cutaneous nerves produces a reflex paralysis of the 
centres of vascular innervation in the cord." Now, if this follows from irritation of the 
cutaneous nerves, can we not expect as much from irritation of the nerves about the 
head of the penis ? The same author mentions the fact that several cases had been 
referred to him by Prof. Dittel, which, upon exploration of the bladder had given nega- 
tive results, while a careful examination of motion and sensation showed a diminution 
of the various forms of sensibility in the legs ; in the trunk there was abnormal excita- 
bility of the nerve trunks or of the genital organs. He cites the case of a girl, aged 
twenty-three years, who was relieved of a paresis of three weeks' standing, by the 
removal of a needle deeply imbedded in the vagina. 
"Leyden reported three cases of paraplegia following diseases of the bladder, which SECTION X DISEASES OF CHILDREN. 
473 
commenced by symptoms of motor and sensory irritation. He found diffuse softening 
of the cord in two cases. He thinks that a sacro-lumbar neuritis may be propagated to 
the cord in diseases of the bladder. 
" Charcot, speaking of urinary paraplegia, says : ' The very number of the cases in 
which we see paraplegia appear in the course of disease of the urinary passages is, of 
itself, enough to show that the phenomenon is no chance coincidence. ' 
' ' From the foregoing I think that we are justified in the conclusion that phimosis and 
adherent prepuce give rise to varied troubles of more or less gravity, manifesting them- 
selves either in the muscular, osseous or nervous systems ; and that the removal of these 
abnormal conditions of the penis frequently affords marked relief, and at times perfect 
and permanent cure. ' ' 
DISCUSSION. 
Dr. De Forest Willard, of Philadelphia, remarked:-The former enthusiastic 
advocacy of circumcision by Dr. Sayre has led many rash and unthinking physicians 
to advise this operation in cases where it is entirely unnecessary, and has also caused 
them to overlook serious central lesions in cases where an adherent prepuce has been 
but an accidental coexisting condition. 
In this, as in every other complaint, too much attention cannot be given to diag- 
nosis and to the proper selection of cases. It is highly important to discriminate 
first between instances of simple adhesion and those in which actual contraction 
exists, since the former only require the slight operation of stripping of the glans, 
while for the relief of the latter, dilatation, incision or circumcision may be needed. 
Stripping can be accomplished in nearly all cases of adhesion under one or two 
years old. It is performed by manipulating the penis for a moment until slight 
rigidity occurs, when gentle backward pressure soon reveals an orifice, pinhole at 
first, but soon enlarging until the meatus is revealed. Immediately around this 
opening, or at some point on the glans, adhesions will usually be encountered, but 
they can be broken up by the thumbs of the operator as he peels off the prepuce 
from the glans. Rarely a probe is required. As soon as the sulcus behind the 
corona is fully reached, the smegma is thoroughly cleaned away and a dressing of 
cosmoline upon borated cotton is applied. This should be speedily adjusted, as 
delay sometimes produces a condition of paraphimosis, for the relief of which dila- 
tation or incision occasionally becomes necessary. Usually, however, two or three 
probes, or the rounded end of a couple of hair pins, slipped beneath the foreskin serve 
to permit the easy replacement of the hood. The dressing need not be disturbed 
until the slight inflammatory symptoms have passed, after which daily retraction and 
washing should be practiced throughout life. 
I look upon subsequent cleanliness of this region as the greatest safeguard, not 
only against reflex irritations, but also against masturbation. Retained filth and 
smegma are far more likely to call a boy's attention to his penis by their unrecognized 
irritative effects than washing can possibly do. 
In the Philadelphia Medical Times, June, 1883, I urged the non-mutilatory opera- 
tion of stripping in all cases where it was capable of giving an easily-moving prepuce, 
but insisted that no tight hood should be left, and that all reaccumulations should be 
prevented. 
The observation of many hundred cases since that time has confirmed the opinions 
then expressed, and I now very rarely circumcise a young child. A recent writer 
states that he seldom performs the operation after eight years of age. My practice 474 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is exactly the contrary ; young children can be relieved by the simpler methods, but 
when a child has reached eight or ten, and has never been able to expose the glans, 
contraction is almost certain to be present, and circumcision must be performed. In 
adults there is rarely any escape when the prepuce is tight. To take advantage of the 
helplessness of young children is akin to the action of the "normal ovariotomist," 
who persuades feeble woman to undergo an operation the analogue of which he would 
not dare to propose to a man. 
My rule is to secure a freely-moving prepuce in all cases where severe nervous 
symptoms arise, when there is muscular incoordination or paralysis, partial or com- 
plete, and in all cases where evidences of malnutrition are present. If the simple 
methods described will not accomplish this result, free dilatation, free incision, or, 
more frequently, circumcision, becomes essential. I am an advocate of discriminate 
circumcision, but not of indiscriminate. In properly selected cases it is of the great- 
est value, and yields most brilliant results. In all necessary conditions, as above indi- 
cated, I do not hesitate to perform it, but it is a comfort to know that in very many 
cases it is wholly unnecessary, and that the same results can be obtained by the more 
simple plan. 
Circumcision is in itself mutilatory, but, like amputation, may become a necessity. 
I do not believe that the removal of the prepuce is hygienic. The object of the 
fold is to protect the delicate skin of the glans during childhood, and its recedence 
is gradual as puberty is neared. If too early exposed, the excitation is increased, 
masturbation and excessive venery are encouraged, and the child is subject to con- 
tracted meatus and other evils of condensation of tissues. He has also to endure the 
mortification of boyish taunts. Furthermore, cleanliness of prepuce and of mind are 
far more potent averters of syphilis than is circumcision. 
It is idle to class this operation among Mosaic sanitary laws. It was ordered long 
before the time of Moses, not upon hygienic, but upon religious grounds, as a dis- 
tinctive mark. Its adoption by other nations was undoubtedly due to the fact that 
their superstitious minds easily accepted the theory that by thus mutilating them- 
selves, the acknowledged blessings showered in past times by the Almighty upon 
this " peculiar people " might be secured to themselves, since this was the only out- 
ward and visible sign of difference. Such barbaric sacrifices are not infrequent, and 
those who practice this rite are certainly not noted either for their morality or clean- 
liness. 
As to the existence of reflex symptoms from a contracted prepuce, there is no 
question. Anatomically, the explanation is easy, and similar effects are seen in ner- 
vous irritations in other parts of the body. Gastric, uterine and dental disturbances 
are common, neuromata, foreign bodies, coxalgia, empyema, fissure of the anus, all 
act at times to produce a peculiar train of phenomena. Why, then, should not an 
irritant acting upon nerves confessedly the most excitable in the body, give rise to 
most grave results, affecting permanent nutrition as well as temporary nerve currents ? 
That these results do not always follow compression of the glans and the retention of 
smegma, is no argument against the existence of such causes. Depressed fractures 
of the skull are not always followed by serious results, and many nerve injuries are 
produced without the occurrence of tetanus, yet this does not prove them to be 
harmless. 
Adherent prepuce will be found in babies so constantly that it may be looked 
upon as almost normal or as a continuation of the intra-uterine condition. Hence, it 
must be remembered that serious brain and spinal disease should not be overlooked SECTION X DISEASES OF CHILDREN. 
475 
as a factor in the production of muscular weaknesses, since the tight prepuce may 
have little or nothing to do with such result. 
On the other hand, when no central lesion exists, the simple stripping of the 
glans will convert many a feeble, puny, illy nourished, wakeful, irritable boy into a 
healthful and happy child. Too little attention is ordinarily paid to this sexual cause 
in its early symptoms, as just indicated, but prompt action at this stage will often 
avert the later and more serious consequences ; in fact, I believe that reflex paresis 
is always preceded by the symptoms of nervous irritability, and can often be pre- 
vented by timely action. 
If the profession will watch more carefully they will find many cases of appa- 
rently obscure malnutrition that can thus be easily explained, and it is certainly a 
comfort to feel that only a small proportion of the younger ones will require circum- 
cision. 
To summarize: 1. In infants, strip the glans in all cases where urinary, nervous or 
muscular symptoms arise. A freely-moving prepuce is more healthful than a naked 
glans. Cleanliness is the best safeguard against disease, and is to be insisted upon 
all through life. 
2. Incise or dilate all cases of moderate contraction. 
3. Circumcise boys over ten years of age, and adults when the glans cannot be 
exposed, and all other cases where reflex symptoms of genital origin arise, and in 
whom the foregoing measures fail to give a freely-sliding foreskin. 
Dr. I. N. Love, of St. Louis, said:-The tenor of the remarks during this dis- 
cussion has been in the direction of conservatism. It has been my judgment and my 
practice for many years in these reflex irritations to pursue the radical course of cir- 
cumcision. I believe thoroughly in the Mosaic law, not only from a moral but also 
from a sanitary standpoint. All genital irritation should be thoroughly removed. It 
is all very well to instruct the mother or the nurse to keep the parts within the pre- 
puce clean, but they cannot or they will not do it. Complete and proper removal of 
the covering to the glans takes away all the cause of disturbance. 
Dr. Sayre takes a more pronounced position on this subject than the majority of 
those who have discussed his paper. An improper performance of a surgical proce- 
dure is no argument against the operation, but rather against the operator. 
For the reasons I have given, I am in favor of the radical application of the 
Mosaic rite of circumcision. 
Remarks by the President:-That a considerable number of ailments or 
morbid conditions result from a narrow prepuce or preputial adhesions, either directly 
or through reflex action, is now generally admitted, and no one has done more to 
disseminate a knowledge of this fact than the author of the paper to which we have 
listened. Sometimes the causative relation of a narrow prepuce and preputial adhe- 
sions to the symptoms is very apparent, as in the following case, which was recently 
treated by me: F. P. L., aged twenty-three months, had been more or less fretful 
during micturition since the age of three months. During the last year he had been 
restless at night, and had apparently been in pain during the half hour and some- 
times even two hours preceding urination ; at such times he often applied his hand to 
the penis or drew upon the prepuce ; sometimes he pressed the hand of the nurse or 
mother to the penis. Various medicines had been given without benefit ; examina- 
tion of the urine gave a negative result, and there was no external evidence of 
inflammation in the parts affected. The child was firmly held by the mother and 
nurse, the foreskin was drawn forward by the thumb and finger, and the point of the 476 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
small two-bladed forceps, commonly used for the ear, was introduced into the pin- 
hole orifice of the prepuce. By gradually separating the blades the prepuce was 
stretched. On the second day the operation was completed, the prepuce was 
retracted beyond the glans, and the masses of smegma, white and firm, were removed. 
They had produced inflammatory redness and thickening of the preputial mucous 
membrane which surrounded them. By daily uncovering the glans, smearing it 
with vaseline and returning the prepuce, the dysuria soon ceased and the child has 
remained well. It is probable that onanism as well as the dysuria was prevented by 
this simple treatment. 
In many instances the causative relation of the preputial disease to the symptoms 
which it produces is not so apparent as in the above case, but after correct treatment 
of the prepuce they disappear. There is one result of phimosis which I did not 
observe that either Prof. Sayre or those who contributed the material for his paper 
noticed. The expulsive efforts accompanying urination sometimes cause prolapsus 
recti, and frequently cause inguinal hernia. In a lecture before the Harveian Society 
(British Med. Journ., Feb. 28th, 1880), Edmund Owen, Surgeon to St. Mary's Hos- 
pital and to the Hospital for Sick Children, says: "Perhaps the commonest cause of 
hernia in childhood is a small preputial or urethral orifice, and next to that I would put 
the smegma-hiding or adherent prepuce." Arthur Kempe (London Lancet, July 
27th, 1878), Senior House Surgeon to the Children's Hospital, says "Phimosis is a 
common occurrence, and numerous ill effects can undoubtedly be attributed to it and 
he alludes to the observations of Mr. Bryant, as published in his book on the " Sur- 
gical Diseases of Children." "In fifty consecutive cases of congenital phimosis, 
thirty-one had hernia, five had double inguinal hernia, and many had umbilical 
hernia besides. In no one was the hernia congenital, its earliest occurrence being at 
three weeks. Circumcision was performed in these cases, and all were much bene- 
fited." 
Dr. Sayre, in concluding the discussion, said that he was very glad to find that 
Dr. Willard and others who had formerly disagreed with his views-and some of 
whom had censured him rather severely-had now come to the conclusion that he 
was correct, and agreed with him that any constriction of the glans penis was a 
source of irritation to the nervous system, which should be relieved either by 
stretching or incision. In all cases where the relief can be accomplished by stretch- 
ing, of course incision is entirely unnecessary, but there are some cases where not 
only incision is necessary to relieve the constriction, but where absolute circumcision 
is a necessity, to remove a portion of the redundant and contracted prepuce. But 
even in these extreme cases the operation should be so performed as to leave suf- 
ficient prepuce to cover the glans, but should be so arranged as to glide freely back- 
ward and forward over the glans without any constriction. 
As to complete ablation of the parts under all circumstances, as recommended 
by Dr. Love, I must enter my strongest protest. 
The cases of hernia and prolapsus of the rectum referred to by Dr. Smith have 
been so fully described in my previous papers that I have not referred to them 
here. That hernia and prolapsus of the rectum should be produced by the constant 
straining at micturition through a constricted prepuce, and that both of these 
infirmities should be immediately relieved by removing the constriction, can be 
easily understood, and I certainly feel very happy that I have drawn the attention 
of the profession so strongly to this important subject ; and to now find that my 
views arc so universally endorsed by the profession as being correct ! SECTION X-DISEASES OF CHILDREN. 
477 
THE MILK SUPPLY OF CITIES. 
L'APPROVISIONNEMENT DU LAIT DANS LES VILLES. 
DIE MILCHVERSORGUNG VON STÄDTEN. 
BY DR. CYRUS EDSON, 
Of New York. 
From a sanitary standpoint the milk supply of cities is second only in importance 
to the water supply. The most vulnerable portion of the community to the attacks of 
disease are the children. 
To protect these is the health officer's first duty. Children are, of necessity, sub- 
jected to influences in large cities that tend to depress and lower their vitality. It is, 
therefore, of the highest importance that they should receive plenty of nourishing food. 
Milk is the chief food of children. No article of food is so liable to be adulterated 
or charged with noxious matter. The peculiar physical properties of milk make it easy 
for the unscrupulous to tamper with it for his own selfish ends and it readily conceals 
within its opaque body disease-producing material with which it may be accidentally 
charged. 
Probably no class of men see more plainly the evils arising from ignorance than 
physicians. When joined to avarice its power to injure is greatly enhanced. Nowhere 
do we see this combination working more successfully to spread evil than among the 
people who " manufacture " milk in and about great cities. 
Milk may be unwholesome by reason of adulteration or by reason of contamina- 
tion with noxious matter. 
We will first consider the adulteration question, and then take up the wider and more 
important subject of the contamination of milk. 
By the adulteration of milk is meant the addition of any substance or the removal 
of any of its constituents. 
The principal adulterant of milk is water, and the next most common sophistica- 
tion is the removal of cream. Many other substances have beeu used to adulterate 
milk, and we find in most text-books long lists of adulterants, including calves' brains, 
rape seed, starch, gum and other material the use of which is doubtful. 
Chalk, salt, carbonate of soda, nitrate of soda and flour have been found by inspec- 
tors in New York milk. 
An ingenious method in use is to dilute with water to which is added flour, salt and 
sugar, and then to enrich the color which, of course, is rendered bluish and whitish, vith 
turmeric and annotto. 
Probably the most dangerous adulterants of milk are the so-called preservatives, 
such as boracic acid, salicylic acid, benzoic acid and antiseptic naphthols. 
These adulterants are becoming very common. In England, I am informed, their 
use is either tolerated or winked at by the authorities, and that scarcely a quart of 
milk is sold in London or Liverpool without having been dosed with salicylic or boracic 
acid. It is true that the amount of these preservatives necessary to effect preservative 
results is small, from two to eight grains to the gallon, nevertheless I believe that they 
are extremely harmful to the delicate digestive organs of young children, and to their 
kidneys, through which they are eliminated. 
Cream is not often adulterated, but now and then attempts are made to adulterate it. 
In 1882 a firm of dairymen tried to make an emulsion of beef and lard oils to imi- 
tate cream. It worked well until the bogus cream was shipped one cold night, when 
the extreme cold caused it to separate and the oil to solidify into cakes and layers of 
lard and tallow. 478 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
I have recently been informed that an artificial cream is being shipped to New York, 
made by adding egg albumen to milk. 
My information is so reliable that I have no doubt but that I shall verify it. I have 
not yet had time to do so. 
DETECTION OF THE ADULTERANTS. 
In order to detect adulteration of milk by the addition of water and the removal of 
cream, it becomes of great importance to determine what the limits are between which 
the constituents of average milk vary. The percentage of fat, for example, varies 
according to the age, breed, time before calving, the quality of the food and the condi- 
tion of the animal. By a careful compilation of the results of several thousand analy- 
ses it has been decided by the legislature of the State of New York that pure milk 
contains at least three per cent, of fat, not more than 88 per cent, of water and 12 per 
cent, of total solids, including fat. 
Detection of IFatcr.-This may be detected by chemical analysis or by the lacto- 
meter. As the former means is reliable only in the hands of a practical chemist, I will 
describe the latter. 
The lactometer is simply a hydrometer whose 0° equals a specific gravity of water, 
viz., 1000, and whose 100° equals a specific gravity of 1.029, the space between the 0 
and the 100 being divided into 100 parts. The 100° is supposed to indicate the specific 
gravity (at a temperature of 60° Fahr.) of pure milk. 
It was found to be an absolute fact that milk from healthy cows never fell below 
1.029 at 60° Fahr. The thousands of samples of milk taken from cows, not only in the 
United States but abroad, confirm this fact. 
Let us suppose, then, that we have a sample of milk which has a specific gravity, at a 
temperature of 60° Fahr., of 90° upon the lactometer scale. As 0° equals specific gravity 
of water and 100° that of pure milk, a specific gravity of 90° would indicate that ten 
per cent, of water had been added to the milk. 
Now, as a matter of fact, the average milk has a specific gravity of about 109° on 
the lactometer. The 100° mark was taken as the standard, because a few samples of 
milk were found that had a specific gravity of 102 on the lactometer, and by putting 
the standard at 100°-1.029 hydrometer-the authorities felt that no injustice could be 
done to any farmer or dealer. 
The lactometer has been more abused than any instrument I know of, and the 
reasons for the distrust with which it has been regarded are, I think, due to- 
1. The fact that formerly a Large number of lactometers were on the market whose 
100° indicated a specific gravity of 1.030, 1.032,'etc., and others that were badly made. 
2. To the fact that the temperature is often overlooked. Any one can understand 
what a great difference this produces in the results. 
3. To the fact that if a sample of milk is taken warm from the cow, placed in a 
bottle, the bottle corked up, and the milk cooled to 60° F., the specific gravity of the milk 
may fall below 1.029, because a large quantity of air has become entangled in the milk, 
and this lowers the specific gravity. A very good illustration of this fact is shown in 
an experiment made by the chemist of our department. The skimmed milk from a 
De Laval Milk Separator was tested. 
Owing to the rapid revolution of the machine, 4000 per minute, the milk was charged 
with air. As it came from the machine it had a specific gravity of 15° at 60°. In one- 
half hour it had a specific gravity of 105° at 60°, and after five hours had a specific gravity 
of 125° at 60° F. 
You cannot dip the lactometer into any white fluid, and say, because the specific 
gravity is less than 100, that this is watered milk; or because the specific gravity is 
greater than 100 that this is pure milk. All that is claimed for the lactometer is that 
if water alone has been added to milk it will surely show that fact. SECTION X-DISEASES OF CHILDREN. 
479 
The opponents of the lactometer always say, "Would it not be possible to skim the 
milk and thus increase its specific gravity, and then add water until quite a quantity 
had been added, without the lactometer indicating anything abnormal?" Of course 
the specific gravity would not indicate anything, except that the milk was pure, but the 
appearance of the milk under such conditions would be a sure indication of the fraud. 
As I draw these lactometers from the cream, from the milk, from the skimmed milk, 
and from the watered and skimmed milk, I think it does not require an expert to detect 
the difference. 
There are several other interesting instruments that have been devised for the detec- 
tion of adulterated milk. I will only show you one other, as I want to call your atten- 
tion to other important matters relating to our milk supply. This instrument is Prof. 
Feser's Lactoscope. 
It supplies us with a simple optical test for determining the per cent, of fat in a 
sample of milk. 
From the quantity of milk employed to render water opaque this can be readily 
determined. The instrument consists of a hollow glass cylinder doubly graduated, one 
scale giving the amount of water added to make four cc. of milk transparent, the other 
showing the per cent, of fat present. 
A description of the various means used by chemists to detect the preservatives 
added to milk would take more time than can be devoted to it here. They would not 
be practical in the hands of busy practitioners, and so I pass them over. 
In testing a sample, four cc. are transferred into the instrument by means of the 
graduated pipette. Water is gradually added, and the mixture thoroughly shaken until 
all of the black lines on the cylindrical body of milk glass can be read. The level at 
which the mixture stands on the percentage of fat scale shows that percentage present. 
The instrument affords a ready and easy means for determining the relative richness 
of different specimens of human milk. In fact I have used it myself for this purpose 
to aid in the selection of a wet nurse. 
The examination of milk by the microscope is of great importance and should never 
be omitted. Pure milk from a healthy animal has the appearance shown in the photo- 
graph that I show among you. The fat globules vary in size very little. It has been 
noted that normal food produces milk in which the globules are more uniform in size 
than in that produced by cows fed on unhealthy food. I show you also photo-micro- 
graphs of skimmed milk and of cream. 
The subject of infected milk now presents itself. 
That milk will absorb the germs of disease with great readiness is admitted by all 
who have at all studied the etiology of contagious disease. In a paper on this subject, 
read before the International Medical Congress of 1881, Mr. Ernest Hart, of London, sums 
up as follows : The number of epidemics of typhoid fever, recorded in the abstract as due 
to milk, is 50 ; scarlatina, 15 ; of diphtheria, 7. The total number of cases occurring 
during epidemics traced to the use of infected milk may be reckoned in round numbers 
as 3500 of typhoid fever, 800 of scarlet fever and 500 of diphtheria. When it is remem- 
bered that within the past ten years all these recorded and authentic epidemics occurred, 
and that before that time we were practically ignorant of the fact that milk is a carrier 
of infection, we realize the importance of taking the most stringent measures to prevent 
contamination of our milk supply. 
Not only is milk liable to contamination by disease germs, but it is also liable to a 
sort of auto-infection. I refer to the development of ptomaines in milk subjected to 
certain influences. We are all more or less acquainted with Professor Vaughan's tyro- 
toxicon. I have seen a number of cases of poisoning produced by milk that could only be 
accounted for on the hypothesis of the presence of tyrotoxicon or some other ptomaine. 
One is interesting on account of the number of persons poisoned ; I will give it:- 
On the 12th of May of this year I was directed by the Sanitary Superintendent of 480 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
New York to investigate several cases of poisoning at 1988 and 1990 Second Avenue, 
of that city, reported by Dr. J. A. Powelson. In the two aforesaid houses twenty-one 
persons were found suffering from symptoms of irritant poisoning. The symptoms 
presented were vomiting, colic, diarrhoea, vertigo, headache and great prostration. All 
had drunk milk purchased from one milkman, who obtained it of a reputable dairyman 
in Dutchess County, New York. All were taken ill in from one to four hours after 
drinking the milk, and those who vomited early were least affected. 
By making an investigation among the customers of the milkman, fourteen other 
cases of poisoning were found, exactly like the Second Avenue cases. 
As several gallons of the poisonous milk were obtained, a most thorough analysis 
was made by E. W. Martin, the chemist to the New York Board of Health. All the 
poisonous metals were tested for, and many of the vegetable poisons, with negative 
results. Professor Vaughan's method of extracting tyrotoxicon was tried carefully, 
and a few grains of a crystalline substance were obtained, which appeared like tyro- 
toxicon, but on feeding it to rabbits no effect was produced. In short, chemical 
analysis developed no results whatever. 
The odor of this milk was peculiar and offensive, being of a sickly, sweet nature. 
So characteristic was this odor that milk found in several families that were affected 
could be readily recognized by it. 
None of the persons poisoned by this milk died, though two came near doing so. 
These two had slight gastro-enteritis before taking the milk. 
A painstaking and thorough investigation was made at the dairy from whence the 
milk came, and of the farms that supplied the dairy, and it was found that hoof rot 
was prevalent on them. 
No evidence could be obtained that milk from animals affected with that disease 
had been shipped to New York, but the farmers had a deep-rooted belief that milk 
from such cows was not deleterious. A sample of milk from an animal with the disease 
was submitted to the chemist and myself, and it was found to have the same peculiar 
odor that was noticed in the case of the poisonous milk, and a small amount fed to 
rabbits made them violently ill. Attempts were made by one at vomiting, and both 
showed great apathy for some time after. 
Vaughan believes that the ptomaines are more liable to be developed in milk from 
diseased animals, and the cases just described would seem to confirm this theory. 
Notwithstanding assertions made to the contrary, I believe that the poisonous milk 
ptomaines are very difficult to isolate by any means known to chemistry. 
We are too often compelled to make our diagnosis by exclusion. All circumstances, 
however, point to the fact that the ptomaines are developed during the decomposition 
of milk, and, consequently, anything that favors decomposition necessarily favors the 
production of ptomaines. 
Want of cleanliness in handling milk, filthy barns, unclean udders, dirty cans and 
bottles, are all sources of danger. The crust that forms around the necks of bottles and 
cans, unless removed, rapidly decomposes, and thus charges the contents of the vessel 
with the germs of putrefaction. 
I believe, with Professor Vaughan, that the most important advantage secured to 
breast-fed children arises from the lessened danger of infection of milk with germs 
which may produce poisonous ptomaines. 
The following rules are given by Vaughan for the prevention of the development of 
tyrotoxicon in milk. 
RULES FOR THE PREVEXTIOX OF THE DEVELOPMEXT OF TYROTOXICOX IX MILK. 
1. The cows should be healthy, and the milk of any animal which seems indisposed 
should not be mixed with that from the perfectly healthy animals. SECTION X-DISEASES OF CHILDREN. 
481 
2. Cows must not be fed upon swill, or the refuse of breweries or glucose factories, 
or any other fermented food. 
3. Cows must not be allowed to drink stagnant water; but must have free access to 
pure, fresh water. 
4. Cows must not be heated or worried before being milked. 
5. The pasture must be free from noxious weeds, and the barn and yard must be 
kept clean. 
6. The udders should be washed, if at all dirty, before the milking. 
7. The milk must be at once thoroughly cooled. This is best done by placing the 
milk can in a tank of cold spring water or ice water, the water being the same depth 
as the milk in the can. It would be well if the water in the tank could be kept flow- 
ing; indeed, this will be necessary unless ice water is used. The tank should be thor- 
oughly cleaned every day, to prevent bad odors. The can should remain uncovered 
during cooling, and the milk should be gently stirred. The temperature should be 
reduced to 60° F. within an hour. The can should remain in the cold water until 
ready for delivery. 
8. In summer, when ready for delivery, the top should be placed on the can and a 
cloth, wet in cold water, should be spread over the can, or refrigerator cans may be used. 
At no season should the milk be frozen; but no buyer should receive milk which has a 
temperature higher than 65° F. 
9. Alter the milk has been received by the consumer, it should be kept in a per- 
fectly clean place, free from dust, at a temperature not exceeding 60° F. Milk should 
not be allowed to stand uncovered, even for a short time, in sleeping or living rooms. 
In many of the better houses in the country and villages, and occasionally in the cities, the 
drain from the refrigerator leads into a cesspool or kitchen drain. This is highly dan- 
gerous; there should be no connection between the refrigerator and any receptacle of filth. 
10. The only vessels in which milk should be kept are. tin, glass or porcelain. 
After using the vessel, it should be scalded, and then, if possible, exposed to the air. 
Adulteration with water is a very common source of contamination, for the adulter- 
ator is not at all fastidious as to the quality of water he puts in his milk. I have 
frequently had in my possession toads and hair worms found in New York milk by the 
inspectors. As water is frequently the carrier of the germs of disease, it follows that 
water contaminated by such germs, if added to milk, will also contaminate it and make 
it a carrier of the same diseases. 
We all know how pure water is in the average country well. I have inspected a 
great number of such wells, and I do not believe that one in a hundred furnishes water 
fit to drink. 
It is safe to say that in 20 per cent, of farms in New York State the cows are 
watered from wells situated in the barnyard itself, contaminated by its drainings. 
This leads us, naturally, from the consideration of milk contaminated by noxious 
matters outside of the cow to the consideration of that contaminated by factors arising 
in the condition of the animal herself. 
Milch cows should be fed on wholesome food and given plenty of pure water to drink. 
Distillery slops are highly injurious as a food for cows. In order to use them as 
feed, the cows must at first be closely confined and all other food withheld, as the 
animals will not eat them unless compelled by starvation. 
After having been forced to eat the stuff they take to it like drunkards to their 
grog, and if permitted will gorge themselves with it. Cows thus fed are never given 
any water to drink, as it is considered by swill feeders that sufficient water is present 
in the swill to supply their need in this respect. 
They are never given fresh air or exercise, both of which are indispensable to the 
well being and health of the animal. 
Vol. Ill-31 482 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
For months they stand yoked between uprights, their noses over the swill trough, 
breathing the emanations from their accumulated filth, in stables that often have only 
six or seven feet headway. 
I have seen cows in such stables, in stalls that were only 2 feet and 29 inches wide. 
In one case only 226 cubic feet of air space was allowed each of the 30 animals stabled. 
(The New York Board of Health insists that at least 300 cubic feet of space shall be 
allowed one infant. ) 
I give these facts because they go with the feeding of distillery swill. I have per- 
sonally seen food of this kind fed, and I have been the means used by the Board of 
Health of New York to effect the punishment of persons feeding it. Yet I have never 
seen it fed except under the conditions I have described. 
As distillery slops contain a large amount of free acid, the direct effect of feeding 
them is to charge the systems of the animals so fed with acid. It produces an acid 
diathesis. The result of this is that the secretions naturally alkaline are acid- 
Even the milk, which should be neutral or faintly acid, is markedly acid. 
Another result of this acid condition is the tendency of the tissues of the cow, 
especially the skin, to ulcerate. Large ulcers often form on the flanks and shoulders 
where the skin comes in contact with the floor on lying down. The tail often ulcer- 
ates, usually within six or eight inches of the buttocks, and drops off Milk from 
animals fed on distillery swill coagulates in tough lumps. I have seen a complete cast 
of the vessel which held such milk formed by the tenacious curd. This cast could be 
handled without breaking. 
The following is a copy of an autopsy made by Dr. A. H. P. Leuf, of Brooklyn, in 
the case of a child of four months, who died from the effects of swill milk:- 
" I made an autopsy on the body of Stanley F. Heyden, of 281 Bergen St., August 1st, 1882. 
I found the stomach exceedingly soft and delicate, and filled with coagulated milk, forming quite 
a firm lump, over three inches in diameter. The stomach was also reddened. The intestines 
were very pale and entirely bloodless, and contained a pale, slimy material, characteristic of 
inflammation. 
"The membrane of the intestines was also closely studded with little whitish specks, which 
were enlarged glands. All the other organs of the body were normal except the marked pale- 
ness. In my opinion death resulted from exhaustion (collapse), due to gastro-entero-colitis, 
augmented by the presence in the stomach of the firm clot of coagulated milk which was too firm 
for the child to vomit up or pass down into the gut, and therefore acted as a foreign body and 
irritant. 
[Signed.] "A. II. P. Leuf, m.d." 
The Brooklyn health authorities investigated the source of the milk that was given 
the child, and found that it came from swill-fed animals. 
It was deficient iu fat, while the curd was tough and abundant. 
In regard to brewery grains, or brewers' grains, as they are generally called, the 
case is different. 
Nevertheless, it is highly wrong to feed them exclusively or even for the most part. 
This is shown by the fact that cows fed on them become what is termed "grain sick." 
The animal loses its appetite and is apt to have diarrhoea. 
I have no hesitation in saying that a little grains judiciously fed with other food 
will do no harm 
Theodor of swill or grains is very perceptible in milk from animals fed on either. 
The proper way to make the "smell test " is to shake the milkman's forty-quart can, 
or have some one do it for you, and then removing the cover quickly smell the inside of 
it (the cover). 
The odor is always present. It is always safer not to use milk having the odor of 
grains, at least not to use it for infant's food. 
In addition to the peculiar and unhealthy curd in milk from cows fed on swill and SECTION X-DISEASES OF CHILDREN. 
483 
brewers' grains, it is certain that such milk will rapidly sour and spoil, even when sub- 
jected to the most favorable conditions for keeping it. The great condensed milk fac- 
tories in New York State, and I believe elsewhere, compel the farmers who supply 
them with milk to sign a contract to feed no brewers' grains, starch feed, distillery swill 
or even ensilage. K 
The reason for this is that milk from animals thus fed cannot be preserved even after 
being condensed, charged with sugar, and put up in hermetically sealed cans ! 
Bad treatment and accidental feeding of certain plants sometimes affects milk in a 
remarkable manner. Milk will suddenly sour only a few hours after being produced, 
or by some peculiar decomposition of its casein it will turn blue or it will become 
stringy, running in strings when poured from vessel to vessel. 
Sandy milk is the result of excess of lime salts derived from food, though I believe 
some observers think that it is due to a disease that causes the lime in the tissues of 
the animal to concentrate itself in the milk. 
Old milkers frequently give milk which has a bitter taste. This milk very rapidly 
decomposes, with the development of a very disagreeable odor. 
A very curious epidemic resembling typhoid fever broke out on Washington Heights 
a few years ago. It was found, on investigation, that the disease was confined to the 
customers of a certain milkman. An examination of the cows owned by this man was 
made, and one was found suffering from an abscess of the udder. At the time the exam- 
ination was made this cow was being milked into the common milk pail. Although 
the investigation was very thoroughly conducted, no other cause could be found, and 
when the cow with the abscess had been quarantined the sickness speedily stopped. 
Milk from animals afflicted with tubercular disease has been proved to have the 
property of transmitting to man that disease, unfortunately common among cattle. 
Highly-bred animals are particularly affected by this scourge. 
One cause of this is that too much attention is devoted by breeders to producing 
wedge-shaped animals. 
It is considered desirable to breed animals having great breadth of hips and a capa- 
cious belly that narrows down toward a thin chest. In this way the lungs and chest 
capacity are sacrificed. The tendency is in narrow-chested animals, as in flat-chested 
men, to develop lung disease and tuberculosis. 
Interbreeding is another curse that spreads the disease. I have known the daughter, 
granddaughter and great granddaughter to be crossed by the father. 
Tuberculosis kills annually more people than any other disease. 
Of 709 autopsies performed on the bodies of children under ten years of age 33 per 
cent, were found to have died from tuberculosis {Medical Record, New York, June 19th, 
1886, p. 713). An analysis of these cases showed that the disease was twice as frequent 
in the abdominal cavity as in the brain. I believe that tuberculosis is rarely an hered- 
itary disease, and base this opinion on the fact that it is almost never found in foetal life 
and is rarely seen in children under a month old. Now, if the disease is more often 
acquired than inherited we must look for some fertile source that affects the younger 
portion of the community rather than adults. 
Milk from tubercular cows has infected pigs to whom it was fed. It is more than 
reasonable to believe that it often infects children. I feel confident that tuberculosis 
will, before long, be included among diseases communicable from animals to man. 
During the spring of 1886 an epidemic of scarlet fever occurred in a certain district 
near London. 
Investigation showed that the families in which the fever appeared used the milk 
from one dairy. An investigation failed to discover that the milk had been exposed to 
scarlet fever contagion. The cows were carefully examined, and were found to be suf- 
fering from a peculiar affection known as blistered or sore teats. Though rather a 
common disease, it was unknown to have had any connection with scarlatina. 484 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A painstaking investigation by Drs. Janies Cameron and E. Klein showed pretty 
conclusively that the disorder was transmissible, and that it was the cause of the scar- 
latina epidemic. 
Bovine scarlatina has been described, but the description is widely different from the 
disease discovered in the case I have just quoted. Klein discovered in these cases a bacil- 
lus which he believed to lie the cause of the disease and the true scarlatinal parasite. 
Besides the teat eruption the cows had fever, quickened respiration, dry, hacking 
cough, sore throat, discharges from the eyes and ears, alteration in the milk secretion 
and some visceral lesions. 
We have seen that milk may be male a source of danger to us by the dishonest, 
careless, or the ignorant. 
By adulteration the consumer is robbed of his proper nourishment. Infected milk 
may act as a carrier and disseminator of disease. 
The danger may be twofold : by adulteration the health of the consumer may be 
reduced and his system made fertile, so to speak, for the growth and development of the 
germs of disease that may contaminate the milk. 
What, then, is the remedy to be applied by the community for the cure of the evil ? 
The first duty of every government is to protect the well-being and health of its citizens. 
Inspectors of milk should be provided, and every city should have at least one such 
inspector to every hundred thousand of population. 
Each inspector should be provided with a lactometer, with which he should carefully 
test the milk offered for sale by dealers. When doubt exists in his mind as to the 
quality of the milk, he should supplement that test by chemical analysis. 
The laws against milk adulteration in New York city are excellent, and other cities 
would do well to copy them. 
But the control of milk adulteration disposes of but a small part of the dangers from 
milk. It is infected milk that is most to be feared, and against it the State provides 
almost no safeguards. 
In order to cope with these dangers a corps of veterinary inspectors should be provided. 
It should be the duty of these men to examine from time to time every herd of cows 
in the State. They should have the power to summarily destroy all animals suffering 
from tuberculosis, the State to reimburse the owner, and to effectually quarantine those 
liable to cause contagious disease. 
But the State has another important duty to perform in addition to enacting laws 
and compelling obedience to them; it should educate the farmer how to properly care 
for his stock, and point out to him the dangers to himself and fellow men of filth and 
lack of hygienic surroundings. 
DISCUSSION. 
Dr. Leeds desired to bear testimony to the valuable work done by Dr. Edson in 
extending the scope and thoroughness of the work of inspection in relation to the 
milk supply of cities. The present principal work of inspectors, which is in detecting 
the percentage of adulteration by water merely, is valuable, but the addition of 
water is the least dangerous adulteration. It is a commercial fraud. But, in carrying 
the work of the inspector into the dairy and the stall, a much more important service is 
done, so far as health is concerned. To do this work thoroughly, a corps of young 
men, with medical training, and specially educated for their duties by familiarity not 
only with chemical methods, but also with microscopy and bacteriology, is required. 
With their aid, the present spread of infectious diseases from cattle to men can be 
successfully combated, and the labors of men like Dr. Edson should be assisted by such 
trained corps of workers and liberal appropriations by the State for their maintenance. SECTION X-DISEASES OF CHILDREN. 
485 
THE USE OF COW'S MILK IN THE ARTIFICIAL FEEDING 
OF INFANTS. 
L'USAGE DU LAIT DE VACHE DANS LA NUTRITION ARTIFICIELLE DES 
ENFANTS. 
DER GEBRAUCH DER KUHMILCH BEI DER KÜNSTLICHEN ERNÄHRUNG DER KINDER. 
BY VICTOR C. VAUGHAN, M.D., PH.D., 
Director of the Hygienic Laboratory in the University of Michigan. 
That cow's milk must form the basis of the food used with most children who are 
for any reason denied the mother's breast, all will admit. I shall not stop to speak of 
the comparative value of the milk of other animals in infant feeding; nor shall I discuss 
the adulterations to which the milk of the cow is subjected. I shall give my time and 
attention to the following points:- 
1. The preservation of milk from putrefactive changes, which are liable under cer- 
tain conditions to occur in it, and which render it wholly unfit for use. 
2. The manipulations to which milk may be subjected iu order to render it more nearly 
like the secretion of the breast of woman, and more suitable for use as food for infants. 
3. The question as to the desirability of continuing milk as a food in certain dis- 
eased conditions of the child. 
That milk and certain of its products are liable to changes whereby they are rendered 
not only unfit for food, but positively poisonous, is a fact which has been long known. 
Cases of cheese poisoning are by no means rare in Germany and in this country ; while 
the serious effects which follow the eating of ice cream, frozen custards, etc., multiply 
as these luxuries become more extensively used. Some three years ago, the writer suc- 
ceeded in isolating the active principle from poisonous cheese, and gave to it the name 
tyrotoxicon.* Later, he found the same poison in milk and in ice cream. The poison has 
been detected now by about a dozen different investigations, and in cheese, ice cream, 
custard, milk, cream puffs and oysters.f Chemically, this poison is diazobenzol, and it 
can be prepared artificially by the action of nitrous acid on aniline. If some normal milk 
be inoculated with poisonous milk, cheese or cream, and the whole be kept for a few hours 
at the temperature of the body, or for a few days at the ordinary in-door temperature, 
the whole becomes poisonous. 
The action of this poison on the lower animals has been studied, and it has been 
found to produce symptoms which agree closely with those of cholera infantum. The 
administration of from 10 to 25 milligrams to a cat causes, after a time, which varies 
from a few minutes to two hours or longer, nausea, retching, vomiting and purging. 
The stomach becomes very irritable, and attempts to take food, and in some instances 
even a sip of water starts the vomiting again. The first stools contain fecal matter, but 
the subsequent ones are rice-water-like in appearance, alkaline in reaction, and devoid 
of fecal odor. The pulse becomes rapid and feeble, and marked exhaustion soon follows. 
The daily repetition of this small dose prolongs these symptoms, and after a few days 
the animal dies of exhaustion. 
With a larger dose, from 25 to 50 milligrams, these symptoms are intensified, and in 
addition the breathing becomes shallow and labored. With still larger amounts, from 
75 to 100 milligrams, there is violent retching, rapid and feeble pulse, but neither vom- 
iting nor purging, and death within from one-half to two or three hours. 
Post-mortem examinations show the mucous membrane of the stomach and small 
intestines usually blanched, soggy, and covered with a thick, ropy secretion. In some 
instances the mucous membrane of these parts appears quite normal. When the smaller 
* Zeitschrift für physiologische Chemie, B. x, H. II. 
fSee article read before the Section on Pathology of this Congress. 486 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
doses, referred to above, are used, the pale appearance of the mucous membrane of the 
stomach and intestines is the only deviation from the normal observed. Where the 
larger amounts are employed, the lungs are found markedly congested. This probably 
arises in part from the violent retching, and in part from the feeble action of the heart. 
That these symptoms and post-mortem appearances agree very closely with those 
observed in the violent choleriform diarrhoea of children all will, I think, admit, and 
that the symptoms of this disease resemble those produced by some powerful poison 
must be evident to all who have been engaged in its treatment. The suddenness and 
violence of the attack, the rapid exhaustion of the little patient, the inefficiency of medi- 
cines, and the speedy dissolution, all indicate the action of some potent poison. Now, we 
know that a substance capable of producing these effects is generated in milk under 
certain conditions of putrefaction. 
The blanched, soft condition of the mucous membrane of the stomach and intestine 
found in cats, after poisoning with tyrotoxicon, corresponds exactly with the state 
of the same organs in children after death from cholera infantum. The congestion of 
the lungs noticed in the lower animals is also present often in the severe forms of the 
disease, and in very rare instances we see children die in a few hours after violent 
retching and with pulmonary congestion, but without either vomiting or purging, just 
as the animals died after very large doses of the poison were administered. 
The above stated facts constitute the evidence upon which we form the opinion that 
tyrotoxicon is frequently concerned in the causation of cholera infantum, the violence 
of the attack varying with the amount of the poison present. 
With these facts before us, we can easily understand why this disease is most preva- 
lent among the poor classes in the large cities. To them fresh, wholesome milk is 
almost unknown. They buy, generally, of the small dealer, who has kept the milk, 
often in filthy cans, in a foul atmosphere and at a high temperature. In the homes of 
many of the poor these conditions, so favorable to putrefactive changes, are also present, 
and often in an intensified form. Even among the well-to-do, insufficient attention has 
been given to the milk upon which the children depend for the whole or the greater 
part of their food. The same is also true in country places. Cows stand in filthy barns 
and are furnished only stagnant water to drink. Then there are the tens of thousands 
of children who must draw their sustenance from nursing bottles, the cleansing of 
which, in many cases, is very inadequately attended to. 
I think that one of the greatest advantages secured by nursing from the breast 
consists of lessened liability of the milk becoming infected with germs which produce 
poisonous ptomaines. 
The exact germ which produces tyrotoxicon is not known, but it is either the butyric 
acid, or some closely allied ferment. It is a true putrefactive germ, and grows best when 
it is denied a free supply of air. The conditions most favorable for its development are 
the exclusion of air and a temperature approaching that of the human body. 
I have elsewhere* presented some rules concerning the care necessary to prevent 
milk undergoing these putrefactive changes, and will ask that I be permitted to repeat 
them here. They are as follows :- 
1. The cows should be healthy, and the milk of any animal which seems indisposed 
should not be mixed with that from perfectly healthy animals. 
2. Cows must not be fed upon swill, or the refuse of breweries, or glucose factories, 
or upon any other fermented food. 
3. Cows must not be allowed to drink stagnant water, but must have access to pure, 
fresh water. 
4. Cows must not be heated or worried before being milked. 
* Medical News, June 18th, 1887. SECTION X DISEASES OF CHILDREN. 
487 
5. The pasture must be free from noxious weeds, and the barn and yard must be 
kept clean. 
6. The udders should be washed, then wiped dry before each milking. 
7. The milk must be at once thoroughly cooled. This is best done in the summer 
by placing the milk can in a tank of cold spring water, or ice water, the water being 
of the same depth as the milk in the can. It would be well if the water in the tank 
could be kept flowing; indeed, this will be necessary, unless ice water is used. The 
tank should be thoroughly cleaned every day to prevent bad odor. The can should 
remain uncovered during the cooling, and the milk should be gently stirred. The 
temperature should be reduced to 60° F. within an hour. The can should remain in 
the cold water until ready for delivery. 
8. In summer, when ready for delivery, the top should be placed on the can and a 
cloth wet with cold water should be spread over the can, or refrigerator cans may be 
used. At no season should the milk be frozen, but no buyer should receive milk which 
has a temperature higher than 65° F. 
9. After the milk has been received by the consumer, it should be kept in a perfectly 
clean place, free from dust, and at a temperature not exceeding 60° F. Milk should not 
be allowed to stand uncovered, even for a short time, in the living or sleeping rooms. 
In many of the better houses in the country and villages, and occasionally in the cities, 
the drain from the refrigerator leads into a cesspool or kitchen drain. This is highly 
dangerous ; there should be no connection whatever between the refrigerator and any 
receptacle of filth. 
10. The only vessels in which milk should be kept are tin, glass or porcelain. 
After using the vessel, it should be scalded, and then, if possible, exposed to the air. 
When these rules are put into operation, milk can be preserved free from putrefac- 
tive changes for a reasonable length of time, and it will remain fresh and palatable. 
When such care is not exercised, the milk may become, as we have seen, highly poison- 
ous within a few hours after it is drawn from the cow. When we take into consider- 
ation the fact that many children must feed exclusively or largely upon this milk, we 
certainly cannot regard the time and expense which the above rules demand as of 
great moment. 
But when milk is to be transported a great distance or kept for any length of time, 
we will find the same necessity for drying it and the preservation of its solids, that 
there is for the curing of meat or the canning of fruit. This evaporated milk may be 
used as it is in the " condensed milk " of trade, or it may be used in the preparation 
of a milk-food, which we will discuss under our second question, and for which we are 
now ready. 
Can the milk of the cow be rendered more nearly like that of woman and more fit 
for food for infants than it is by simple dilution with water and sweetening with milk- 
sugar? Woman's milk differs from that of the cow in the following particulars : (1) In 
the proportion between the casein and the other albuminous constituents, and in the 
nature of the casein. (2) In the amount and probably in the nature of the milk-sugar. 
There are other minor differences, but those mentioned are probably the only ones of 
importance to us in the present discussion. Physiological chemists agree that there is 
less casein and more albumen in woman's milk than in that of the cow. König * gives 
the following figures, as the averagesofa great many analyses, concerning the nitrogen- 
ous constituents of the two kinds of milk:- 
Total Nitrogenous Constituent. 
Casein. 
Albumen. 
Woman's milk, 
2.36 per cent. 
0.59 per cent. 
1.23 per cent. 
Cow's milk, 
3.41 " 
2.88 " 
0.53 " 
* Nahrungs- und Genussmittel, Zweite Auflage, S. 252. 488 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Indeed, Radenhaussen* claims that woman's milk does not contain any casein at 
all, but that its nitrogenous constituents consist wholly of albumens and peptones. 
Kirch nerf has shown that the albuminose or galactin of Bouchardat and Quevenne, 
the lactoprotein of Millon and Commaille, and the whey protein of Hammersten, are all 
identical and are peptones. The same investigator concludes that the difference in the 
digestibility of woman's and cow's milk is due to the large amount of peptone in the 
former. Moreover, as was first shown by Biedert, the gastric juice coagulates cow's 
milk in large, hard clots, while by its action upon woman's milk it produces a flocculent 
precipitate. These facts can leave no doubt that there are differences between the albu- 
minous constituents of woman's and those of cow's milk, and it is altogether reasonable 
to suppose that these differences influence the digestive organs. In many children, 
digestion is so good that cow's milk does not tax the stomach. For these children, 
artificial digestion is not only not necessary, but not desirable. But I cannot see why 
the casein of cow's milk should not be partially digested for those children in which 
unaltered milk produces unpleasant digestive disturbances. I say "partially digested," 
and that it should not be completely digested, I am certain. It is unscientific to feed 
any one for any length of time upon completely digested food ; especially is this true 
of children. To relieve the action of the gastric juice altogether is to diminish its 
secretion. The bones, muscles and brain are weakened by inactivity, and the stomach 
is no exception to this rule. It must have something to do or it will soon be unable to 
do anything. There may be, and doubtless are, exceptional cases, in which the tem- 
porary administration of peptones exclusively is desirable. But these are exceptional 
cases, and the administration of the completely digested food should be only tempo- 
rary. Certainly these cases do not include healthy children. 
In the preparation of a milk food, the milk should be partially digested by the 
action of pancreatin, then boiled to destroy the ferment and prevent its further action, 
then evaporated in vacuo. To the mild solids thus obtained, dextrinized flour, obtained 
by roasting, should be added. In this way, the extra carbohydrate, above that present 
in the cow's milk, will be obtained, and this carbohydrate will, in some important 
respects at least, resemble the sugar of woman's milk. According to Biedert, the sugar 
from cow's milk ferments more readily than that from woman's milk, and certainly 
glucose ferments more readily than milk sugar obtained from either of these sources. 
Such a food as this prepared in a dairy district might be transported any distance 
and kept for any reasonable length of time without decomposition. It would be suffi- 
ciently nutritious in itself, and the addition of milk to it would be both unnecessary 
and undesirable. It would not contain any vegetable matter difficult of digestion, and 
it would contain a sufficient amount of inorganic salts, in which many of the artificial 
foods now so largely used are greatly deficient. Especially is this true of the salts of 
lime. 
Upon my third topic, I will be very brief. The question is asked : Is it desirable 
to continue the use of milk in cholera infantum and kindred diseases? The following 
simple experiments may aid us in answering this question. If several four ounce bot- 
tles be filled, one with good milk, a second with the same milk to which a few drops 
of another milk in which tyrotoxicon has been generated are added, a third with a 
meat peptonoid preparation inoculated with a few drops of the poisonous milk, a fourth 
with beef tea or rice water inoculated with the poisonous milk, and if these bottles be 
placed in an air chamber and kept at the temperature of the body for three hours, no 
tyrotoxicon will be found in the pure milk or in the meat preparation, while it will be 
found in the milk which was inoculated with the poisonous ferment. Why the germ 
t Zeitschrift für physiologische Chemie, B. V., S. 13, u, 256. 
f Beiträge zur Kenntniss der Kuhmilch und ihrer Bestandtheile. SECTION X-DISEASES OF CHILDREN. 
489 
does not grow as rapidly in the meat preparations as in the milk is not a matter to be 
discussed here. The fact is all that we need, in giving a practical answer to the ques- 
tion which we have asked. It shows that this poison is not generated as rapidly in the 
meat preparations as it is in the milk. 
A few of the best clinical teachers have recommended that the use of milk be pro*- 
hibited in the treatment of cholera infantum. They ascertained the advantage thus 
secured by experience. Now, I think that we have the true explanation of the value 
of this treatment. To give the best of milk in cholera infantum will be a means of 
supplying the germ which is present in the alimentary canal with material from which 
it will elaborate the poison. But I have elsewhere discussed at some length the nature 
and treatment of cholera infantum, and it would be outof place to discuss that subject 
in full here. 
I have only one more thought to offer. It may be embodied in the following ques- 
tion: Why do the diarrhoeal diseases of infancy prevail most extensively in filthy 
localities ? Because the ferment which leads to putrefactive changes in milk abounds 
in filthy places. It has its home in the fermenting filth of street gutters; it is present 
in decaying pavements, and it is carried by every breath of air that comes in contact 
with decaying, souring, vegetable matter. Then, although the food of the child may 
be above suspicion, so long as its surroundings are filthy, so long as it inhales the 
germs of putrefaction, poisons may be generated in its body. 
I have stated that the ferment which produces tyrotoxicon is either the bacillus 
butyricus or some closely allied germ. We know that the butyric acid ferment does 
grow and thrive often in the human stomach. 
Then to give our practical conclusions, we may say: (1) Cow's milk used as a food 
for infants must be taken from healthy, properly fed animals. (2) It must be preserved 
from putrefactive changes while being transported and stored for the child's use, and 
(3) After having been taken into the child's stomach it must be preserved from putre- 
factive changes, and this cannot be done so long as the child is overfed and breathes an 
atmosphere laden with the germs of putrefaction. 
DISCUSSION. 
The President asked the writer of the paper whether he had noticed if the 
animals experimented on by the tyrotoxicon, and presenting symptoms similar to 
those of cholera infantum, had elevation of temperature. In this disease the 
temperature is always elevated, and in the severe form of it, accompanied by 
frequent stools and vomiting and rapid prostration, the temperature rises to 105° 
or 106°. 
Prof. Vaughan replied that he intended to give attention to this point, but had 
not thus far. 
The President also spoke in reference to the anatomical characters observed. 
Although if death occurs after a brief attack of cholera infantum, as twelve or 
twenty-four hours, the gastro-intestinal surface is pallid, yet if a longer time has 
elapsed, as three or four days, it is usually injected. He could not avoid the con- 
viction that the disease is inflammatory in its nature, although a different opinion 
had been expressed by good observers. 
Dr. Vaughan replied that he had not observed whether those animals experi- 
mented on by the tyrotoxicon had elevation of temperature, but thought it not 
improbable that animals poisoned by it, if they lived sufficiently long, would present 
the symptoms and lesions of gastro-intestinal inflammation. 490 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SOME OBSERVATIONS ON HEADACHES IN CHILDREN, AND 
THEIR RELATION TO MENTAL TRAINING. 
QUELQUES OBSERVATIONS SUR LES MAUX DE TÊTE DES ENFANTS ET LEUR 
RAPPORT À L'ÉDUCATION MENTALE. 
EINIGE BEOBACHTUNGEN ÜBER KOPFSCHMERZEN BEI KINDERN, UND IHRE BEZIEHUNG 
ZUR GEISTIGEN AUSBILDUNG. 
BY WILLIAM HENRY DAY, M.D., 
Member of the Royal College of Physicians of London ; Physician to the Samaritan Hospital for 
Women and Children. 
It is an honor to be invited to contribute a paper to this great International Medical 
Congress. When I reflect on the readiness with which our transatlantic brethren 
responded to a similar appeal from the mother country in 1881, I feel that there is a 
mutual dependence, close and intimate, which augurs well for the advancement of the 
work in which we, as members of a great profession, are severally engaged. Distance 
no longer divides us. The wide sea is no barrier to our intercourse. A ceaseless activ- 
ity, a laudable competition everywhere prevails to promote the ends of science, and the 
distant parts of this busy, struggling world are brought closer and closer to compare 
the labors of fellow workers at home and abroad. 
In all I have to say, I shall hope for your lenient criticism, which ever lightens the 
weight of responsibility. No man undertakes a light task, in the present day of active 
and unceasing work, when he attempts to elucidate, or throw a further gleam of light 
upon, any topic in scientific or practical medicine ; still, even the smallest fact is im- 
portant, and is often the starting point of some great achievement in science. Every 
thoughtful investigator contributes to the general stock of knowledge, in however 
small a degree, and gives a fresh impetus to research. Great truths sometimes have 
their origin in great errors. 
The great work of national education in this country, which dates from the pass- 
ing of Mr. Foster's Act in 1870, has had the effect of calling widespread attention to 
the excessive demands made by schools and teachers upon children. In nearly all 
European countries, among the poor and rich alike, abundant proof has been adduced 
that over-pressure is present in all. The rate of progress is stimulated by a universal 
rivalry which no protest can check. 
In every branch of the public service, and in every profession the competition of 
the entrance examinations is becoming more and more severe. This exhausts the 
nervous system during the most active period of physical growth, when it is so import- 
ant not to overtax it. Mere cramming for a particular examination can never favor 
intellectual progress; it does not cultivate the reasoning and reflective powers; it is 
simply getting together a certain number of figuresand facts which are not long remem- 
bered, and serve no useful purpose beyond the hour. To say nothing of the immediate 
disastrous effect of this system in encouraging excessive brain activity in delicate and 
underfed children, it will, in the course of time, favor a great increase in nervous dis- 
eases among the community at large. The evil seed has been sown in their youth, 
and when they reach maturity, and a robust constitution is indispensable for the duties 
of life, they will probably fail in endurance, for the push and pressure thrown upon 
them in early years will prevent any but the strongest discharging responsible work as 
it should be discharged, and will thus entail national loss. 
I cannot but think that the excessive strain which teachers often produce is as much 
caused by their want of a sound training for the work they attempt as by their use of 
too ambitious a curriculum. Teachers, as a body, do not understand the physiological SECTION X-DISEASES OF CHILDREN. 
491 
and psychological natures of children; and until they do, there will always be the 
twofold danger of attempting too much, or of attempting it in the wrong way and by 
the wrong means. But I will not now enlarge upon this topic. 
The physician recognizes in this severe ordeal grave danger to the brain and nervous 
system of growing children, by which the mind is narrowed, the character weakened, 
and disease invited. Headache is one of the first and most persistent consequences of 
this baneful practice. 
I shall not speak of those headaches which are the mere accompaniment of acute 
and febrile diseases, or due to some pathological state of the brain itself, but of head- 
ache incidental to childhood and to the period of active growth and change, commenc- 
ing about the second dentition (particularly from 12 to 15 in girls), when school work 
begins to be keenly felt. This headache constitutes a disease in itself, a real illness; it 
is sometimes so persistent that the child is often obliged to give up his studies in con- 
sequence. But in any variety of headache we must not lose sight of the temperament 
and predisposition to nerve disturbance. In some children, as in some adults, there is 
always going on an excessive expenditure of nervous energy ; in their pleasures and in 
their amusements, in their studies, or pursuits of any kind, there is the same wear 
and tear, because they are unable to control themselves, and have not the power of 
self-management when extra strain is put upon them. The balance is upset, and they 
cannot readjust it. But if we take a less susceptible class of children, another class 
whose physical and mental organization is stronger, who are sturdy and not emotional, 
they are less moved by any of the vicissitudes of life, they pursue their studies regu- 
larly and quietly, and w'hen they begin to feel tired they can calmly lay them aside 
before they are too exhausted or have passed the limit when they cannot check them- 
selves. Rest soon reinforces these children, and they return to their studies with their 
strength restored. They may go through the whole curriculum of study, or even pass 
through life, and never experience a headache at all. The brain is more strongly devel- 
oped, and the vital organs are also in a sound state, and air and active exercise are far 
more congenial to these subjects than is intellectual work. Not that they wish to 
escape the latter, but the mind never dwells on it when not engaged in it, and they 
take their school work fairly in turn with their out-door amusements, so that the bal- 
ance is harmoniously maintained. 
HEADACHES 
In the young are of greater significance than in the adult, and should receive the utmost 
care in investigating their nature and origin. They maybe slight or severe, superficial 
or deep-seated; they may occupy the forehead, the vertex, the temples, or the occiput. 
The pain may be dull or sharp, gradual or sudden, continued or paroxysmal. These 
headaches may last a few hours or continue for months ; they may destroy the happi- 
ness of a lifetime, and in old age depart; they may be associated with disordered sensa- 
tion or disturbance of vision. Nearly all seem to owe their essential origin to disturb- 
ance in the nervous system before the vascular area is involved. Mental and emotional 
excitement can originate active congestion in the brain as readily as it is induced by 
cardiac hypertrophy or a general plethora. Passive congestion is favored by any 
exhausting cause. 
Dr. Ferrier, in speaking of brain and mind, says, " that the degree of development 
of the frontal lobes is characteristic of the mental powers, the richly convoluted brains 
belonging to the highest intellects, and the poorest to the inferior intellects. ' ' It also 
appears from his statements that the slighter development of the frontal lobe convo- 
lutions is more especially marked in the female brain, which resembles, in this respect, 
the fœtal brain in its later stages of development. There are male brains which 
approach the female type, and female brains which approach the male type. As a rule, 
the convolutions are better developed in all the lobes when the frontal convolutions are 492 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
especially complex.* When we come to consider the actual size of the brain in the 
two sexes, we lind that the average weight of the adult male brain is five ounces 
greater than the average weight of the female brain ;f but if the size of the body be 
taken into consideration, the disproportion may not be great. After all, the actual size 
of the brain does not account for the difference of intellectual power between men and 
women. It is not, as Ferrier observes, a mere matter of brute weight or quantity, 
though a brain below a certain standard of weight is not compatible with normal 
intelligence. J According to the investigations of Sir Crichton Browne, the gray matter 
of the female brain is shallower than that of the male, and the supply of blood is pro- 
portionally less. These differences he dates from embryonic life, and comes to the 
conclusion that they constitute a " fundamental sexual distinction." 
CAUSES OF HEADACHES IN CHILDREN. 
The activity of the brain cannot be maintained without blood. It must be well 
nourished. A certain quantity of blood is indispensable to the performance of its 
healthy functions. If it be deficient in arterial supply, then its vitality is lowered, the 
mind is impaired, and the thoughts are confused. Not less important is the quality of 
the blood. If it be impure and deficient in nutritive qualities, it invites nervous 
change. Slight mental effort or violent muscular exertion will induce this, if the 
blood is not purified. The lungs, the liver, the bowels, must be in a condition to purify 
the blood. These facts are sometimes overlooked in searching out the cause of 
headaches. 
I have, in a paper on "Headaches in Children, referred to excess of blood iu the 
brain (cerebral hyper æmid) and to deficiency of blood (cerebral anaemia). These two 
factors are most necessary to keep in view, for the cerebral circulation is greatly 
influenced by the relationship that exists between the nerves and blood vessels. They 
comprise the two great types of headache among school children, and among children 
generally. 
The brain fails early in some children while in others it gathers strength as years 
advance. In childhood, when growth is actively proceeding, the constitution is so 
impressible that there is a remarkable tendency to nervous trouble; rapid development 
of organs disturbs the excito-motery system, and at this period of life there is great 
liability to disease. This predisposition being once established, almost any influence 
may excite nerve disorder. 
Heredity greatly predisposes to nervous headaches in children, just as it does to 
gout and cancer in later life. It is handed down from parent to parent, sparing those 
of the offspring who may be vigorous, but striking down the susceptible and weak. 
The expression is familiar, "I take after my father," or, " I take after my mother." 
It seems probable that in certain structures of the tissues there is an especial liability to 
take on certain diseases. 
The habits and education of some children are just of that kind to invite nerve dis- 
order. Change these circumstances, and it no longer exists. 
The class of sufferers, then, belong to those of a nervous temperament, who are 
easily moved to excitement or depression; they are restless, active, giving all their 
mental force or energy when required. These children are liable to anæmic headache 
and brain disturbance, not to congestion of organs and plethora so readily as those of 
the sanguine temperament. Maternal health during pregnancy has been recently shown 
by Dr. Langdon Down to have a great influence in the production of idiocy in the child. 
*" The Functions of the Brain," 1886, p. 467. 
■(■"Carpenter's Physiology," 1876, p. 736. J Op. cit., p. 467. 
Read before the Harveian Society, Feb. 2d, 1882. SECTION X-DISEASES OF CHILDREN. 
493 
Sickness, uterine hemorrhage, emotional disturbance and grave febrile disorders lead, in 
the offspring, to epilepsy and chorea. In congenital idiocy, heredity is a great factor, 
neurotic disease being fearfully transmissible. Prolific child-bearing tends to produce 
feeble-mindedness in the children; violent shocks of all kinds, distressing news and 
severe emotional disturbance to pregnant women have weakened the mental powers of 
their offspring. Dr. Down's inquires lead to the conclusion "that the mental condition 
of the embryo took its impression from the mental condition of the father at the time 
of conception. ' ' The ' ' over-education of women, when only the emotional side of their 
nature is cultivated, leads to the production of feeble-minded children."* 
Careful inquiry will now and then elicit a history of syphilis in the parents, or 
some form of nervous disease in them, or of convulsions in infancy, or of such inherited 
tendency before birth. There may be, and there often is, a combination of causes to 
invite nerve disturbance, as feeble health, fatigue, mental shocks, and the want of food. 
No explanation has yet been forthcoming to account for the predisposition to some dis- 
eases, but we do know, where it is latent, how readily they are invited; what a trifle 
will disturb the balance and originate changes of function and alteration in structure. 
What do we know regarding the obscure diseases of the nervous system in children, 
such as tetany, or chorea, or what of certainty about epilepsy ? The phenomena vary 
in each disorder. That they are due to some derangement of the nervous system, or to 
some irritation acting on excitable nervous structure, cannot be gainsayed; but what more 
do we know ? I have known children who suffer from periodical headaches to exhibit 
symptoms not unlike an approaching attack of epilepsy-perhaps epileptic in their 
nature, but falling short of the culminating point. 
OVER-PRESSURE. 
I will endeavor to look upon this question in the most impartial manner, and to 
arrive at no hasty conclusion. The agitation concerning ' ' over-pressure, ' ' in all parts of 
the world where the old system has given place to the new, would not have arisen 
without cause. It is not limited to the United Kingdom ; it comes from nearly every 
country in Europe. We must admit that enthusiasts are prone to exaggerate when they 
witness a few cases of break-down, and fail to remember the thousands of children who 
pass through their school life happier and better for the regular hours and discipline 
that is maintained. Still, the outcry is real; and if it draws attention to the evil where 
it exists, improvements will inevitably follow, and cases of over-strain will become less 
frequent. 
It will be conceded that no system of education, however carefully conducted, will 
meet the requirements of all children. The State cannot legislate for individuals. The 
child of sanguine temperament and robust constitution is happy with his educational 
training, and he can throw off any feeling of strain the moment he gets into the play- 
ground, and forget all about it ; but the child of nervous temperament is too anxious 
and miserable at the idea of failure. He is defeated by his own anxiety. This applies 
more to girls, whose leisure hours are very differently passed. They are far less active 
than the opposite sex, who throw their whole thoughts into cricket or other amusements, 
which girls cannot always do. Girls are by nature more nervous and impressionable; 
the mind is more easily over-strained, and they brood over their tasks long after they 
are set aside, which is so much wasteful expenditure of nerve force. 
Mr. Romanes, in an interesting article on the " Mental Differences between Men and 
Women," f has collected evidence from High School girls who are studying with a view 
of competing for first classes at Cambridge. Many work habitually ten or eleven hours 
*"Lett. Leet. B. M. I.," 1887, Jan. 22d, pp. 149, 150, 151. 
f The Nineteenth Century, May, 1887. 494 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
a day, and near the time of examination from fifteen to eighteen hours. The power of 
endurance in these girls is proved beyond doubt, but such over-pressure is often the 
prelude to an early break-down. 
The experience of every-day life assures us that but few men attain to eminence, or 
are capable of sustained effort in any calling, if they are of delicate constitution. The 
sound mind in the sound body is indispensable. Broadly speaking, those who have had 
a happy and healthy childhood are the most successful competitors in the race of life. 
The intellectual type of boy, endowed with a strong brain, is not easily overworked. 
He possesses the instinct of knowing how to take care of himself, while the intellectual 
boy with a feeble brain and over-zeal to accomplish his work soon fags and degenerates 
in power. He is not well balanced in mind or body, and lacks the capacity to meet the 
demands made upon him without feeling too acutely the worry and strain. But those 
who are dogged and indolently inclined, who are indifferent, and without ambition for 
success in life, never put forth their efforts. This type is probably the exception in the 
female sex; moreover, being physically weaker than boys, they are mentally more liable 
to break dow n. It has been truly said, that many persons spend more hours in thinking 
over the work they have to do than it would take them to do it twice over. Deficiency 
in energy of will is often physical at bottom.* Nowhere has a more correct statement 
been made than that the mental force of girls tends, in a large number of cases, to dis- 
solve into emotion.f 
It has been proved, however, both in this country and in America, that young girls 
are more acquisitive than boys of the same age, and there is stronger pojver of percep- 
tion, but as adolescence is reached, and the brain is more fully developed, boys show 
greater originality of mind and power of amassing 
Headaches, I am convinced, have become of more frequent occurrence among poor 
children, and deaths from meningitis are more on the increase, since the Education Act 
came into operation. I have met with cases of meningitis in school children in whom 
headache was neglected, and the initial and curable stage allowed to pass by. If this 
mischief be invited by over-pressure, we may justly and indignantly protest against a 
system which exacts harder lessons than the child can well accomplish, and against the 
misguided effort to maintain his attention. 
Where, for economy's sake, very large numbers of children have to be taught 
together, it is impossible, even with the best system, to prevent the weaker and more 
delicate children from suffering. Still, we have overwhelming testimony from medical 
men and teachers, that infinite mischief to the mind, to the eyesight, and the general 
health of the scholars is frequently caused by the increasing requirements of the Educa- 
tional Department. The Act of 1870, which only provided for Elementary Education, 
consisted of reading, writing, arithmetic, and needle-work ; but since then other sub- 
jects have been added, namely, geography, elementary science, history, Euclid, alge- 
bra, mensuration, chemistry, physics, botany, physiology, Latin, French, etc. Although 
these subjects are optional, and only a few are allowed to be taken up at one time, the 
spirit of emulation that is encouraged too often tries the strength of the children 
beyond endurance, and makes too great a demand upon the tender intellect. Children 
who are poorly fed and poorly clothed, or who are delicate, cannot be expected to accom- 
plish much varied intellectual work without an early break-down, especially when they 
come, as many of them do, from wretched homes, where a family of five or six fre- 
quently live in one room. 
The facts obtained by Dr. Hertel from fourteen schools in Copenhagen show' that 
out of a total of 3141 boys, one-third of the number is made up of sickly ones, and 
* "Over-work, from the Teacher's Point of View," by Mrs. S. Bryant, D. Sc., 1885, p. 6. 
f Idem, p. 8. J Op. cit., Itith. Century. SECTION X-DISEASES OF CHILDREN. 
495 
that most of these children enter on school life with impaired health. That this is a 
very grave state of things must be admitted, such children being incapable of much 
intellectual exertion, at a period when all their force and vitality are needed for physi- 
cal development and when outdoor life is so essential. At about the age of twelve, 
when the children pass from the mixed classes into the modern division, the percentage 
of sickly children rises in the first modern class to 38.8, and in the second classical 
forms to 41.9. Dr. Hertel remarks that the increased sickliness in both instances is 
owing to the development into manhood, commencing about the thirteenth year. There 
is a fall in the sick percentage in the higher forms. 
From nine to twelve, according to Dr. Kotelman, the increase in height is 5.71 inches, 
the increase in weight 19 pounds; from thirteen to sixteen the increase in height is 
9.37 inches, the increase in weight 44 pounds; from seventeen to twenty the increase 
in height is 2.43 inches, the increase in weight 23 pounds. These investigations prove 
that when physical development is most active, at thirteen, or thereabouts, and growth 
is rapidly proceeding in bone and muscle, if the mind is forced to such an extent, the 
evil consequences may be permanent. 
Reviewing all the facts which he has collected, Dr. Hertel arrives at the conclusion 
that 20 percent, of the children are sickly on entering the Danish schools; after two years 
they advance to 30 per cent., and shortly before puberty they suddenly rise to 40 per 
cent. This shows what an extraordinary influence school training, with the change 
of habits, has upon the health of young persons during the period of life when growth 
is making its most supreme efforts. The outdoor life which is so natural and conge- 
nial to boys, is exchanged for a sedentary and thoughtful occupation. Such a contrast 
cannot take place without an influence on their health and spirits.* 
VENTILATION 
Is a matter requiring careful consideration. I am sure that defective ventilation of 
school-rooms is a most fertile cause of headache. If the air of these rooms, or any 
inhabited apartment, is impure, in consequence of too many persons being crowded 
together, so that the products of respiration or uncleanliness from any cause contami- 
nate the atmosphere they breathe, it is injurious to the health, and the nervous system 
is sure to suffer. We can form some idea of this from the close atmosphere of theatres 
and ball-rooms, and the headache induced by them. Although the air of any room 
where a large number of persons assemble cannot possibly be as pure as the outer air, 
mechanical contrivances can be adopted to render the atmosphere of any apartment 
moderately pure. In many of the best arranged dwelling houses of London no sen- 
sible difference is experienced on entering them. There is no disagreeable odor; but, 
enter them when they are brilliantly lighted and the space is crowded, and even with 
the best appliances a closeness is felt if the carbonic acid in it reaches seven or eight 
per 1000 volumes. If it reaches nine or ten per 1000 volumes it is "close and gusty."f 
It seems to me headache is as often the result of a polluted atmosphere as of the 
lessons imposed on the pupils. 
It is indispensable that wherever large numbers of children are assembled together 
there should be a constant supply of fresh air, in order that the atmosphere may be 
kept pure and sweet. The rooms should be frequently disinfected to destroy the 
organic emanations. Our board schools, being of modem structure, are well adapted to 
insure this supply of purer air, and every care has been taken, from a sanitary point of 
view, that the health of the children should not suffer, but the proper use of the sani- 
tary means must rest with the teacher. Persons who live habitually in an impure 
* " Over-pressure in High Schools in Denmark," 1886, pp. 23-33. 
" Parke's Manual of Hygiene," 1873, p. 134. 496 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
atmosphere breathe noxious gases and vapors, without a knowledge of their existence, 
their olfactory organs having lost their normal sensibility. It is only when persons 
coming from the open air enter impure dwellings that they are fully aware of the state 
of things. 
NEK VOUS HEADACHES. 
A weak cerebral circulation, whether arising from general debility or from heart 
weakness, invites nervous headache in those predisposed to it. If a child or an adult is 
wanting in constitutional strength and vigor, nerve disturbance will ensue when he is 
overtaxed by intellectual effort or by any exhausting illness. To unravel the relation- 
ship existing between the mind and the body would demand a philosophical inquiry, 
into which I will not venture. The brain is a complicated organ, and some of its dis- 
eases are not explained by a minute examination of its structure after death. 
The mental functions are in some degree dependent upon material organization, 
and are closely related to it. Intimate as is the alliance, dissection of the nervous sub- 
stance does not clear up the difficulty ; still, we are able to compare how the one acts 
and reacts upon the other, and of the connection that exists between them. 
All cases of nervous headache in school children cannot be traced to mental 
strain. If the brain be normal, and the general health good, no danger will result 
from carrying out the educational code ; but in weakly and sensitive children the 
foundation of serious illness may be laid by enforcing a degree of intellectual exertion 
which a healthy child could bear with impunity. 
Headache is one of the first symptoms that arises. As soon as it declares itself the 
•whole aspect of the child is altered, and he is engrossed with his own sufferings. Mel- 
ancholy takes the place of cheerfulness. He is kept at work, because his ailment is not 
noticed by his teachers or by his parents. With this state of things, the child soon 
becomes anæmic, loses his appetite, and the headache, which at first was occasional, 
becomes habitual. Dr. Treichler states that one-third of the pupils at Darmstadt, 
Paris, and Nuremberg suffer from it.* He considers the cause to be over-intellectual 
exertion entailing work at night, and taking up a variety of subjects.! 
The anæmia produced in these cases sets up disturbance in the ganglion cells of the 
cortex of the cerebrum, the quality and quantity of the blood become changed, and the 
brain loses energy and activity. The mind is consequently enfeebled, and the mental 
faculties are clouded. When this is once brought about, children become emotional 
and excitable ; hence the cerebral vessels become too suddenly filled with blood to 
bear it with impunity, and this dilatation of the vessels (local hyperæmia), through 
vasomotor disturbance, is another common cause of this form of headache ; the vessels 
of the brain are partially paralyzed, and the ganglion cells too exhausted to grasp new 
ideas, as Dr. Treichler observes. 
Of 7478 boys and girls examined by Professor Bystroff, in the St. Petersburg schools, 
during five years, ending in the spring of 1886, he found headache in 868, or in 11.6 
per cent. The percentage increased with the ages of the children and with the num- 
ber of hours occupied in study; thus, it occurred in only five per cent, in children eight 
years of age, while from fourteen to eighteen it attacked from 28 to 40 per cent. 
The author attributes these obstinate headaches in school children to excessive mental 
labor. J 
Similar experience is recorded by Dr. Hertel. He found headaches increase as the 
oldest classes were reached. In the lower mixed classes it was 5 per cent. In the 
two highest classes it rose to 38 per cent. This class is the most exposed to head- 
ache and bleeding at the nose-proofs, as he justly states, that mental work favors 
* Intellectual Timet, April, 1880. j- Ibid. 
J "On Headaches in School Children," Brit. Med. Journ., May, 1886. SECTION X-DISEASES OF CHILDREN. 
497 
congestion of the brain, and I would add constipation and the troubles resulting from 
a sluggishness of the bodily functions. I am frequently meeting with boys and girls 
in whom headaches, nose bleedings, and muscular twitchings have followed studious 
application to books. The same holds good with respect to the frequency of nervous- 
ness and anaemia, f 
FRONTAL HEADACHES. 
The most frequent form of headache from intellectual work and overstrain is pain 
across the forehead, generally the whole forehead, and especially along the superciliary 
ridges. There is a dull, oppressive weight ; it is felt on waking and increases during 
the day. Any reading or intellectual exertion involving close attention, reasoning or 
reflection, increases the pain, and the child will often be seen leaning his head forward 
on his hands, oppressed with suffering. The forehead, which at first is cold like the extrem- 
ities, becomes hot after an interval, the temples throb, and the child cannot bear the 
light. There is tension and fullness in the cerebral vessels. The appetite is generally 
poor, or is absent altogether, frequently the tongue is furred and the bowels are torpid. 
The face at first is pale and drawn, then it may become flushed, and vomiting, which 
brings relief, may then ensue. I have known such children become very torpid and 
listless from this form of congestive headache, and avoid their companions. They sleep 
and dream heavily, often of their tasks, while in other cases they become quite changed 
in character, and are nervous, restless, and irritable. Here the brain is rather irritable 
than congested. Such children are sometimes furious in temper if any opposition is offered 
to their wishes, or they are low-spirited and will not utter a word unless spoken to. If 
a girl, she may be so emotional as to burst into tears on the slightest provocation. 
Sometimes any intellectual effort, however easy and however much sought after by the 
pupil, cannot be accomplished without the recurrence of headache ; even reading aloud 
to another person, and the small attention given to it by the pupil will bring on the 
pain. The study of mathematics, or anything involving much strain, will make the 
suffering all the greater. 
There is sometimes a disproportion, as I have hinted, between the cerebral develop- 
ment of the child and the intelligence he possesses; just as the muscular system suffers 
pain and weariness when it is imperfectly nourished. 
If the headache is moderate, the child, either of his own accord or at the desire of 
his teachers, continues his work, but it is a trouble to him, for he is taken up with his 
pwn suffering, and the mind is so unhinged that he soon forgets what he has learned. 
There is no disguise with one who is really suffering from a genuine congestive head- 
ache ; he can generally be recognized ; his whole manner bespeaks pain, and he cannot 
change his thoughts, the least movement increases the pain, and he desires to be alone. 
NEURALGIC HEADACHE (ONE-SIDED HEADACHE) 
Is not of frequent occurrence among children as a consequence of school work. It 
is rarely traceable to this cause, yet it is sometimes met with. Whenever it is com- 
plained of the teeth should be carefully examined, as a carious tooth will often be found 
to cause the trouble, though in anaemic and exhausted children the pain may continue 
a long time after the removal of the tooth. People of all ages may have carious teeth, 
and yet only suffer headache or facial neuralgia when the health is reduced. Such suf- 
ferers belong more especially to the neurosal temperament, the nervous system becom- 
ing lowered after intellectual exertion. The most striking cases in my experience have 
been in delicate constitutions, and among half-starved children, who live in wretched 
homes and who are deprived of fresh air and wholesome food. After long and painful 
illnesses I have known it very severe. The pain is always paroxysmal, coming and 
Vol HI-32 
f Op. cit., p. 36. 498 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
going when least expected. It is almost invariably unilateral, affecting one or other of 
the branches of the fifth nerve on one side only. There are certain painful and tender 
spots in the course of the affected nerve, and sometimes hyperæsthesia. When severe, 
the face betokens terrible anguish and despair. The patient cannot bear the noise of 
other children and becomes fearfully irritable under it. In the intervals of pain he is 
cheerful and energetic. He seldom vomits. In a case of this kind there may be con- 
gestion of the conj unctivæ, lachrymation, throbbing of the temporal arteries, frequent 
pulse, and sometimes, though rarely, so much vomiting that the child is thought to be 
bilious. In 1881 I saw a little girl, eleven years of age, who had been a victim of it 
from four years of age. It followed an attack of acute tonsillitis and enlarged cervical 
glands. In another case it was a sequel of whooping-cough and diphtheria. During 
the second dentition, when the teeth are slow in appearing, neuralgic headache involv- 
ing the branches of the fifth nerve, as they ramify over the brow and temple, is some- 
times observed in boys and girls. I have known attacks of facial neuralgia frequent in 
young, anæmic and excitable girls, who exhaust themselves by great mental application 
and insufficient rest and relaxation. They throw off the acuteness of the seizure by 
resting for a few days, but the pain returns when school work is resumed. 
IRRITABLE BRAIN. 
An occasional effect of school work is to produce an irritation of the brain, in other 
words, an excessive and morbid sensibility, which may be followed by congestion and 
meningitis. I have elsewhere referred to simple cerebral irritation as a functional dis- 
order in very young children, independently of any association with congestion or 
inflammatory exudation. I have spoken of an "irritable diathesis" in these cases, 
and, although the pathology is obscure, I believe that anaemia of the brain from defi- 
cient circulation is the primary change.* 
Children so affected are of nervous and anxious temperament; they are delicate in 
constitution, sometimes rickety, or reduced by diarrhoea, or by the eruptive fevers. 
Delayed dentition, the presence of intestinal worms, a slight blow on the head, or expo- 
sure to the sun or cold may invite it. But whatever the cause, the nervous system is 
weak and unstable. The most typical cases to which I have drawn attention are in 
young children from two to live years of age, before they have gone into the school room, 
when one or other of the causes to which I have alluded would be in operation. As a 
consequence of school work, I have met with it in boys and girls. In one case a boy 
eleven years of age suffered from this state of brain. He complained of headache after 
school examinations, but it never seemed severe. He was rather strange in his man- 
ner, and, as I have observed in similar cases, could not concentrate his attention. It 
was accompanied with fainting fits, and he could not obtain any sound rest at night, 
dreaming and tossing about. His temperature would sometimes run up to 102° in the 
evening, and fall to the normal point in the morning. Recovery followed complete rest 
for six weeks and good nursing. 
In these cases we must not wait till the patient complains of headache. It is 
important to recognize the first symptoms of cerebral irritation. There may be nothing 
definite, but we know the boy or girl is not well by some alteration in his or her dispo- 
sition; the absence of self-control, petulance, anger, restlessness at night, and weariness 
over lessons should be enough to direct our attention to a group of symptoms which, 
if unheeded, will end in a break-down. 
In girls, more especially from thirteen to fifteen years of age, a tendency to hysterical 
disturbance sometimes accompanies this state of brain, often invited by close and con- 
tinuous study when important physiological changes are taking place in their constitu- 
* "On Irritable Brain in Children," Med. Soo., London, 1886. SECTION X DISEASES OF CHILDREN. 
499 
tion. They are first exhausted, then they become irritable, and finally hysterical. 
Being by nature softer, weaker, and more sensitive than boys, the forced efforts to 
acquire knowledge in many subjects cannot be borne with impunity. Even great energy 
•of character and determination of will are sure to lead to failure when the health is 
delicate. They require rest and relaxation at this period of their lives to enable them 
to throw off the languor and depression induced by laborious study and close applica- 
tion. 
The vision is constantly affected as a result of over-strain, and myopia is common 
among children in elementary schools. Dr. Widmark examined the condition of the 
eyes of young persons attending some of the schools in Stockholm. He examined 704 
males and 742 females. He found that from six to eight years of age there was no 
myopia; at nine, though the girls were still nearly free from it, 14 per cent, of the boys 
were distinctly myopic. This difference arises from the boys having to work harder in 
the preparatory school before admission to a secondary school. After this age myopia 
goes on increasing in both sexes until, at sixteen, when girls usually leave school, the 
percentage is 33. The percentage among the boys is 39. Among the advanced pupils 
myopia was more common and more marked among the girls. Dr. Widmark attributes 
the latter circumstance to delicacy of sex, but mainly to inferior physical education, 
and needlework and music in place of outdoor games.* Excess of work for the eye 
seems to be more detrimental to girls than to boys. 
A Government Commission recently made an inquiry concerning the eyesight of the 
children in the classical department of the largest schools in Denmark. They found 
that the percentage of short-sightedness increased with the number of the class ; thus, 
among boys in the first class it was 14.7 per cent., increasing gradually upward till it 
reached 45.4 in the sixth class, f Sir Crichton Browne proved, in 1885, that as many as 
25 per cent, of the children in our elementary schools were short-sighted, and Mr. Bru- 
denell Carter's experience is in the same direction. Myopia, hypermetropia and astig- 
matism are the chief disorders. 
If this large percentage of boys suffer from myopia, there must be a considerable 
number of children who are hypermetropic, which is more likely to produce headache. 
One very startling case of this kind came under my notice some years ago. A delicate 
boy, twelve years of age, during a long and painful illness, which proved fatal four 
years afterward, was in the habit of reading a great deal in the recumbent posture. He 
became hypermetropic, and, according to an oculist, had the sight of a man at seventy. 
He also suffered from terrible paroxysms of headache, of the one-sided or genuine neu- 
ralgic type. Every ophthalmic surgeon is acquainted with a variety of headache (ocular 
headache) which arises from excessive strain on the eyes for the accomplishment of 
minute work of any kind or reading small print. 
From the foregoing observations it will follow, as a matter of course, that these head- 
aches cannot be successfully overcome till the cause is removed. Once invited, they 
take a hold which may last more or less for life. Look at the question as we may, the 
system of education and the habits of life have changed like past manners, customs 
fashions and pleasures. The nervous system is in a state of greater tension and trembles 
more in the balance than formerly. First with respect to education and over-pressure 
where it exists. It is evident that no system can be adopted unmixed with evil of some 
kind. The most carefully-devised plan for instruction has its drawbacks and its short- 
comings. Though existing regulations may be sound, there is room for improvement. 
It is proved beyond the possibility of doubt that strong and well-fed children, who live 
in comfortable homes, can accomplish the standard subjects without any risk of a 
break-down, while those children reared in squalid homes and badly fed are likely to 
* The Lancet, February 28th, 1887, p, 456. 
f Op. cit., p. 147. 500 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
fail in the elementary subjects taught in our schools, and headache is about the first 
symptom they complain of. These children would succumb under almost any system 
of education. Their constitution will not bear the training prescribed for the gener- 
ality. Pressed beyond their strength, their growth is stunted, they lose their appetite, 
become irritable, and lack interest in everything. 
Life passed in large towns and cities, with the noise, the bustle, and the impure 
atmosphere, is terribly exhausting to the poor school child, who has not the same advan- 
tages as the country child who breathes purer air and lives on more wholesome food. 
Constitutional weakness is not so quickly invited. The country child pursues his work 
in a steady, quiet, plodding way, and is not so easily driven, hurried or terrified by over- 
zealous teachers. Headaches among these children are rarely met with as a conse- 
quence of education. But the case is quite different with delicate children who are 
educated in our large towns and cities. Headache is the first symptom to attract our 
attention in these cases. It has a very injurious effect upon the health and spirits of 
the child. He loses color and becomes anæmic; pathological changes lead to a disturb- 
ance in the nutrition of the brain, which, being badly nourished, is quickly fatigued. 
Headache and irritability of the brain are followed, sooner or later, by a passive dilata- 
tion of the cerebral blood vessels. Now, it is in children who have suffered from an 
irritable brain that grave danger is to be apprehended if undue pressure is put upon 
them as they grow older. Sir Crichton Browne, in this country, Hertel (Denmark), 
Treichler (Bad Lenk Bern), Kjelberg (Sweden), are unanimous in opinion that the 
school system of their respective countries is injurious to the growing powers of such 
boys and girls, by enfeebling the mind, and thus destroying the force of character in 
after-life. 
Professor Kjelberg, of Upsala, is of opinion that the true powers of mind and force 
of character are wanting among the young men of the rising generation. Dr. Hertel's 
observations show that headache and nose-bleeding are common among boys in the 
Danish schools, the school work tending to produce congestion of the brain; they do 
not obtain sufficient sleep, some even sitting up late, till midnight, and working ' ' over 
eleven hours a day,"* so that they have neither the time nor the strength and inclina- 
tion for outdoor exercises to maintain the general health. To overwork a young 
brain is to enfeeble it. 
All strain falls heavily upon delicate constitutions. If the child who has suffered 
from an irritable brain cannot obtain sufficient sleep, and has become over-anxious in 
his work, congestion of the brain, leading to meningitis, is an occasional result. I have, 
within the last four years, seen four children who died from meningitis, traceable, I 
think, in the most conclusive manner, to school work and night lessons at home. 
No course of instruction in a school can be framed to meet the capacity of every 
child, but I think a medical board should be established, which would help us in this 
direction, and decide whether the child is fitted to go through the code as laid down by 
the educational department. Sir Crichton Browne, upward of three years ago, advo- 
cated the weighing, measuring, and medical examination of every child in every 
elementary school, and the recommendation was an excellent one. If we only take a 
casual glance at some children, we see at once that it would be preposterous to view all 
of them, at a given age, as equal in mental capacity and physical strength. But this 
is what the school board does. It lays down, almost of necessity, hard-and-fast lines. 
It presupposes that the same amount of intellectual work is obtainable from a child 
that is delicate and weak as from one that is vigorous and strong. As Sir Spencer 
Wells puts it: "The vice of the system is that it is indiscriminate."! It seems to 
* "Over-pressure in High Schools in Denmark," by S. Hertel, 1885. 
j- " Inaugural Address, delivered before the Congress, at York, 1886." SECTION X-DISEASES OF CHILDREN. 
501 
me, therefore, that Sir .Crichton Browne's suggestion for a regular medical examination 
should be adopted, in order that it may be ascertained whether a particular child is 
capable of going through a part or the whole curriculum of school work. If this was 
adopted, sickly children, and those with a history of irritable brain, would be weeded 
out, or, at any rate, the same course of study and application would not be expected 
from them. 
A child of ordinary health and intelligence, who goes to school regularly and gives 
moderate attention to his studies, is scarcely likely to suffer from headaches in conse- 
quence, unless he is predisposed to them; but there are many children who attend our 
board schools whose physical and mental powers fail under the attempt ; they become 
excited with the forced effort they employ to keep pace with their rivals, and so mis- 
chief, which might have slumbered or passed away, is awakened, and failure results. 
Home lessons, in addition to regular attendance at school, is surely unsuitable for deli- 
cate and very young children. I could quote several instances in which grave mischief 
has followed the over-exertion of a child's mind. 
If intellectual training in the young be carried too far, and at the expense of physi- 
cal health, deterioration must result. Competitive examinations are now carried to a 
point far beyond the capabilities of many boys and girls, and it has become of the great- 
est importance not to lend too much encouragement in this direction. Yet year by year 
the forcing system goes on in every country in Europe, and the supervision which ought 
to be exerted is not provided. 
We must understand the laws of nature if we are to be and to keep in harmony 
with them. As Mr. Herbert Spencer pointed out long ago, and as all experienced and 
thoughtful teachers believe, those who have to do with the rearing and training of 
children should be thoroughly acquainted with their physiological and psychological 
natures, with what promotes and what injuriously affects the development of these. In 
our actual studies and methods of education this is too often neglected, and artificial 
conditions are created which act injuriously on the organism. The child gradually 
drifts into ill health, nutrition is impaired, and growth, instead of being uniform and 
progressive, is checked, and the brain loses its energy. 
In the treatment of recurring headaches in school children many points require 
attention. In the first place, education must be abandoned for a time and the child's 
thoughts be directed into another channel, so that the brain may lie fallow or be other- 
wise and more gently exercised. The mischief is brought on by over-strain, which first 
induces irritation of the brain, followed by congestion and disturbance of the cerebral 
circulation. I frequently see children whose parents, in ignorance of the circumstances 
which have led to this trouble, will not consent to their studies being temporarily 
relinquished, and the consequence is they gradually drift into bad health; the bowels 
become costive, the appetite is capricious or destroyed, and headache and confusion of the 
brain become chronic. The pain, in these cases, is almost invariably frontal-a dull, 
heavy, continuous pain across the centre of the forehead or immediately over the eye- 
brows. It is an oppressive pain. This character of headache is invariably aggravated 
by iron and quinine. Bromides should be given three times a day in full doses to 
lessen excitability and quiet the brain; if there be nausea, let them be administered 
in effervescence with carbonate of soda and ammonia; keep the bowels gently open. At 
the onset, it is sometimes advisable to give a full saline purgative, so as to drain the 
portal circulation and indirectly relieve the head. Above all, bathe the head with a 
large sponge well soaked in tepid or cold water. Let it be done frequently during the 
day. I have known this to give more relief than any other remedy that could be sug- 
gested. It lessens the congestion of the over-filled vessels, promotes their contraction, 
equalizes the cerebral circulation, and exerts a sedative action on the nervous centres. 502 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
TREATMENT OF IRRITABLE BRAIN; 
As soon as the patient shows signs of cerebral irritation, all school work should be 
abandoned. Slight headache, disturbed sleep and easily-induced fatigue are warnings. 
If promptly attended to, they will, in most cases, vanish; but if they are unheeded, 
and the child continues to exert his brain, the circulation will become more disturbed, 
the headache will increase in severity and the temperature run up three or four 
degrees, from mental excitement and exhaustion. Rest of mind and body is to be 
adopted, as in all forms of headache traceable to school work. Bromide of potassium 
and hydrate of chloral will be required if there be restlessness and any febrile disturb- 
ance. These remedies will tend to lessen congestion and arterial tension, should these 
be present, and will calm the excited brain. Cold applications to the head will often 
invite sleep and tranquillize the patient when chloral and bromide fail. When the pain 
subsides, and there is no vomiting, milk, beef tea, and other simple kinds of nourish- 
ment should be given. It must not be forgotten that this irritation, if not carefully 
watched, may pass into severe congestion and meningitis. 
TREATMENT OF NEURALGIC HEADACHE. 
Here, also, rest and relaxation are of primary importance. If the pain is traceable 
to over-exertion of the mind, lessons must be discontinued and the general health 
attended to. When no cause can be ascertained, it is often hereditary. If it should 
prove to be of malarial origin, then quinine and arsenic are the remedies to employ; 
and if there be anæmia-a very frequent cause-then iron is the most reliable drug. It 
is an excellent plan in these cases to give the child one or two teaspoonfuls of cod-liver 
oil after breakfast, before he goes to school, this being one of the best means we possess 
for strengthening the nervous system. It increases the red corpuscles in the blood and 
improves digestion. A small quantity of alcohol, in some shape or form, with the two 
chief meals of the day, may be necessary. If there are decayed teeth they must be 
attended to. Severe supra-orbital neuralgia has yielded to the lancing of the second 
molar tooth.* 
NECESSITY FOR SLEEP IN SCHOOL CHILDREN. 
The importance of sleep cannot be over-estimated in children whose brains are 
much taxed by school work. Complete suspension of mental activity and rest of the 
muscular system are needed for at least nine hours out of the twenty-four, children of 
sensitive temperament requiring a large allowance of sleep by reason of a more rapid 
expenditure of nervous energy. If home lessons are required of such children after a 
day's work at school, they are sure to prove injurious. Children of bilious and phleg- 
matic temperament may not need much sleep, because they are habitually torpid, and 
the "wear and tear " is not so great with them. But there are children in whom the 
disposition to somnolency exists, and their health would seriously suffer if they did not 
obtain it. Whenever sleep is profound and children cannot be easily aroused, it is an 
evidence that they have not had enough. Sleep, to be healthy and restorative, should 
be quiet and dreamless, the functions of the mind being completely suspended. 
The study of health and disease ever offers something new. Our bodily organs are 
exposed to constant change; they are prostrated by pain, stimulated by pressure, sub- 
dued by fear; they sympathize with our mental state, and in order to realize the con- 
nection we should carefully consider every little fact which has an import and a mean- 
ing; not that we may speculate on what may happen in the future, but that we may 
know what is happening in the present. As Milton tells us-• 
Not to know at large of things remote 
From use, obscure and subtle, but to know 
That which before us lies in daily life, 
Is the prime wisdom -Paradise Lost. 
* Brit. Med. Jour., May 5th, 1882. SECTION X-DISEASES OF CHILDREN. 
DISCUSSION. 
503 
Dr. Wm. S. Dennett, of New York, said:-J/r. President, Gentlemen and 
Ladies-I thank you for the privilege of taking part in the discussion of this inter- 
esting and suggestive paper, the reading of which afforded me great pleasure, inas- 
much as it dealt not only with the detail of the subject from a purely medical point 
of view, but because the author has been led to consider one of the many relations 
that exist between medical and educational science. 
Here we are brought face to face with the fact that there is no well-recognized 
medical specialty so narrow in its scope that it does not afford room for the broadest 
investigation. The organ to which the specialist gives his attention may not be more 
than an inch in diameter, but if he is himself worthy to claim a place in the ranks 
of the liberal profession, he is likely to find himself at any time shoulder to shoulder 
with other men from different fields, each doing his part in some great work that 
raises him from the position of a business man to that of a philanthropist. 
There is a great deal of routine and drudgery in medical art, and the art is what 
we all must needs practice. But there is nothing narrowing or uninteresting in 
medicine as a science, and most of us are glad occasionally to leave the art behind us 
and interest ourselves to some purpose in broad questions of a political or a social 
nature. 
In this particular question of the influence which the medical profession ought to 
have in the direction of the affairs of the public schools, and the methods in accord- 
ance with which educational institutions should be conducted, we are all interested. 
My brothers in ophthalmology will bear me out in the assertion, that a very 
important part of the work that has been done by them during the fifty years since 
physiological optics has become a science, has had to do with questions that concern 
the medical profession as guardians of the race, and as being, in some measure, 
responsible for the welfare of the coming generation ; and that one of the most 
widely-recognized fields of useful action has been the investigation of the influence 
of school life on the visual apparatus of the individual and the race. It is with no 
little satisfaction that we are reminded, in listening to Dr. Day's concise and emphatic 
paper, that representative men from almost every branch of medical science are 
interesting themselves in the same, and there is, perhaps, no field among the prob- 
lems of the day where concerted action is more needed or where it promises more 
gratifying results, than in the subject before us. 
The condition of the schools of the civilized world tells us that our influence has 
been too little felt in the past. But the action of the colleges that are now begin- 
ning to add to their professorships those whose sole duties are to look out for the 
physical well-being and physical education of their students, tells us that we shall 
have abundant opportunity to make for ourselves a better record in the future. 
The history of Greece and Rome, and the faces and figures that their artists have 
left, give undoubted proof that there was a time when physical well-being was the 
all-important factor ; while, to-day, we seem to have forgotten that there is such a 
thing as a body to be cared for. We must neglect no opportunity to interest our- 
selves in such matters until ventilation, exercise and recreation are as much under 
the supervision of competent authority as grammar, arithmetic and geography. 
Dr. Day, in his careful enumeration of the causes of headache, mentioned those 
caused by refractive changes in the eye, and he has given some interesting statistics 
in regard to the frequency of such changes. No one familiar with the literature of 
the subject will think for a moment that the matter has been over-stated. We all 
know that myopia, hypermetropia and astigmatism are frequent causes of headache, 504 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and that permanent cure is often effected when this cause has been discovered and 
corrected. 
But headache is much more frequently associated with these troubles in adults 
than in children. Indeed, one of the unfortunate things about myopia in school 
children is, that it commences and increases in such a way that the victim has had 
no warning until after the damage is irreparable ; and it is this fact that has led the 
oculist so often to ask that periodic examinations of students be required. 
We all recognize the type of headache to which Dr. Day has referred as associated 
with refractive troubles, as well as the occipito-cervical feelings of discomfort which 
are associated with muscular insufficiency. The medical profession might congratu- 
late themselves if every case of incipient myopia were attended with pain, for then 
the child would have a tangible warning of the occurrence of this serious ailment. 
But the fact is, that though headache is an occasional symptom of myopia, it should 
be borne in mind by every one who is interested in the nervous diseases of children, 
the large majority of such cases have no emphatic warning of this kind, and often 
no warning of any kind. The principal symptom is a failure of vision for distant 
objects. And, as the speaker has mentioned recently, in a short article in the New 
York Medical Record of July 9th, all our children are allowed to grow up without 
even an approximate idea of what the healthy eye should see. 
Such oversight is very unfortunate, and not only the ophthalmologists, but the 
neurologists and all others interested in school hygiene, should hasten to remedy this 
oversight, among the many others which exist in the matters of school management. 
And this is not said in the spirit of one who complains of the past or of the 
present, but of one who hopes for the ftiture ; not of one who wishes to ignore the 
fact that the schools, as they exist to-day, are such that we point to them with 
pride, but of one who wishes to press forward earnestly in the good work that has 
already been done, so that no one can say that we, as heirs of all the ages, failed 
to appreciate the trust that we have received from our fathers, and to do for our 
generation as much as they have done for us. Progress in one age necessitates 
reform in the next, and there is no doubt that the very efficiency of the educational 
methods that we have received has made it incumbent on us to protect our children 
from the evil effect of over-exertion and stimulation, and many of us will be called 
upon to help to decide how it shall be done. We must not be too revolutionary in 
our methods. There are those who think that because intemperance has at some 
time done injury in our midst, and is still doing injury, the world should be governed 
by rales that would make of it a large asylum for inebriates. There have been dys- 
peptics who, in the fancied interests of reform, have tried to make their fellow-men 
do homage to their own weak stomachs by eating only Graham bread and abstaining 
from a more varied and stimulating diet. 
And some of us have heard lately that grammar should be abolished from the 
public schools because its intricacies have proved too much for some of the delicate 
intellects that have been brought to bear upon it. The writer of the paper to which 
I have the honor to respond has justly said that no hard and fast lines can be drawn 
to fit all classes of scholars, and he has described two classes of nervous and mental 
organizations which cannot be subjected to the same treatment, either in or out of the 
public schools. But let us who have, or who hope to have, influence in matters of 
educational reform, not make the mistake of sacrificing the strong to the weak in 
every particular. Let us teach more rather than teach less, but let us, as far as is prac- 
ticable, arrange that the first may ran while the slow may walk, and that neither 
shall be sacrificed overmuch to the other. And let us all hope ere long to see the day SECTION X DISEASES OF CHILDREN. 
505 
when the physician shall share with the metaphysician the responsibility of educat- 
ing our young ; when he shall have his place in the corps of public instructors, 
and when physical exercise as well as mental shall be a part of the daily cur- 
riculum in all institutions of learning. Let me ask, in closing, that those of my 
hearers who shall be in future called upon to assist in framing the laws which 
shall govern our school boards, shall bear in mind the necessity of tending as much 
as possible to some arrangement which will allow the bright and strong to take more 
while the feeble take less ; while each is able to receive his proportionate share of 
improvement. We must remember, too, that the science of education is as much a 
science as the science of medicine, and that while there are certain matters on which 
we as physicians can speak with authority, it becomes us to think carefully before 
insisting on any wholesale changes which do not seem good to our co-laborers in the 
pedagogic field, who are to-day as active and progressive in their departments as we 
are in ours, and who are cognizant of the fact that to certain types of mental organi- 
zation ambition is as injurious as laziness, and that only in the most exceptional 
cases is child or adult to be allowed to do his utmost. Whether he is training for a 
boat race or studying for a prize, he can ill afford to work himself to the limit of his 
endurance. Such effort is always injurious; the risk is sometimes necessary in the 
active business man; never to the scholar. 
Dr. J. G. Wiltshire, Bath, Me., remarked-I have listened to the paper with 
pleasure and profit. I arise to offer my thanks for his admirable presentation of the 
subject and to respectfully submit a few remarks which may serve to bring out more 
prominently a truth alluded to by Dr. Day. He states that the observations of 
ophthalmologists, in their investigations of the vision of students in a given country, 
have revealed the fact that myopia was found to exist in so many instances as to con- 
vey the idea that hypermetropia preexists much less frequently in children than 
myopia ; when, in fact, the converse obtains-the myopia occurring secondarily as a 
consequence of efforts of accommodation, and congestion of the eyeball when the 
students bow their heads toward the desks in their studies. The myopia steadily 
increases in percentage and extent as the amount of close work increases. Dr. 
Risley, of Philadelphia, found that myopia, commencing in the primary classes with 
a low percentage, steadily increases as the pupils pass to the highest grade in our 
public schools (see Sœlberg Wells, p. 631). Besides, Dr. Day admits that in the cases 
cited by him the myopia increases in degree and percentage as the student advances 
in his student life. Doubtless, in many of his cases there was no preëxisting myopia, 
the eye being emmetropic or hypermetropic, but afterward becoming myopic in a 
way that suggests the idea that this error of refraction is produced by the efforts of 
the muscles of accommodation and convergence while in the act of study. 
How is this change in the shape of the eyeball brought about? We will first 
suppose that we have emmetropic or hypermetropic eyes to deal with in children 
who are occupying low desks or high seats. In order that they may indulge a 
natural indolence they lean over their books, thus bringing the object of vision so 
near them that the rays of light no longer enter the eye in a slightly divergent 
direction, but in a highly divergent direction, so as to cause the eye to summon an 
extra effort of accommodation in order to focus them upon the yellow spot or centre 
of vision, and thus avoid producing circles of dispersion on the retina, as they would 
otherwise do. The combined efforts of accommodation and convergence will insure 
acute vision for awhile, but shortly headaches and other evidences of asthenopia 
announce themselves ; at this juncture the extrinsic muscles of the eye will begin to 
compress the ball, and the stooping attitude of the child favoring congestion, all 506 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
conspire to weaken and lengthen the tunics of the ball in an antero-posterior 
diameter, thus producing myopia. 
I can well see how astigmatism, hypermetropia and myopia can produce head- 
aches in those who violate the requirements of normal accommodation and conver- 
gence. To correct head symptoms due to errors of refraction and accommodation, we 
must remove the cause by selecting for our patients proper glasses. For hyperme- 
tropia give a convex spherical glass of proper strength ; for myopia select a concave 
spherical glass of the proper strength ; for astigmatism order a proper cylindrical 
glass with its axis in the correct meridian. 
Dr. Dennett, New York, replied that the statistics relative to myopia and other 
refractive troubles had been so long and so fully collected and tabulated that there 
was little or no uncertainty in the meaning of the deductions which could be made 
from them. It was easy enough for one to put his hand on the records of some- 
thing like a quarter of a million examinations. 
Dr. Dennett believed, that hypermetropia did precede myopia, and that no one 
thing could to-day be spoken of as the principal cause of that trouble, but that there 
were some reasons for thinking it to be one of the penalties that we pay for a civil- 
ized and thoughtful ancestry. 
He remembered to have seen some statistics collected among the Italian peasantry, 
where reading and writing were uncommon, but where there was undoubted descent 
from an old civilization, and where the percentage of refractive troubles was nearly 
as great as existed among the student classes in Germany. He referred to an article 
written about ten years ago by Dr. Hunt, of Boston, relative to the connection 
of this trouble with embryonic changes, in which the development of brain 
encroached on the growth of the tissues which go to make up the framework of 
the eye (sclera) and other parts of the body. 
Remarks by the President.-The interesting and instructive paper to which 
we have listened is from the pen of one who has given much attention to the head- 
aches of childhood. His long experience and many observations relating to this 
subject give weight and prominence to the views which he expresses. This paper, 
from one who is justly regarded as an authority, will probably lead to a better under- 
standing of the common ailment of which it treats, so that remedies can be more 
satisfactorily and effectually applied. Another equally prominent London physician, 
who holds an official position in this Section, Dr. Charles West, has also made a 
careful study of headaches in children. In his Lumleian Lectures he says, "In 
infancy and childhood . . pain referred to any part signifies, almost without excep- 
tion, that disease of some sort or other is going on there, or near at hand. " Dr. 
West continues, " There are two classes of cases in which it is of especial importance 
to bear in mind this caution : The one, those cases in which pain is referred to the 
head ; the other, those in which it is situate in one of the lower limbs. In the former 
case the pain is almost invariably symptomatic of organic disease of the brain ; in the 
latter, with almost equal certainty, of hip-joint disease. " . . . He adds, " I shall not 
think I have said too much if I do but impress on the minds of any of my younger 
brethren . . . the excessive rarity of pain in childhood, except as a sign of local 
disease." As regards the headaches of children in New York City, where my 
observations have been made, I think that these remarks of this distinguished and 
able contributor to pediatric literature should be modified. I accept the statement 
as entirely true, that persistent headache in a child, attended by fever and not 
influenced by treatment, especially by quinine, is a symptom of local cerebral disease, SECTION X-DISEASES OF CHILDREN. 
507 
usually meningitis. We have probably all had unpleasant experience with cases like 
the following : A child of perhaps six or eight years, of parentage not decidedly 
unhealthy, and with no marked tendency to tuberculosis, without history of injury 
of the head, or of otorrhœa, loses appetite, becomes fretful, is quiet, but is able to 
walk about, has a temperature of 101° or 102°, complains of a dull frontal headache, 
without vomiting and without any appreciable change in the appearance and action 
of the eyes., We hesitate in diagnosis between a fever arising from malarial influence 
and meningitis. We prescribe, tentatively, alternate doses of one of the bromides 
and quinine, but the dull headache persists. The treatment does not exert any 
appreciable controlling influence upon the disease, and in a few days-four or five- 
inequality of the pupils and other symptoirfs indicate unmistakably a meningitis. 
The tache cerebrale of Trousseau gives but little diagnostic aid in such cases, for it 
can often be produced in febrile states not due to disease of the nervous centre. 
Cases like the above, occurring in my own practice and in the practice of others, a 
considerable number of which I have had the opportunity to examine, have long 
since convinced me that headache in a child, if attended by fever, and without any 
appreciable local cause elsewhere than within the cranium, if it persist beyond the 
fourth or fifth day, uninfluenced by the bromides and quinine, almost without excep- 
tion, indicates intra-cranial disease ; and it is important that an early diagnosis be 
made, that the friends may have sufficient forewarning, and the proper treatment be 
early employed. 
But headache in children, persisting for weeks, or even months, without fever, is 
a common ailment in New York, especially in school children and in girls ; I have 
observed it most frequently in children between the ages of six and twelve years. 
The child with this form of headache loses its customary vivacity, but still pursues 
its studies in the school ; it sleeps as usual at night, or is rather restless ; its appetite 
may be moderately good or impaired, and there is no marked deviation from their 
normal state in other functions. The headache not infrequently increases during the 
school hours, and many children return from school with complaint of an increase in 
the cephalalgia, which soon, by the rest at home, diminishes, but does not cease. 
Most children with this form of headache are tolerably well nourished, and 
apparently lose but little flesh and strength, except as impairment of the strength 
may be indicated by languor. One having had a ruddy complexion loses it, and the 
countenance has more pallor than in health. 
This form of headache is in a certain proportion of cases accompanied by neuralgic 
pain in other parts, especially in the left side of the chest, or in the sternal or 
epigastric region. Wherever the pain is located, whether it be, as is usual, a frontal 
cephalalgia, or be seated in the trunk, pressure over or near the roots of the nerves 
which supply the affected part increases the pain. Thus, pressure upon the nucha, 
close to the occiput, or upon the lower part of the occiput, increases the frontal 
headache. If thoracic pain is present pressure upon the spine at a certain point 
increases it. I have observed cases in which pressure a little below the occiput, 
upon the cervical vertebrae, caused pain in the region of the eyes and nose, and lower 
still, at some point in the thorax. The site of the pain varying according as the 
pressure was made higher or lower along the spine. 
This form of cephalalgia is apparently a marked exception to the rule stated by 
Dr. West, that persistent headache in children has a local cause. Perhaps in some of 
these cases there may be a local cause in the condition of the eye, errors of refraction, 
by which the pain is increased, but I think that those who have studied this form of 
headache will admit that its chief and common cause is a depressed or perhaps over- 508 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sensitive state of the nervous system, and an anæmic condition of the blood. It is 
common among the children of the tenement-house population in the cities, and is, 
I presume, rare in the rural districts, where a better state of the general health 
prevails. 
The prognosis is favorable, but the headache is usually protracted, continuing till 
a better state of the general health is obtained. However, I have known patients to 
recover quickly when taken from school and sent to the country, in the summer 
months. If removed from the severe discipline of the schools, allowed a more 
generous diet, with abundant recreation in the open air, many recover without the 
aid of medicine, but vegetable and ferruginous tonics assist in promoting recovery. 
The elixir of calisaya bark with iron, or some similar tonic, should be prescribed. A 
child brought from a tenement house to the children's class at Bellevue rapidly 
recovered under the use of the following prescription :- 
B. Potass et ferri tart, g j 
Tinct. cinchon. comp., £iv. 
Dose, oue teaspoonful, in water, 3 or 4 times daily. 
The frequency of this form of headache in city practice, and the fact that system- 
atic writers do not seem to me to give it the attention which it deserves, induce me 
to make these remarks. 
THE PATHOLOGICAL ANATOMY OF LARYNGEAL DIPHTHERIA 
AS RELATED TO INTUBATION. 
L'ANATOMIE PATHOLOGIQUE DE LA DIPHTÉRIE LARYNGÉE PAR RAPPORT 
À L'INTUBATION. 
DIE PATHOLOGISCHE ANATOMIE DER KEHLKOPFDIPHTHERIE MIT HINSICHT AUF DIE 
INTUBATION. 
BY WILLIAM PERRY NORTHRUP, M. D., 
Pathologist, New York Foundling Asylum. 
In preparation for the discussion of the methods of relieving the urgent symptoms 
of laryngeal diphtheria, it is not amiss to first of all contemplate the nature of the 
lesion. 
In this paper I shall undertake no review of the history of the disease, shall not try 
to disprove the dual theory, shall propose no new theory. What I shall do, is, lay 
before you some of the facts observed in autopsies on children dying of diphtheria in 
whom there has been found diphtheria of the larynx. Let it be remembered that I do 
not say whether all or any of them have been croupy or have been intubated. I mean 
simply to see what facts force themselves upon our minds in studying these records, and 
there is but one constant factor, viz., the cases all had pus and fibrin exudate in the 
larynx. Cases of diphtheria in which the pseudo-membrane was not found in the 
larynx after death have been excluded. 
The name diphtheria has been used because in each case, sooner or later, ash-gray 
pseudo-membrane has been observed in the pharynx, and there has been parenchyma- 
tous nephritis associated w ith it, and also a tendency to heart failure. 
The autopsy records of the New York Foundling Asylum show 116 cases, in which 
there was found after death pseudo-membrane, pus and fibrin exudate upon the mucous SECTION X-DISEASES OF CHILDREN. 
509 
membrane of the larynx. Of this number 68 began with symptoms showing that the 
larynx was invaded before or at the same time that pseudo-membrane was seen in the 
pharynx. In other words, there was first of all croup. 
Of the 116 cases 38 showed pseudo-membrane in the pharynx, and the child subse- 
quently became croupy. In the remaining cases the order of precedence was indeter- 
minate. 
Ninety cases of so-called "membranous croup" have been analyzed. Of the 90 
cases under consideration nine showed pseudo-membrane from the tip of the nose to the 
finest bronchi ; six from the nose to the bifurcation of the trachea ; 17 from the pharynx to 
the main bronchi. In 17 cases pseudo-membrane was found in the larynx and trachea; 
in three, in the pharynx and larynx ; .in one, in the larynx only. 
With but one exception, the pseudo-membrane was continuous to the extent of its 
distribution. In this exceptional case there was well-marked pseudo-membrane from 
the pharynx to the middle of the trachea. From this point to the bronchi of the fourth 
division there was no exudate to be seen, and yet beyond this point there were well- 
formed casts of the finest bronchi. 
Such was the distribution of the membrane in 90 cases. 
The cases are collected from no epidemic and are distributed over the records of 
five years. I purposely separate them from 26 cases to be later considered by themselves. 
Of the 90 cases 50 were females. The average age was two years, seven months. The 
number of children dying under one year was 13 ; between one and two years, 12; 
between two and three years, 10 ; between three and four years, 36 ; between four and 
five years, 11; between five and six years, one; between six and seven years, one. 
Others were indeterminate. The greatest mortality, then, was between three and four 
years, where we find 36 of the 90 cases. Above and below this age the number falls 
abruptly to ten and eleven. In 54 cases the average number of days from the begin- 
ning of croupy symptoms till death was three and four-fifths days. In two cases 
croup was the first symptom, and the children were dead in 20 hours. 
Emphysema.-The interstitial variety has been observed in eight cases; the vesicular 
in nine. 
Pneumonia.-This complication attained to the number of 56 in 90 cases. 
Twenty-nine had pneumonia enough to be sufficient cause of death. In twenty-seven 
cases bronchial diphtheria was the prominent cause of death. Eighty-four cases 
showed extensive invasion of the respiratory tract, 22 followed measles, eight followed 
scarlatina. 
In the spring of 1887 there occurred an epidemic of measles, which rapidly added 
26 cases to the records. Since it presented peculiarities these cases will be discussed by 
themselves. Of the 26 cases all had measles and pneumonia. Eight had scarlet fever 
with measles and pneumonia. Of the 26 cases 15 had, besides measles and pneumonia 
and diphtheria, well-developed nephritis. The complications show the severity of the 
epidemic. 
In previous autopsies on children dying after having worn the O'Dwyer tube from 
three to seven days, there was found merely rubbing away of the superficial epithelium. 
The loss of substance did not extend below the epithelium layer. 
When we come to observe these twenty-six cases occurring in rapid succession during 
an epidemic of measles, in which several children had, beside measles, pneumonia, 
scarlet fever, diphtheria and nephritis, we may not be surprised that the tube was 
harmful to the tissues. 
Each time the child swallowed, the lower end of the tube was thrown against the 
anterior wall of the trachea. In case the tissues are well nourished they may suffer 
but little.. 
When, as in the above cases, the system is overwhelmed with complications and the 510 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
vitality of the tissues is lowered, it is not surprising that this foreign body causes injury 
to the parts. So it does. The mucous membrane is rubbed away, the submucous 
tissues are rubbed away, the cartilages are laid bare, and the ulcer thus formed grows 
wider. This occurred in some cases where the tube had been worn no more than three 
or four days. 
It is well to emphasize this point. Up to this epidemic, ulcers of the trachea extend- 
ing deeper than the mucous membrane had not been observed. During this fatal epi- 
demic of measles, which rapidly added 26 cases to the records, five severe ulcers were 
found where the lower end of the laryngeal tube had rubbed against the anterior tracheal 
wall. I have never seen any ulcers of the larynx caused by the head of the tube. 
Slight superficial destruction of epithelium has been found, but nothing to amount to a 
complication. 
We come now to speak of pneumonia, which occurred in 56 of the 90 sporadic cases 
and in 26 of the 26 cases of the epidemic. Jn nearly all these cases pneumonic consoli- 
dation has been sufficient in extent to leave no doubt as to the nature of the complica- 
tion. 
When there has been doubt, the post-mortem diagnosis has been made on the micro- 
scopic findings. Infiltration of the capillary bronchi accompanied with beginning paren- 
chymatous changes is here denominated broncho-pneumonia. In studying so import- 
ant a complication of laryngeal diphtheria as this, it is important that all should agree 
upon the names employed. It has been quite common to call the condition of many 
such lungs collapse. This test has been recommended to differentiate collapse from 
hepatization. Pass a pipe into the bronchi and blow gently through it. If the lung is 
in collapse it will easily and fully inflate under gentle pressure. If it does not inflate, 
it is pneumonic. This test is crude in the extreme. Collapse exists mostly associated 
with the pneumonic process. 
I have never failed to find in atelectic areas abundant evidence of inflammatory pro- 
cess, both in the capillary bronchi and air passages and in the alveoli. In a lung removed 
from the thorax, it is easy to force air through the obstructing plug, and fill out the 
remaining capacity of the partially collapsed alveoli. In such lungs it is often possible 
to restore the rose color by inflation, but it is deeper red than normal, and scattered 
through it are impermeable lobules of hepatization. 
82 of the 116 cases had pneumonia, either evinced by well-marked and unmistakable 
signs of consolidation or revealed by the microscope. 
This does not seem so extraordinary, either, when we reflect in how many cases 
pseudo-membrane advanced along the air tubes to the capillary bronchi. 
The prevalence of pneumonia as a complication certainly need not be urged as proof 
that it is schluck pneumonic. A diphtheritic inflammation is creeping down the bronchi. 
By preference it selects dependent portions of the lung. That may argue that the pro- 
ducts of inflammation drain into these portions and excite inflammation of similar 
nature there. Whatever the method, the inflammation advances to the finest bronchi 
by continuity of tissue. Theoretically, it may cease to advance and remain " capillary 
bronchitis," but, practically, this is not met with. 
The microscope reveals beginning parenchymatous changes and commonly scattered 
hepatized lobules. 
SCHLUCK PNEUMONIE. 
Ten years ago much was said about foreign body pneumonia. Particles of food, 
secretions of the mouth, might enter the lungs and cause pneumonia. Since that time 
this term has been used mostly in connection with surgical injuries, where hemorrhage 
into the trachea has taken place, or where foreign bodies of whatever kind have passed 
beyond the large bronchi and have become lodged. 
When the O'Dwyer tube came into use, and it was said the patient had difficulty SECTION X DISEASES OF CHILDREN. 
511 
in swallowing milk because it occasioned cough, then immediately arose the shout 
that schluck pneumonie was the cause of death. A priori it would seem reasonable. 
Again, examining a cadaver lying on its back, it will be seen that from the main 
branches of each lung two large branches put off, one to the lower posterior portion of the 
upper lobe and one to the lower lobe running nearly parallel with its posterior margin. 
From this large and long bronchus numerous smaller bronchi put off to the posterior 
margin and dependent portion. From their relations to the trachea and main bronchi, 
it seems these two bronchi are well adapted to catch the drain of the trachea and 
main bronchi, and through the smaller dependent branches to conduct to the posterior 
margin of the lower lobes and lower posterior portion of the upper lobes. 
This a priori reasoning is fortified by the pathological selection. It is in the lower 
lobes, posterior portion, that we find the first pneumonia, and very commonly there is 
with it consolidation of the lower portion of the upper lobe posteriorly. 
It would seem, then, that we might establish the fact, if there were pneumonia from 
the passage of milk into the dependent branches. Especial attention has been devoted 
to this point, and thus far no evidences have been found of the presence of foreign 
material. 
Furthermore, the experiment has been tried of inducing schluck pneumonie by 
feeding the child on milk and other fluids, having finely divided carbon in suspension. 
If this insoluble powder, having a strong contrasting color, were taken into the lungs in 
elective regions, it would be possible to find it later. 
In these experimental cases the powdered carbon (bone black) was given while the 
child was able to swallow fairly well, so as to make the test satisfactory, and for the 
same reason it was discontinued when the child became enfeebled and was about to die. 
I may say that I have never found any evidence that milk or bone black had passed 
into the lungs of a child wearing a laryngeal tube. The smallest particle of milk bath- 
ing the under surface of a swollen and insufficient epiglottis would excite violent 
cough. It does so in laryngeal tuberculosis in the adult. 
Tread as lightly as we may, it is obvious that we are striving to avoid the terms 
" Membranous Croup " and " Croupous Laryngitis." To me it is a conviction that these 
records from which I summarize show that the kind of croup met with at the New York 
Foundling Asylum, requiring mechanical interference, is none other than diphtheria 
invading the respiratory tract. The two most familiar classes of cases are these : First. 
A child having measles coughs croupy. The next day patches are seen on the pharynx. 
One day later the dyspnoea has advanced so far as to require intubation. 
On autopsy-(I append an autopsy, because nearly every measles case, complicated 
with laryngeal diphtheria, develops pneumonia and dies). On autopsy, the larynx, 
trachea, and bronchi contain tenacious, continuous pus and fibrous exudate and the 
lungs show pneumonic consolidation. Examination of the kidneys reveals parenchy- 
matous nephritis. Urine drawn from the bladder contains hyaline and epithelial casts 
and kidney epithelium. 
The second case is a child, running about the ward in the evening, showing no symp- 
toms till the attention of the nurse is attracted by a hoarse cough. During the night 
dyspnoea develops rapidly, and in early morning a tube is required and inserted. The 
urgent symptoms are relieved, but in thirty-six hours the child succumbs to the rapid 
invasion and overwhelming poison. There is no physical sign of pneumonic consolida- 
tion. On autopsy, we find membranous croup indeed. 
What are the findings in this rapidly fatal case ? The pharynx shows nothing or 
only a few grayish points on the tonsils. The epiglottis is swollen, and poorly adapts 
itself to its work of guarding the entrance to the respiratory tract. The concavity of 
the epiglottis is covered with pus and fibrin exudate, continuous and tenacious ; so is 
the inside of the larynx; the same is true of the trachea, the same of the bronchial 512 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tubes, and even from the finest bronchi of portions of the lungs can be drawn out 
casts of the capillary tubes. There may also be, even in this short course, scattered 
small masses of pneumonic consolidation. The kidneys are not usually so early affected. 
For these reasons it is deemed advisable to use the term laryngeal diphtheria to 
apply to this lesion, as expressing more accurately the nature of the disease, and to 
reserve the term membranous croup for the croupous larnyngitis of medical history. 
TO SUMMARIZE : 
1. The cases here studied are 116 in number ; 90 of which were sporadic, 26 epidemic. 
They all occurred in the New York Foundling Asylum, an institution which has the 
constant care of 1800 children from the ages of a few weeks to five and seven years. 
2. In the sporadic cases the laryngeal tube of Dr. O'Dwyer caused no ulceration 
worthy of consideration. 
3. In the epidemic cases, numbering 26, there were five serious ulcers. 
4. The causes of death have been mostly extension of pseudo-membrane to the 
bronchi, and pneumonia. 
5. I have been able to find no evidence that milk or other foreign material has 
found its way into the lungs. The pneumonia is broncho-pneumonia and not schluck 
pneumonie. 
DISCUSSION. 
Remarks by the President.-Membranous croup has always been regarded 
as a most important disease, on account of the extreme suffering which it causes, 
and its usual fatal termination. It has in recent years become much more prevalent 
than formerly, through the spread of diphtheria, for wherever diphtheria prevails 
membranous croup is common as one of its local manifestations. In New York city, 
where diphtheria has been established since 1858, 4982 died of croup during the six 
years ending with 1886, or more than two, in the average, each day. During the 
same period 8925 died of diphtheria without croup. Therefore, in this city about 
one-third of those who die of diphtheria have croup, for it is admitted by all New York 
physicians that there is scarcely a case of membranous croup within the city limits 
except in connection with diphtheria. In Brooklyn, during the seven years ending 
with 1886, 2506 children died of croup, or one each day, and 5011 died of diphtheria 
without croup, so that, as in New York, one-third of those who die of diphtheria 
die of croup. The increasing prevalence of croup as diphtheria extends and 
becomes established, is equally shown by the statistics of other cities. 
We will now have the opportunity, which all of us will appreciate, of learning 
the anatomical characters of croup from one whose opportunities for studying its 
pathology are not equaled in the Western hemisphere. SECTION X-DISEASES OF CHILDREN. 
513 
LE TUBAGE DU LARYNX CONTRE L'ASPHYXIE DU CROUP ET 
LES RÉTRÉCISSEMENTS DU LARYNX. 
INTUBATION OF THE LARYNX IN THE ASPHYXIA OF CROUP AND LARYNGEAL 
STENOSES. 
DIE INTUBATION DES KEHLKOPFES GEGEN DIE ASPHYXIE DER CROUP UND LARYNX- 
STENOSEN. 
PAR LE DR. E. BOUCHUT, 
De l'Hôpital des Enfants Malades à Paris. 
En présence des résultats si défavorables donnés par la trachéotomie dans l'asphyxie 
du croup ; de la difficulté de cette opération pour un grand nombre de médecins peu 
expérimentés, des accidents qui accompagnent parfois cette opération, des nombreux 
cas de morts qui ont lieu sur la table opératoire dans nos hôpitaux et en ville, j'ai pensé 
qu'on pouvait essayer de donner de l'air aux malades par les voies supérieures du 
larynx sans recourir à l'opération sanglante de la trachéotomie. 
Il suffisait pour cela de placer dans le larynx par la bouche à l'aide d'une sonde 
conductrice, une canule dilatatrice d'un diamètre approprié qui permette le passage 
de l'air et le rejet des finisses membranes et des mucosités bronchiques. Cela est très 
facile. De cette façon on supprime toute opération sanglante et les dangers qui s'y 
rattachent. 
J'ai fait ces essais en 1858, sur plusieurs enfants avec une réussite très satisfaisante. 
J'ai eu trois guérisons sur dix opérés et je vais communiquer au Congrès le dernier cas 
qui s'est terminé d'une façon très heureuse. 
Hélène X. âgée de 18 mois est reçue à l'hôpital des enfants malades et entre dans le 
service de M. Bouchut, le 12 Janvier, air No. 1 de Sainte-Cathérine. 
Elle est malade depuis quatre jours environ, le visage est maigre ; elle a une grande 
difficulté pour respirer, et la respiration est accompagnée de cornage. 
A chaque inspiration les muscles inspirateurs sont fortement contractés. Les narines 
se dilatent et le diaphragme est refoulé en haut de façon à présenter cette forme de 
dyspnée qu'on appelle le tirage. 
Après l'examen de la gorge, où. l'on constate l'existence de fausses membranes, on 
diagnostique le croup. 
Le 12, les conditions de la malade sont extrêmement graves, il y a lividité de la 
face, les muqueuses sont cyanosées et la diminution de la sensibilité ou anesthésie 
caractérisant l'asphyxie annonce une fin prochaine. 
L'âge du sujet laisse les assistants indécis au sujet de savoir si l'on fera la trachéo- 
tomie. A mon arrivée j'examine la malade et décide le tubage de larynx, je fais de 
suite l'opération. 
Opération.-Pour cela je pris un tube ou canule d'argent de 0zzz 2c. de long et de 
0zzz 007m. de diamètre, ayant à son extrémité supérieure un mince bourrelet et un 
petit trou dans lequel on fait passer un gros fil de soie. 
J'introduis dans le tube à titre de mandrin conducteur l'extrémité d'une sonde 
d'homme, pourvue elle même d'un petit relief d'arrêt, et j'ai soin de tenir dans ma 
main le cordon en soie de façon que le tube soit fixé au-dessous du bourrelet de la 
sonde par le fil qui est dans ma main avec la sonde. La malade est couchée sur le dos, 
la tête soulevée par deux coussins, et pendant l'opération elle reste toujours dans la 
même position. 
Se place dans la bouche de l'enfant l'index de la main gauche, protégé par un long 
anneau métallique qui laisse découverte par une dernière phalange du doigt, et j'arrive 
ainsi à toucher la glotte. En la conduisant sur le doigt, je pousse la sonde garnie de 
Vol. Ill-33 514 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
sa canule dans le larynx, et si elle est d'un diamètre approprié, à l'aide de son bourrelet 
saillant, elle reste fixée entre les cordes vocales. Je retire alors la sonde conductrice 
en ne tirant pas sur le fil de soie, et ce fil resté libre dans la bouche, je le fixe au cou de 
l'opérée. Tout cela s'effectue dans l'espace de quelques minutes. 
Aussitôt après l'opération la malade porte plusieurs fois les mains au cou et à la 
bouche, comme pour exercer des tractions sur le fil. Le corps étranger placé dans son 
larynx, tout en ne lui causant aucun phénomène réflexe, la gênait évidemment. 
Peu-à-peu elle devint plus tranquille et la respiration devint plus facile. Elle put 
boire sans suffocation, et manger un potage. 
Le 14, quoique dans un état toujours assez grave la malade n'eut plus d'accès de 
suffocation. La dyspnée persista, mais sans les caractères inquiétants qui avaient 
nécessité l'opération. Elle eut plusieurs accès de toux désagréables. Le bruit de scie 
persiste, la face est rosée, la sensibilité normale, l'intelligence intacte. 
Le 14, j'enlève le tube, en pénétrant avec l'index de la main gauche jusqu'au con- 
tact de la glotte, et en exerçant de petites tractions sur le fil. Peu après la petite 
malade commence à devenir inquiète, le nombre des respirations augmente, les lèvres 
se cyanosent. 
Le tube dans lequel étaient amassées quelques fausses membranes est nettoyé et 
réappliqué immédiatement de cette façon on a pu éviter l'accès de suffocation qui se 
préparait. 
Le 15, l'enfant pendant la journée d'hier a été tourmentée d'une dyspnée intense 
entrecoupée de rémissions longues. 
Au moment de la visite la peau est froide, le pouls petit, les respirations fréquentes 
et encore difficiles. 
Le 16, la malade respire mieux, reprend ses forces, et passe le reste de la journée 
dans de lionnes conditions. La diarrhée a diminué, elle a dormi la moitié de la nuit, 
mais le tube est sorti pendant le sommeil, et il y eut un accès de suffocation. Le tube 
est remis. 
Le 17, peu d'instants après l'application du tube, il y eut une amélioration notable, 
la journée a été calme, la nuit tranquille malgré quelques secousses de toux; la face est 
moins colorée, les mains sont chaudes. La respiration est à peu près normale. 
On Enlève le Tube.-L'amélioration continue, la journée et la nuit ont été bonnes, 
la respiration, accompagnée du bruit de scie, est encore assez difficile, mais moins fré- 
quente, la malade a envie de jouer. 
Les 19 et 20, même état. 
Le 21, la respiration, malgré le bruit de scie, est bonne, toux légère persistante. 
Les phénomènes de la maladie s'améliorèrent peu-à-peu, et la malade quitta l'hôpi- 
tal le 27 Janvier, 1858, guérie complètement. 
Comme on le voit dans cette observation, le tube placé dans le larynx au moment 
où l'enfant était asphyxiée demi anesthésique, a été bien supporté. Il s'est engoué 
alors, on l'a retiré à l'aide de fil de soie, et il a été remis. Au sixième jour, il a pu 
être enlevé définitivement. La respiration s'est rétablie par degrés et la guérison était 
complète au quinzième jour. SECTION X-DISEASES OF CHILDREN. 
515 
[Abstract.] 
TUB AGE OF THE LARYNX IN STRICTURE AND IN THE ASPHYXIA 
OF CROUP. 
BY DR. E. BOUCHUT, 
Of Paris. 
In view of the unfortunate results of tracheotomy, the difficulty which is met by 
inexperienced physicians in performing the operation, the accidents which sometimes 
occur, and the number of deaths which take place on the operating table in our hos- 
pitals and in private practice, I looked elsewhere for some means of conveying air to 
our patients, through the larynx, without operative interference. 
The end sought was gained by placing in the larynx, with the help of a guide 
passed into the mouth, a tube wide enough to allow the admission of air and the expul- 
sion of false membrane and bronchial mucus. This easy procedure took the place of 
the bloody operation and its attendant perils. 
In 1858 I performed several experiments upon infants, with very good results. I 
had three recoveries in ten cases. I will relate to the Congress the last of these cases 
which recovered :- 
Helen X.; aged eighteen months; was admitted to the Children's Hospital in my 
service on January 12th, au No. 1 de Sainte Catherine. She had been sick about four 
days. There was emaciation, great difficulty of breathing and wheezing expiration. 
At each inspiration the respiratory muscles were violently contracted, the nostrils were 
expanded and the diaphragm was pushed up in the manner which characterizes what is 
called the drawing respiration (le tirage.) Examination of the throat led to the diag- 
nosis of membranous croup. 
On the 12th the symptoms were very serious. The lividity of the face, the blue- 
ness of the mucous membrane and the failure of sensibility which attends asphyxia, 
indicated the approach of death. The age of the patient caused my assistants to hesi- 
tate before performing tracheotomy. On my arrival I decided on tubage of the larynx 
by the following method :- 
Operation.-I procured a silver tube, or cannula, about two cm. long and seven mm. 
in diameter, having at its upper end a flange and a little hole through which was 
passed a silk thread. I introduced in the tube, as a guide, the end of a urethral 
sound, on which there was a projection or shoulder, and took care to hold in my hand 
the silk thread in such a way as to fix the cannula against the lower side of the shoulder 
of the sound, which was held in the same hand with the thread. The child was placed 
on her back, with the head on two cushions, and this position was maintained during 
the operation. Introducing into the child's mouth the index finger of my left hand, 
protected by a long metallic ring which left uncovered only the distal phalanx, I 
touched the glottis. Guiding it by the finger, I pushed the sound and its cannula into 
the larynx, and as it was of the right diameter, with the help of its flange, the cannula 
was retained between the vocal cords. I then withdrew the sound without disturbing 
the silk thread, which I fastened to the child's neck. All occupied but a few minutes. 
Immediately after the operation, the child several times raised her hand to her neck 
and mouth to pull away the thread. The foreign body in the larynx caused no reflex 
phenomena, but was apparently an annoyance. By degrees she became quiet and the 
respirations easier. She was able to drink and took some broth. 
Jan. 14th. Although still in an alarming condition the patient had had no attacks 
of suffocation. The difficult breathing persisted, but without the threatening symp- 
toms which call for an operation. She had several distressing attacks of cough. 516 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The wheezing continued, the face was flushed, and the sensibility and intelligence were 
normal. 
Jan. 14th. I removed the tube, introducing the index of the left hand as far as the 
glottis and drawing gently on the thread; very soon the patient became restless, the 
respirations increased in frequency and the lips became blue. The tube, which con- 
tained a mass of false membrane, was cleaned and replaced without delay, and thus was 
prevented an immediate attack of suffocation. 
Jan. 15th. I learned that the child had been troubled the preceding day by attacks 
of intense dyspnoea, occurring at long intervals. At the time of my visit the skin was 
cold, the pulse small and the breathing labored. 
Jan. 16th. The patient was breathing better, was stronger and had passed the pre- 
ceding day comfortably. The dyspnoea was less and she had slept half the night. But 
during sleep the tube had been expelled and there was an attack of suffocation. It was 
replaced. 
Jan. 17th. Shortly after the reapplication of the tube there was marked improve- 
ment. The day and the night had been quietly passed, except for several coughing 
spells. The face had a better color, the hands were warm and the breathing w as 
nearly normal. The tube was finally removed. Improvement continued. Day and 
night she was comfortable. The breathing was still noisy and not entirely easy, but it 
was less frequent, and the child wanted to play. 
Jan. 19th and 20th. The same. 
Jan. 21st. The breathing, in spite of a slight wheeze, was good. Slight cough 
persists. 
The symptoms of the disease gradually disappeared and the patient was discharged, 
entirely well, January 27th, 1858. 
In this case we have seen that a tube placed in the larynx when the patient was 
asphyxiated and half unconscious was well borne. It became obstructed and was 
removed with the aid of the silk thread, and was replaced. On the sixth day it was 
finally removed. Respiration was established by degrees and recovery was complete 
on the fifteenth day. 
INTUBATION OF THE LARYNX. 
INTUBATION DU LARYNX. 
INTUBATION DES LARYNX. 
BY JOSEPH O'DWYER, M. D., 
Attending Physician to the New York Foundling Asylum. 
In the beginning of the year 1880 I began my experiments, at the New York 
Foundling Asylum, with the operation now known as intubation of the larynx. As 
the history of the evolution of this operation is long and of no particular interest to 
any <jne except myself, I will merely describe briefly, as I show them, a few of the 
more important modifications that have been made in the tubes. 
About the time referred to tracheotomy was looked upon with marked disfavor at 
the Asylum, for the reason that we could not show a single recovery to demonstrate its SECTION X DISEASES OF CHILDREN. 
517 
usefulness. We had no argument to offer in favor of it, except euthanasia, and not a 
few of even the most intelligent of the laity fail to understand how a child's suffering 
can be relieved by cutting its throat. 
The failure of tracheotomy in my hands, not only in hospital but private practice 
also, was, therefore, the incentive that led me to seek a substitute. The one that 
naturally presented itself to me, as it had to hundreds of others, was a flexible catheter 
passed into the larynx through the mouth or nose. 
Dr. E. R. Chadbourne, then resident physician to the New York Foundling Asylum, 
and to whom I am much indebted for valuable assistance in the early part of this work, 
also used a prostatic spiral catheter inserted into the larynx, through the nose, with 
relief to the urgent dyspnoea in several cases. A brief trial of this method was suffi- 
cient to demonstrate that it was impracticable, but it was the use of these long tubes that 
suggested the short ones. The end of a catheter projecting from the mouth or nose, 
besides other objectionable features, gave the child an opportunity to seize and remove 
it whenever it succeeded in freeing its hands. Therefore, why not shorten it so as to 
rest within the nostril or in the pharynx, with some device to prevent it from slipping 
down; and, finally, why not solely in the larynx? 
Here was a large cavity above for the lodgment of a tube with expanded upper 
extremity and narrow opening below, to prevent it from slipping through. As soon as 
thought of, it was almost demonstrated that a tube could be so constructed that one 
end would extend into the trachea while the other occupied the vestibule of the larynx, 
and thus permit the epiglottis to close over it during the act of swallowing. But here 
was encountered the first stumbling block. What was to hold it down ? What would 
take the place of the tapes tied around the neck that served to retain the tracheal 
cannula ? I regarded it as self-evident that a plain tube of this kind, having the form of 
the rima glottidis, would be immediately rejected, and, therefore, did not consider it 
worth a trial. 
After much thought on the subject the only solution of the problem that occurred 
to me was to construct the tube in the form of a bivalve, the blades of which would 
separate when inserted, and thus give a greater transverse diameter below than between 
the vocal cords. I tried several modifications of this form, which always proved self- 
retaining and gave prompt relief to the dyspnoea, but the triangular open space 
between the blades allowed the swollen tissues to intrude, and also served as a lodging 
place for detached fragments of pseudo-membrane. 
When fully convinced of the failure of this form I was obliged to fall back on the 
plain tubes that I considered it useless to try in the beginning. They were made of the 
same oval or elliptical shape and of the same length, about one inch, with a small but- 
ton hole in the posterior angle near the upper extremity, by which they could be 
removed. These tubes were retained much better than I expected, but this, as I sub- 
sequently learned, was due to the protrusion of a small process of the mucous mem- 
brane through the opening just referred to, which had to be dispensed with, as it formed 
a nucleus for the accumulation of secretions. When I procured tubes without this 
opening I soon found that they would not be retained except in very young children, 
or by using a tube a size too large to be safe. I then increased the length so as to 
bring the lower end within about one-fourth of an inch of the bifurcation, believing 
that this means would prevent their expulsion, and at the same time diminish the 
danger of obstruction from loose or partially detached masses of pseudo-membrane. 
In order to determine the proper length for these tubes it was necessary to make a large 
number of measurements of the trachea at different ages. 
While these tubes were not so frequently rejected, coughing, or even bending the 
neck, was sufficient to force them upward above the tip of the epiglottis, where, owing 
to their lightness, they would remain until pushed down by the finger. On inspecting 518 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the pharynx after an attack of coughing they could often be seen in this position, and 
sometimes projecting behind the soft palate. 
To the sides of the same tubes I now added a second shoulder about one-fourth of 
an inch from the upper extremity, which left a furrow between for the vocal cords to 
rest in. In order to prevent this secoud shoulder from offering any obstacle to the 
introduction of the tube it was made wedge-shaped with the thick end directed 
upward. This device proved satisfactory in retaining the tubes, but rendered their 
removal very difficult with the imperfect extracting instrument I was using at that time, 
and was, therefore, not used in many cases. 
The difficulty was dually overcome by a very simple device, without interfering 
either with the insertion or removal of the tubes, and consisted in increasing the trans- 
verse diameter in the middle by leaving the metal thick at this point and tapering 
gradually toward either extremity. A tube constructed in this way, when projected 
upward by coughing, will slip back into position by pressure of the vocal bands on the 
sloping sides, aided by its weight, unless the thickest portion should reach the chink, 
when it would, in all probability, be expelled. 
This retaining swell is only made thick enough to hold the tubes loosely in the 
larynx in order to permit of their easy expulsion in case of sudden occlusion by masses 
of pseudo-membrane too large to pass through. Owing partly to this and partly to the 
difference in the size of the larynx in different children of the same age, they will 
sometimes be expelled when perfectly free from obstruction and before the laryngeal 
stenosis has been permanently relieved. 
The difficulty that I encountered in devising a means of preventing the rejection of 
the tubes was evidently not experienced by Bouchut, from the fact that he makes no 
mention of it in his reports. The explanation is easily found. Bouchut used tubes of 
cylindrical form and of large size, which were retained by the pressure exerted on all 
sides, especially the lateral pressure of the vocal cords; and it was this that furnished 
Trousseau with the only argument, founded on fact, that he could bring against the 
operation, viz., that when used in the larynx of the dog they produced ulceration, not 
only of the soft parts, but destruction of the cartilage as well, and the inference was 
that the same would take place in the child's larynx. 
I have here a tube that is not even cylindrical, which has nothing to retain it except 
its size, and nothing more is necessary. If placed in the larynx of a child six or seven 
years old it would be retained indefinitely. It is short, of large caliber and was intended 
to serve a double purpose. 
1. To facilitate the expulsion of masses of pseudo-membrane, when such is known 
to exist in the trachea and which cannot be expelled through the small lumen of the 
ordinary tubes. As yet, I have not used it for this purpose. 
2. As a laryngeal dilator: I have noticed in several cases of croup that the dyspnoea 
was relieved for several hours, and sometimes for as long as two days, when the tube 
had been retained for only a very short time. A larger tube producing a greater 
amount of dilatation should accomplish more. So far I have not given it a satisfactory 
trial in this respect, but sufficient to demonstrate that it is useless in the ordinary 
severe forms of croup, especially in young children. But in cases of slow development, 
in older children, who require only a little help to struggle through, using this form of 
tube and leaving it in for two or three hours, with string attached, will give a better 
chance of recovery, even if it should be necessary to insert it often, than wearing a 
tube continuously for several days. Tracheotomists all recognize the importance of 
getting rid of the cannula at the earliest possible moment, and the same rule applies to 
that in the larynx. 
Impressed with the importance of this, I tried to hasten the disappearance of the SECTION X-DISEASES OF CHILDREN. 
519 
stenosis by coating the tube with various astringents incorporated in gelatine, but so far 
without result. 
Previous to the time of making the modification last described, I was using tubes 
with very small shoulders, that would rest on or in close proximity to the vocal cords, in 
order to permit some contraction of the ary-epiglottic folds above the tube, to aid the 
epiglottis in protecting the larynx during the act of swallowing. Theoretically, deglu- 
tition should be less difficult with the tube thus deeply placed in the larynx than with 
the large-headed tubes now used, that ride much higher; but, practically, I have found 
no difference. At the same time it is proper to state that Dr. Waxham's experience 
with the same tubes does not coincide with mine. 
There are two serious objections to the small-headed tubes :- 
1. The danger of being pushed through into the trachea in attempts at extraction. 
2. The tendency of the swollen tissues to overlap and obstruct the upper opening. 
With the large-headed tubes now in use the first accident is impossible unless the 
glottis is first lacerated by passing the extractor down beside instead of into the tube, 
and forcibly removing it while the blades are widely separated. I saw this occur after 
several unsuccessful attempts at extraction had been made. When I saw the case the 
tube could not be felt by the finger, and I had much difficulty in removing it. A larger 
size was used, which also passed so far down that the tissues closed over it and it was 
removed by the string, which was still attached. I did not understand the case at the 
time, but the explanation came soon after, during practice on the cadaver. The tube 
slipped into the trachea and I removed the larynx and found the cricoid cartilage com- 
pletely cut through anteriorly and the glottis more than doubled in size. I was thor- 
oughly convinced that no matter how extensively the soft parts might be lacerated the 
tube would still be held by the cricoid cartilage, as it was on this I relied, more than 
on the vocal cords, to hold the small-headed tubes that I used so long Without this 
accident. 
To diminish this danger as much as possible, I have added a regulating screw to the 
extractor, which prevents the blades from opening to their full extent. 
About the same time that I increased the size of the heads I reduced the length of 
the tubes from one-fourth to one-half inch, in order to facilitate their introduction, and 
also gave a backward curve to the upper extremity, to carry it away from the base of the 
epiglottis, where the straight tubes frequently produced ulceration. I have recently 
been trying tubes having a still greater posterior curve, believing that they would inter- 
fere less with the functions of the epiglottis. But while I have noticed no difference in 
this respect, I have, so far, failed to find any ulceration or even abrasion of the mucous 
membrane on the anterior wall of the trachea corresponding to the lower end of the 
tube. With the tubes in general use ulceration at this point is sometimes found, and 
the manner in which it is produced I will describe later. 
I suppose that without exception the first criticism passed on these tubes by phy- 
sicians who see them for the first time is that the caliber is too small to admit a sufficient 
quantity of air to the lungs or to afford room for the passage of secretions. It will 
therefore be necessary to give my reasons somewhat in detail for adopting tubes of small 
in preference to those of large caliber, as this is contrary to the teaching of all trache- 
otomists. 
If a large cannula is better than a small one for the trachea, it is equally so for the 
larynx, the same arguments applying to both. 
I began with tubes of about the same caliber as those generally used by tracheoto- 
mists, but the change from the cylindrical to the oval shape, while giving a long antero- 
posterior diameter which conformed to the chink of the glottis, where there was ample 
room, did not conform to the sub-glottic division of the larynx, which, like the trachea, 520 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is cylindrical but very much smaller than it. The difference in size between these por- 
tions of the breathing tube will be best appreciated by comparing a section from the 
cricoid cartilage with one from the trachea of the same subject. 
I found ulceration in this portion of the larynx at points corresponding to the long 
diameter in every case in which a tube of such size had been retained for any length of 
time. 
This defect could only be remedied by using cylindrical tubes which would conform 
in shape to the cricoid portion of the larynx or by diminishing the long diameter at the 
expense of the lumen of the tube. The former plan would materially increase the 
pressure on the vocal cords, with the consequent danger of ulceration and permanent 
impairment of function. I therefore adopted the latter method of shortening the 
antero-posterior diameter, until ulceration ceased to occur, and demonstrated, by using 
these tubes of diminished caliber in a large number of cases of croup, that there was 
ample breathing room left, and further, by using them on children several years older 
than the age for which they were intended. 
Several times, on removing the tube at the usual time, the fifth or sixth day in cases 
that were progressing without dyspnoea or other bad symptoms, I have found the 
lumen reduced to one-half or less, by closely adherent gummy secretions. 
In one child two years old, that had considerable dyspnoea, which was attributed 
solely to broncho-pneumonia that was present, I found the tube, when removed on the 
fifth day, to all appearances completely stopped up. On passing the obturator through 
it, what looked like a solid cast was pushed out. Had I foùnd it in this condition on 
removal after death, I would have certainly attributed the fatal result to this cause. 
Such cases prove conclusively that the full lumen of even these small tubes is not 
necessary for the free entrance and exit of air in a state of rest. 
A still more convincing proof of this fact is, that I have used the tube intended for 
children from eight to twelve years of age in a woman forty years old who had chronic 
stenosis of the larynx. The only time that this patient was able to assume the recum- 
bent posture and obtain a comfortable night's sleep, in over two months, was the first 
night that she had this little tube in her larynx. 
I might quote many similar examples in which respiration was carried on through 
a small fraction of the normal lumen of the larynx or trachea and yet air enough be 
admitted not only to sustain life but also to be compatible with health and comfort in a 
state of repose. Nature has supplied us with a superabundance of breathing space in 
order to provide for the great increase in the consumption of oxygen during violent 
muscular exercise and to allow for considerable curtailment, by the various diseases to 
which the respiratory organs are liable, without endangering life. 
There is, therefore, no necessity that a tube in order to be large enough for free 
respiration should even approximate in size to that of the larynx or trachea. 
As far as respiration alone is concerned, no objection can be offered if a tube be 
many times larger than is necessary, for such exists normally. But there is another 
reason besides the mere entrance and e.tit of air, that demands serious consideration, viz., 
the removal of the secretions that are almost constantly present in the lower air pas- 
sages in croup, owing to the frequent association of bronchial catarrh with this disease. 
While the extrusion of masses of pseudo-membrane is accomplished with greater 
ease and with less danger of sudden occlusion through a tube of large than of small 
lumen, I believe the reverse is the case with the ordinary secretions, and it is on this 
ground alone that I claim an advantage for tubes of small over those of large caliber. 
Secretions, if not removed in the ordinary manner, will accumulate and be drawn 
downward into the alveoli, and not only interfere with the important function of the 
lungs, but also give rise to inflammatory changes. 
If we glance for a moment at the mechanism of cough, nature's method of keeping SECTION X-DISEASES OF CHILDREN. 
521 
the air passages clear, we find that after the lungs are filled by a deep inspiration, there 
is a violent spasmodic expiratory effort coincidently with complete closure of the glottis, 
by which the imprisoned air is subjected to a marked degree of compression before it is 
permitted to escape. It is this compression alone which imparts to the air that friction 
power which is sufficient to scrape off, so to speak, tenacious secretions from the mucous 
membrane of the trachea and bronchi. No one will claim that there is any power 
to expel secretions with ordinary expiration, nor with the most forcible and rapid 
expiration, as long as the vocal cords retain the position occupied when their antagoniz- 
ing muscles are in a state of rest-that is, the cadaveric or expiratory position. Close 
approximation of these organs is absolutely necessary to give full expulsive power to 
the cough; some degree of approximation to give any at all. This can be demon- 
strated by any one who will try to cough with an open glottis. A familiar and still 
more forcible illustration is the simple act of blowing the nose, which is almost identi- 
cal with coughing. If both nostrils are clear, even closing one is not sufficient to give 
much power to expel secretions; both must be almost or completely occluded in the 
same manner as the glottis, until the air has been compressed. 
With these facts before us, it is not difficult to understand the manner in which the 
act of coughing is modified by a tube in the larynx or trachea. There is no longer the 
ability to close the glottis, and the air escapes before it has undergone any considerable 
degree of compression, and consequently its expulsive power is impaired, and the impair- 
ment will be in proportion to the size of the tube. 
Coughing, therefore, through a tube of small caliber, by retaining the air better, 
stimulates in some measure the normal method, which is the strongest argument that 
can be offered in favor of it. 
It is this inability to promptly get rid of secretion after intubation or tracheotomy 
that I regard as the most fruitful cause of pneumonia as a complication of croup. In 
my experience, this complication is rare in cases that struggle through without opera- 
tive interference. 
Trousseau, who first recommended the use of large tracheal cannulas, gave as a 
reason for this that the improvement that at first succeeds the operation of tracheotomy 
in some cases, soon gives place to a return of the dyspnoea, and attributes this change 
to the inadequate size of the cannula employed, which does not provide for the perma- 
nent admission of a sufficient quantity of air. In illustration of this fact, he says: 
Place a quill in the mouth, and closing the nostrils, endeavor to breathe entirely through 
it; at first you breathe easily enough, but soon your respiration becomes laborious, and 
at length you are fain to throw away the quill, and with open mouth once more to fill 
your lungs completely. 
This, I claim, is no illustration at all, for the simple reason that the difference 
between the size of the adult larynx and a quill is so enormous that the comparison is 
absurd. , 
If any one wishes to try this experiment, and will use a tube bearing anything near 
the same proportion to the lumen of the adult air passages that the smallest tracheal 
cannula ever used bears to those of the child, he will find no difficulty, except the feel- 
ing of oppression produced by closing the nostrils, in breathing through it for an indefi- 
nite time. To verify this statement to some extent, I will show you an adult larynx 
and trachea with tube in situ. This tube was worn by three different persons, from one 
to three weeks at a time, all of whom could breathe through it with perfect comfort. 
With it I will also pass a larynx and trachea from a child four years old, with tube of 
proper size in position. 
No measurements are necessary to demonstrate that the lumen of the small tube is 
greater in proportion to that of the trachea which contains it, and consequently affords 522 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
more breathing room than the lumen of the large tube compared with that of the adult 
trachea. 
The early return of the dyspnoea, to which Trousseau alludes, and on which he based 
his argument in favor of larger tubes, can, with greater probability, be attributed to 
the entrance of blood or the accumulations of secretions, or both, than to the inade- 
quate size of the cannula employed. I have repeatedly observed marked improvement 
to the dyspnoea follow the removal and reinsertion of a tube that was perfectly clear, 
from the expulsion of retained secretions by the increased cough excited by the opera- 
tion and the deeper respiration induced by the struggles of the child. 
Such a result following the introduction of a larger tube would naturally be 
attributed to the increased breathing room thus afforded. 
Another subject to which I will briefly call your attention, and one that is of 
interest principally in relation to intubation, is the seat of the stenosis in croup. 
It had heretofore been universally regarded as confined to the chink of the glottis, 
but while this is the rule, there are exceptions, where the fatal obstruction is situated 
lower done in that narrow portion of the larynx bounded by the cricoid cartilage. As 
it can only be demonstrated in cases that have died without operative interference, and 
the opportunity of examining such is rare, I can form no estimate of the frequency 
with which it occurs. 
I have here a specimen illustrating this, but to a much less marked degree than I 
have seen in other cases. One cross section is made through the cricoid cartilage about 
a quarter of an inch below the cords, and another a little lower down or just through 
the beginning of the trachea, where a small quantity of pseudo-membrane can be 
seen. 
If any fibrinous deposit exist above it is insignificant, the obstruction being due 
solely to the infiltration of the mucous membrane and underlying tissues. 
The opening that still exists, and which, in all probability, is greater than was pre- 
sent during life, although very small compared with the normal caliber of this portion 
of the larynx, appears to me, when compared with other cases, large enough to admit 
a sufficient quantity of air to sustain life. The little patient from whom this specimen 
was taken had been suffering from double broncho-pneumonia and naso-pharyngeal 
diphtheria, complicating a severe type of measles, for some days before the development 
of croup. 
When I saw the case, a few hours before death, it appeared to be getting as much 
air as the crippled lungs could use, and did not show any signs of suffering in this 
respect. It had a good voice and noiseless breathing, and on these symptoms, especially 
the former, I made a diagnosis of sub-glottic stenosis. 
The fatal issue was, therefore, only hastened by the laryngeal obstruction. 
This specimen also shows marked stenosis of the rima; the vocal cords are seen lying 
very close, but from this it would be impossible to estimate the amount of breathing- 
room that may have existed during life, by reason of the forcible inspiratory expansion 
of the glottis. 
In sub-glottic stenosis, on the contrary, we can estimate very closely as to the 
amount of breathing-room that existed during life, as this portion of the larynx is sur- 
rounded by an unyielding cartilaginous wall, and not susceptible of any other change 
except decrease of its caliber. Swelling of its mucous membrane, which is always 
more or less involved in croup, can take place only toward the centre, and the opening 
found after death represents very nearly that which existed during life. For the same 
reason it will be easily understood that obstruction at this point will offer more or less 
resistance to the passage of a tube which will require some force to overcome. As a 
matter of fact, some force is necessary, but it is slight in comparison to what we would 
be led to expect from examining a larynx such as I have just shown. SECTION X-DISEASES OF CHILDREN. 
523 
Intubation has still two very serious defects to be overcome. First, the difficulty 
of swallowing fluids while a tube remains in the larynx. Second, the difficulty of 
removing large masses of pseudo-membrane from the trachea through the natural chan- 
nels. With the object of remedying the former, I have tried several modifications in 
the shape as well as the size of the heads of the tubes, the most important of which I 
will show you. I have found no improvement in deglutition with any of them. 
The one presenting a concave upper surface would render the insertion of the extract- 
ing instrument a very easy matter, if further experience should prove that swallowing 
was even as good as with the ordinary tubes, that are slightly convex above. The same 
objection applies to this as to the funnel shape given to the aperture in the upper 
extremity of the early forms, namely, that while the extractor enters more readily 
fluids will do the same. 
I believe it is only a question of time until some means will be found to overcome 
this difficulty, and it may be in some modification of Waxham's device of an accessory 
rubber epiglottis. 
For the removal of pseudo-membrane from the trachea, I have had three instru- 
ments made, none of which I have yet tried, except on the cadaver. The curved por- 
tion of this instrument, when left long enough to reach to the bifurcation of the 
trachea, renders its insertion into the larynx impossible, except by passing the finger 
behind the lower extremity and bending it forward as it reaches the neighborhood of 
the arytenoids. It would probably be easier in the living subject, where the larynx 
occupies a higher position than after death. This instrument can be covered with thin 
rubber in the same manner as Otis' urethrometer, after which it is constructed. 
I first tried to have an instrument made on the principle of the oesophageal bristle 
probang, using piano wire and watch-spring steel, but failed. 
The second instrument is more suitable for breaking up false membrane, in order to 
render its expulsion by coughing less difficult. 
The last device of this kind promises the most. It consists of a conical and very 
flexible soft silver tube-the one I have here is a little too stiff-with a rubber air 
chamber at either end. It is intended to be inserted with a short curve and pushed 
down in the same manner as an elastic catheter would be. When well down, the lower 
air chamber is inflated by pressing on the bulb attached to the handle, and withdrawn 
in this condition. The bulb attached to the handle should only contain sufficient air 
to fill the lower one, otherwise there is danger of rupturing it. The latter can be 
divided into several compartments, like a sausage, by tying it down at one or more 
points. 
I have had a cylindrical tube made, funnel-shaped above, to pass these instruments 
through. This has the advantage over passing them directly through the larynx, of 
giving the patient a chance to get some air during the operation. 
A set of tubes suitable for children of all ages under puberty is now composed of 
six instead of five, as formerly. I found that while the largest of the old set intended 
for children from eight to twelve years was well retained in girls, boys of the same age 
frequently rejected them. The sixth tube can, therefore, be held in reserve in case the 
other is expelled, or it can be used in boys from nine to twelve years inclusive. 
If used after puberty, a string should be left attached and fastened round the ear as 
a matter of safety, as I have no knowledge, so far, in regard to the size of the larynx 
during the period of adolescence. 
No one for a moment would suppose that a good workman, with a set of these tubes 
before him, would find any particular difficulty in copying them, but it is a fact, neverthe- 
less, that the best instrument makers in New York have succeeded in reproducing them 
only after many failures and repeated instructions. Some gave it up after several trials, 
and no two now make them exactly alike. 524 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
As they are being made to a considerable extent by those who have never received 
any instruction whatever, I will point out the most important defects found in such 
tubes and the accidents liable to result from what appear to be mere trifles. 
The first of these is leaving out the backward curve given to the upper extremity, or 
that portion of it covered by the shoulder. This can be shown by placing any straight 
surface in contact with the anterior portion of the tube. The object of this curve is to 
carry it away from the base of the epiglottis, where the straight tubes formerly used 
always left their mark, sometimes in the form of a perforating ulcer. With the large- 
headed tubes now used this curve is even more necessary, and for another reason: 
while the small-headed tubes swing like a pendulum from the vocal bands, the large 
head, by holding the tube higher in the larynx, converts it into a lever, with the pos- 
terior commissure acting as the fulcrum. 
During every act of swallowing the upper short arm of the lever is pressed back- 
ward with considerable force by the base of the tongue, which pushes the epiglottis 
before it, and tilts the lower end against the anterior wall of the trachea. 
This is the cause of the ulceration not unfrequently found in that situation. 
This curve is the great stumbling block to the instrument makers, who find great 
difficulty in making the obturators fit accurately with it. 
Another important defect is leaving the metal thin on the anterior and posterior 
aspects of the lower extremity, where it should be thick enough to form a blunt, 
rounded surface that will not inj ure the mucous membrane. 
A tube with these two defects has all the elements necessary to produce extensive 
ulceration on the anterior wall of the trachea. 
The metal should likewise be left thick on the anterior surface of the upper extrem- 
ity, to prevent the formation of a cutting edge under the epiglottis, but as thin as pos- 
sible at all other parts of that portion of the tube that occupies the larynx. Many not 
knowing the object of this, have regarded it as a serious defect, by occupying space that 
should be added to the caliber. 
The tube, when attached to the introducer and ready for use, should be immovable, 
and this, owing to the joint in the shank of the obturator, together with the curve in 
the tube, is very difficult to obtain, and can only be secured by accurate fitting of the 
upper part of the obturator. Any motion of the tube causes it to slip off as soon as it 
comes in contact with the base of the tongue or other part, which is very embarrassing 
even to the expert operator. Other defects of minor importance I will not mention. 
The introduction of a tube into the larynx of a struggling, half-asphyxiated child 
is not the simple operation that those who have not tried it believe it to be. An oper- 
ator who possesses more than usual dexterity, combined with coolness and an easy case to 
begin with-for there is a great difference in this respect-will experience no particular 
difficulty in properly placing the tube, and he will regard it as a very simple operation. 
If, on the contrary, the operator who has less dexterity should, on his first attempt, 
encounter a difficult case, he will come to the conclusion that it is a difficult operation 
to perform, which it undoubtedly is in exceptional cases. Such was that of a child two 
years old, with very small mouth, small pharynx and soft, almost normal epiglottis. 
Two physicians of considerable experience with intubation failed, after repeated 
attempts, to place the tube in the larynx, and I only succeeded on the third trial. 
The same conditions, as regards room, obtain in very young children, but I have seldom 
encountered any difficulty, except when the epiglottis is not implicated to any extent 
in the disease and it is difficult to get the finger under it. In removing a tube from a 
child five months old, the epiglottis doubled on itself, and I was obliged to hook it up 
with the extractor; with a swollen, rigid epiglottis this does not occur. 
When intubation of the larynx shall have attained that degree of perfection where 
further improvement is impossible-which will probably be many years hence-and, SECTION X-DISEASES OF CHILDREN. 
525 
what is equally important, when a sufficient number of operators will have acquired 
proficiency in the use of the instruments, this operation, as well as all other surgical 
measures, will still remain unsatisfactory in the treatment of croup, because of its many 
and fatal complications, and from the very nature of the disease itself. 
I was thoroughly familiar with the pathology of croup treated with and without 
tracheotomy before the beginning of my experience with intubation, and knowing 
particularly how often the pseudo-membrane invades the small bronchi, I never antici- 
pated any wonderful results from the operation, and never developed as much enthusi- 
asm on the subject as many others have. 
Those who obtain good results in the first few cases will naturally conclude that 
their success will continue, and they will over-estimate the value of the operation. 
Those, on the contrary, who have bad results in the beginning will condemn it as use- 
less. The truth will be found between these extremes. 
Placing a tube in the larynx or trachea is at best only a temporary means of admit- 
ting air to the lungs, and simply affords time for nature and art to subdue the disease. 
What we need is a remedy that possesses a curative, or at least a controlling, influ- 
ence on the inflammatory process that produces the fibrinous exudation. Evidence of 
the strongest kind is accumulating in favor of the bichloride of mercury as having the 
latter quality. As far as I have been able to learn, those who have used this remedy 
in conjunction with intubation have obtained better results than I have without it. I 
will mention particularly Dr. Francis Huber, of New York, who faithfully and persist- 
ently used the bichloride from the appearance of the first symptoms of croup, and 
obtained 20 recoveries in 47 cases intubated-the best results yet reported in an equally 
large number of cases. * 
Four of his recoveries were infants under one year, which is also significant, as the 
youngest recovery that I have had was fifteen months. Dr. Huber also says, in his 
paper read before the New York Academy of Medicine June 2d, 1887, that he was 
obliged to resort to intubation in only one out of every three or four cases of croup that 
he was called upon to treat. 
I have had many cases that I can safely say came near getting well; only a little 
something more was necessary to pull them through; probably this little help was the 
bichloride, which they did not get. 
In comparing the results obtained by tracheotomy and intubation, the most import- 
ant question is not whether, in a given number of cases, one will save more lives than 
the other, but which operation can be performed or will be permitted in the greater 
number. 
Tracheotomy never was and never could be popular, and has never been performed 
in any more than a fraction of the cases of croup, because of the great repugnance to 
any cutting operation that exists among the poorer class of people, where this disease 
principally prevails. 
I know, from my own experience of twenty years in practice, and from conversa- 
tions with a large number of physicians on the subject, that this operation has not been 
resorted to in more than one-fourth of the fatal cases of croup that have occurred in 
New York city, and which amounts to about one thousand a year. 
This is certainly not from any scarcity of surgeons competent and willing to do the 
operation, but from the impossibility of obtaining the consent of the parents and 
friends of the patient. 
Even if tracheotomy were performed in only a small percentage of the cases of 
croup, a disease that prevails so universally in every country, city, town and hamlet, 
the number of operations every year must mount into the thousands, and yet why is it 
so difficult to collect statistics of any considerable number outside of hospital reports ? 
It is simply because the few only who obtain good or fair results publish their cases. 526 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The exceptions to this rule are rare, because there is nothing to be gained and much to 
be lost by reporting bad results. 
It is not uncommon for physicians who have been in practice for a quarter of a 
century in the large cities, and who, in all probability, have seen hundreds of fatal 
cases of croup, to report one or two dozen tracheotomies, usually with a large percent- 
age of recoveries, proving that the operation was performed only in the most favorable 
cases and where good nursing could be obtained. 
METHOD OF OPERATING. 
A set of intubation instruments consists of six tubes, each supplied with a separate 
obturator, an introducer, an extractor, a mouth gag and a scale. The obturator, 
when in position, projects a little beyond the lower extremity of the tube, and is 
rounded off into a probe point, to prevent pushing down pseudo-membrane and injuring 
the tissues of the larynx. It also serves as a means of attachment to the introducer. 
The numbers on the scale indicate the years for which the corresponding tubes are 
suitable. The smallest tube, when applied to the scale, will reach the first line, marked 
1, and is suitable for children of one year and under. This tube can be used with 
children of two years with perfect safety, as far as slipping into the trachea is concerned, 
but the probability of its being coughed out would be great. The second size reaches the 
line marked 2, and is suitable for children between one and two years old. The third 
size is for children between two and four years old, and the next size for children from 
four to seven years old. The next size, reaching the line marked 8-12 on the scale, 
is for children up to twelve years of age, but not after puberty, as the sudden increase of 
the size of the larynx at tjhis time would render it liable to pass through into the trachea. 
The largest size is intended for those children whose larynx is so large that the No. 5 
tube is not retained. 
The female larynx in children, as in adults, is smaller than the male, which should 
be taken into consideration in selecting the tube, as well as the size of the child com- 
pared with its age. For instance, in a small, delicate girl of four years, a No. 2 tube 
would be the proper one, while, on the other hand, in some boys of three and a half 
years it would be advisable to use the 5-7 size, especially if the case is a considerable 
distance from you ; and coughing out the tube would entail some danger and a great 
deal of inconvenience. 
When the proper tube is selected for the case, a fine thread of braided silk is passed 
through the small hole near its anterior angle, and left long enough to hang out of the 
mouth, its object being to remove the tube should it be found to have passed into the 
oesophagus. The obturator is then screwed tightly to the introducer and passed into the 
tube. It is well to push off the tube once or twice before using it, to see that everything 
works smoothly. 
The following is the method of introducing the tube, which is done without the use 
of an anæsthetic. The child is held upright in the arms of the nurse, with its head on 
her left shoulder, to avoid interfering with the mouth gag ; and the arms are secured to 
the sides either by being held below the elbows by the nurse or by wrapping a sheet 
around the body. The legs should be secured between the nurse's knees. The gag is 
inserted in the left angle of the mouth, well back between the teeth, and opened as 
widely as possible without using undue force. An assistant holds the head, thrown 
somewhat backward, wThile the operator inserts the index finger of the left hand, to 
elevate the epiglottis and direct the tube into the larynx. 
The instruments should be worked in the median line, the operator facing the patient 
squarely. The handle of the introducer is held close to the patient's chest in the begin- 
ning of the operation and rapidly elevated as the tube approaches the glottis. Very 
little force is necessary to overcome the obstruction, and if the tube does not enter the SECTION X-DISEASES OF CHILDREN. 
527 
larynx easily, it should be withdrawn and another attempt made. It should be pushed 
well down into the larynx before it is detached from the obturator, and while removing 
the obturator it is necessary to keep the finger in contact with the head of the tube to 
prevent it from being also withdrawn. The string should not be removed until the 
dyspnoea is relieved and the operator is certain that the tube is in the larynx. In some 
cases the tube causes so very slight an amount of irritation that I allow it to remain 
for ten or fifteen minutes to excite more cough, and thus expel the accumulated secretions 
and overcome any collapse of the lung that may exist. When the thread is withdrawn, 
the finger must be kept in contact with the tube to prevent its being also withdrawn. 
In removing the tube, the child is held in the same position, but the head is not 
thrown quite so far back. The finger which is used as a guide for the extractor is 
brought in contact with the head of the tube, and then pressed toward the patient's 
right, in order to uncover the aperture and allow the extractor to enter in a straight line. 
Continuous pressure with the thumb is made on the lever above the handle while the 
tube is being withdrawn. 
Owing to the small aperture of the tube compared with the size of the larynx, the 
extraction of the tube is more difficult than its insertion. It is during this part of the 
operation that the greatest amount of injury is liable to be done to the larynx by pushing 
the instrument down, outside of the tube, and removing it forcibly with the blades 
widely open. It requires no force whatever to remove a tube from the larynx, and if 
any resistance is felt, it will be found that the point of the extractor is not in the tube, 
but caught in the surrounding tissues. To reduce this danger as much as possible, I 
have added a regulating screw, which prevents the blades from opening any wider than 
is necessary to hold the tube firmly. It can be adjusted to suit a tube of any size. 
INTUBATION OF THE LARYNX: ITS ADVANTAGES AND DISAD- 
VANTAGES, WITH STATISTICS OF THE OPERATION. 
INTUBATION DU LARYNX, SES AVANTAGES ET DÉSAVANTAGES, AVEC DES 
STATISTIQUES DE L'OPERATION. 
INTUBATION DES LARYNX : IHRE VOR- UND NACHTHEILE, NEBST STATISTIK DER 
OPERATION. 
BY F. E. WAXHAM, M.D., 
Professor of Diseases of Children in College of Physicians and Surgeons of Chicago ; Clinical Professor of 
Laryngology and Rhinology in Chicago Ophthalmic College. 
Nothing in the history of medicine has excited more widespread interest in America 
than this new operation, which promises to supersede tracheotomy. Too frequently in 
the past have we been obliged to sit helpless and witness death from slow stran- 
gulation, because we have not been allowed by parents to perform tracheotomy. Too 
frequently, indeed, physicians in this country have been so unfortunate in their expe- 
rience with tracheotomy that they have even doubted the utility of the operation. How 
natural, under these circumstances, that they should give a substitute that promised so 
much their hearty approval. 
The origin of the operation in France, by Bouchut, some thirty years ago, and its 
failure, the revival of the operation in America by Dr. O'Dwyer, and his patient 
labor in modifying the instruments and making them of practical value are now facts 528 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of history. Previous to 1885 he alone was performing the operation in America. 
During 1885 a few others, knowing of his work, joined in the research, while now, in 
only a little over two years, we find operators all over the United States, and the num- 
ber of cases reported reaching one thousand. This is a record beyond parallel in the 
history of any operation, and is sufficient evidence that it is a procedure well worthy of 
earnest attention. 
It is far from me to denounce or disparage tracheotomy. It is a noble operation- 
one that has saved many a life in the past, and will continue to save many in the 
future. 
While advocating intubation we must not forget its dangers. 
One of the greatest disadvantages of the operation is the difficulty of performing it. 
There are comparatively few who possess the manual dexterity necessary for perform- 
ing the operation quickly and well. Those who are not intimately acquainted with the 
anatomy of the parts, or who are not naturally dextrous, must practice patiently and 
faithfully upon the cadaver, which is not always convenient or possible. 
Another disadvantage is the danger of injuring the soft tissues from lack of skill in 
performing the operation. If the tissues are torn or bruised, or the trachea perforated, 
it can be readily seen that the chances of recovery will be greatly lessened. 
Still another disadvantage is the difficulty of extracting the tube. It is generally 
conceded that the removal of the tube requires more skill than its introduction. If a 
tube with a very small head is used, so that it sinks deeply in the larynx, and beyond 
the reach of the finger, great difficulty will be experienced in removing it. 
Still another danger results from pulling up the membrane below the tube, thus 
occluding it. To guard against this danger we must use judgment in selecting the 
tube. To use a tube that fits tightly will endanger the patient's life, as it cannot, in 
such a case, be rejected by sudden and powerful efforts, and the child dies from sudden 
asphyxia. We may also guard against this danger by watching the patient carefully, 
and quickly extracting the tube if not rejected. If the membrane is not then expelled 
we may use the trachea forceps or resort to tracheotomy. This danger, however, is a 
slight one ; almost invariably the tube and membrane will be expelled together. Mem- 
brane may be pushed down ahead of the tube when it is introduced. In such a case 
the tube should at once be removed, when, if the membrane is not rejected, the trachea 
forceps should be used, or tracheotomy performed, as in the former case. 
Still another disadvantage is the difficulty of swallowing and the consequent danger 
of pneumonia from the entrance of food and fluids into the lungs. I am convinced that 
this danger has been greatly exaggerated by the opponents of the operation. This dan- 
ger may be obviated, first, by the careful selection of the tube, and, second, by the most 
watchful care in feeding and management of the case. Many, in selecting a tube, choose 
the largest that can be introduced. This is a great mistake, as it gives rise to two dan- 
gers: first, to sudden suffocation in case there is detachment of large patches of mem- 
brane below the tube, and, second, there will be greater difficulty of swallowing, and, 
consequently, greater danger of broncho-pneumonia. Let us observe the caution not 
to introduce too large a tube, and then let us be imperative iu our directions in regard 
to the use of only semi-solids. Cracked ice and ice cream may be given to quench the 
thirst, and stimulants given only by enema. If we observe these precautions we will 
not frequently meet with pneumonia from this source. These are the dangers and the 
disadvantages of intubation. None are so grave that they cannot be overcome. 
In contrast to the disadvantages we may enumerate many advantages which the 
operation possesses over tracheotomy. It can be performed by the expert quickly, 
almost instantly. There is no loss of blood to further prostrate the patient. There is 
no injury to the soft tissues, and little or no pain. There is no shock from the opera- 
tion. There is no danger from septicæmia or erysipelas, as from an open wound. There 529 
SECTION X-DISEASES OF CHILDREN. 
is very little irritation from the tube, much less than from a tracheotomy tube. There 
is no open wound to heal by slow granulation. The air enters the lungs through the 
natural passages, is warm and moist, and there is consequently no drying of mucus in 
the tube, and no cleansing is required. Recovery is rapid after removal of the tube. 
We can do with less skilled attention than after tracheotomy. We can, therefore, save 
many patients where poverty precludes the skilled attention so necessary after trache- 
otomy. 
Consent of parents is much more easily obtained than for tracheotomy, and we will 
save many patients where this operation would not be allowed. 
In addition to all these advantages there is still another-the most important of 
all : We can save as large a proportion of cases as by tracheotomy, at all ages, and a 
much larger proportion among children less than three years. 
In collecting the following statistics I have been greatly assisted by Dr. Dillon 
Brown, of New York, and Dr. E. F. Ingals, of Chicago. These statistics show that the 
operation has been performed by- 
Dr. 
U 
T A'n 1 Private practice 
J O'Dwyer, (Hospih/ „ 
Dillon Brown 
81 times, 
R5 " 
with 20 recoveries. 
" 9 " 
100 
II 
11 
23 
ll 
U 
F. E. Waxham 
120 
ll 
11 
31 
ll 
U 
F. Huber 
52 
ll 
ll 
24 
ll 
U 
J. M. Bleyer 
42 
ll 
ll 
11 
ll 
U 
W. P. Northrup 
33 
ll 
ll 
6 
ll 
II 
E. F. Ingals 
12 
11 
ll 
3 
ll 
II 
S. A. McWilliams 
3 
11 
ll 
0 
ll 
l1 
Wm. Cheatham 
15 
ll 
ll 
1 
ll 
II 
Geo. W. Mason 
4 
ll 
ll 
2 
ll 
II 
H. O. Bates 
6 
ll 
ll 
3 
ll 
II 
F. Henrotin . 
9 
ll 
Cl 
3 
ll 
II 
J. S. Multiinger 
2 
11 
11 
1 
ll 
II 
Harles 
2 
ll 
ll 
2 
ll 
II 
J. B. Wheeler 
1 
ll 
ll 
0 
ll 
ll 
E. D. Fergurson 
1 
ll 
ll 
0 
ll 
il 
Chas. Dennison 
1 
ll 
11 
1 
» c 
ll 
F. Tipton 
•• 
1 
<1 
ll 
1 
ll 
ll 
S. H. Dunning 
7 
ll 
11 
5 
ll 
il 
I. H. Hance 
6 
ll 
ll 
1 
ll 
il 
E. E. Montgomery 
.. 
15 
ll 
ll 
8 
ll 
il 
A. E. Hoadley 
•• 
13 
ll 
ll 
2 
" 1 
il 
J. Tascher 
11 
ll 
ll 
4 
ll 
c l 
O'Shea 
37 
cl 
ll 
14 
ll 
ll 
A. B. Strong 
, » 
34 
ll 
ll 
2 
ll 
il 
F. C. Schaeffer 
... 
4 
ll 
ll 
0 
ll 
< l 
C. E. Denhardt 
24 
ll 
ll 
10 
ll 
il 
A. Caillé 
17 
ll 
ll 
7 
ll 
il 
Roswell Park 
13 
ll 
lc 
4 
ll 
ll 
F. Van Fleet.... 
22 
ll 
11 
7 
ll 
il 
D C. Cocks 
... 
21 
cl 
ll 
6 
ll 
II 
T. H. Meyers 
.. 
21 
ll 
ll 
4 
ll 
II 
G. H. Cocks 
14 
ll 
cl 
4 
11 
II 
W. K. Simpson 
10 
ll 
ll 
0 
ll 
U 
J. A. Anderson 
10 
ll 
ll 
1 
ll 
II 
E. S. Cocks 
10 
ll 
ll 
3 
ll 
II 
J. J. Reid 
10 
Cl 
ll 
4 
ll 
ll 
Geo. McNaughton 
10 
ll 
ll 
2 
ll 
II 
J. Eichberg 
6 
ll 
lc 
2 
ll 
II 
W. H. Prescott, 6 ) 
II 
W. B. Bolles. 2 k 
10 
ll 
ll 
2 
ll 
II 
H. S. Smith, 2 J 
- 
Carried forward, 
875 
233 
Vol. Ill-34 530 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Brought forward, 
875 times, with 233 
Dr. H. H. Mudd 
6 
4 4 u 
2 
u 
" Carl Beck 
5 
u u 
4 
44 
" G. W. Gay 
. 4 
Cl ll 
0 
44 
" J. McManus 
5 
ll 11 
2 
ll 
" H. D. Ingraham 
3 
ll ll 
0 
ll 
" A. S. Hunter 
3 
ll ll 
0 
ll 
" N. S. Roberts 
3 
ll ll 
1 
44 
" David Prince 
2 
ll ll 
2 
44 
" ,W. E. Shaw 
2 
ll ll 
0 
44 
" J. W. Niles 
1 
ll ll 
• 0 
. 1 
" J. R. Richardson 
47 
ll ll 
17 
U 
" E. C. Morgan 
1 
ll ll 
0 
44 
" F. Donaldson, Jr 
1 
ll ll 
0 
44 
" Langniann 
1 
ll ll 
1 
44 
" H. F. Ivins 
1 
ll ll 
0 
44 
U A. G. CäS6 
1 
ll ll 
1 
44 
" s. S. Palmer 
1 
ll ll 
0 
ll 
" B. T. Shimwell 
1 
ll ll 
0 
44 
" W. L. Carr 
2 
ll ll 
0 
44 
" F. K. Priest 
5 
ll ll 
0 
44 
" J. E. Winters 
6 
ll ll 
0 
44 
" F. W. Merriam 
3 
ll ll 
2 
4 4 
" H. W. Berg 
8 
ll ll 
2 
ll 
" Forscheimer 
n 
ll ll 
2 
H 
" John A. Robinson 
1 
ll 11 
0 
4 4 
" C. G. Jennings 
4 
11 ll 
0 
ll 
" D. Collins 
2 
ll ll 
0 
ll 
" M. P. Hatfield 
8 
ll ll 
0 
44 
■ 
■ 
1007 
269 
Total number of operators, 69. 
Total number of cases, 1007. 
Total number of recoveries, 269. 
Percentage of recoveries, 26.71. 
The ages were recorded in 661 cases, and were as follows :- 
There were 31 patients under 1 year of age, with 5 recoveries, 
or 16.12 per cent. 
" 97 " 1 
15 
44 
15.46 
4 4 
" 149 " 2 " 
29 
4 4 
19.46 
44 
" 140 " 3 " 
42 
4 4 
30.00 
44 
" 98 " 4 
32 
44 
32 65 
< 4 
" 56 " 5 " 
19 
44 
33.92 
44 
" 27 " 6 
10 
ll 
37.03 
44 
" 32 " 7 " 
16 
ll 
50.00 
Cl 
" 12 " 8 
5 
ll 
41.66 
ll 
" 10 " 9 '* 
5 
ll 
50.00 
ll 
" 2 " 10 
1 
U 
50.00 
ll 
" 5 " 11 
2 
44 
40.00 
44 
" 2 " 14 " 
0 
4 4 
00.00 
44 
Total, 661 
181 
27.38 
Average age, 3 years and 3 months. 
There were 277 patients under 3 years of age, with 49 recoveries, or 17.68 per cent. 
There were 384 patients over 3 years of age, with 142 recoveries, or 34.37 per cent. 
The history of a single patient in this connection may not be uninteresting, as the 
history of one is that of many. On August 22d, 1887, I was called by Dr. Oscar J. 
Price, of Chicago, to perform intubation upon Dora B., a little girl of three years, and 
the following history was obtained: The little patient was brought to the Doctor's 
office on August 14th, with a mild attack of bronchitis, for which he prescribed, with SECTION X-DISEASES OF CHILDREN. 
531 
benefit. A few days later the child was exposed during inclement weather, and became 
worse. On August 21st the Doctor was called to the house and found diphtheritic 
membrane covering the tonsils and uvula, a croupy cough, husky voice, and considerable 
dyspnoea, showing that the larynx was invaded. In spite of thorough and energetic 
treatment the child became rapidly worse. On August 22d I was summoned in great 
haste and found the patient moribund. No pulse could be detected at the wrist, the 
hands were cold, the features livid and the child actually dying. No hope was enter- 
tained of recovery, but it was decided to give the little patient at least a chance for life. 
A tube was quickly introduced and the child soon revived. The respiration became 
easier and the pulse returned, although very rapid and feeble. As the child revived 
coughing was induced and considerable ropy mucus and softened membrane were 
ejected. Cracked ice was given to quench the thirst and semi-solids for nourishment. 
As the child swallowed very poorly, stimulating enemas were given. The child 
improved perceptibly, although the pulse continued from 130 to 150 per minute. The 
temperature ranged from 101° to 102°. 
On the third day, as the little patient seemed so very feeble, the tube was removed, 
but the dyspnoea gradually returned, and within eight hours became so urgent that 
the tube was again introduced. Although the patient seemed very feeble, she was in 
a far better condition than when the operation was first performed. The child took 
but little nourishment, but still a sufficient amount to sustain life. Two days later 
the tube was again removed, after being in position five days. Respiration was now 
unimpaired, and the little patient made a gradual but perfect recovery. The interesting 
features in this case were, first, the low vitality of the child when the operation was 
performed, and yet the perfect recovery, and, second, notwithstanding that the child 
took nourishment poorly, more so than is usual in such cases, yet there was no broncho- 
pneumonia developed, such as many attribute to the falling of food and liquids into the 
lungs. 
Intubation of the larynx, to be successfully performed, depends, first, upon judg- 
ment in selecting the proper tube. 
Second, upon the delicacy and skill with which it is performed. 
Third, upon the most careful management of the case. 
Fourth, upon faith in the operation. 
That intubation has been performed 1000 times within two years, and that 269 lives 
have been saved from certain death, entitles the operation to a place in the history of 
medicine. 
INTUBATION OF THE LARYNX.-HISTORY. 
INTUBATION DU LARYNX.-HISTOIRE, 
INTUBATION DES LARYNX-GESCHICHTE. 
BY DILLON BROWN, M. D., 
Attending Physician Out-door Department of Bellevue Hospital. 
I. CATHETERIZATION OF THE LARYNX. 
Catheterization of the air passages dates its history from the time of Hippocrates. 
He suggested that in cases of inflammatory cynanche, " cannulas should be carried into 
the throat along the jaws, so that the air can be drawn into the lungs." This practice 
had many followers among the ancients until abolished by Asclepiades and Paul, of 
Egina, who introduced bronchotomy. The remembrance of catheterization was almost 532 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lost unPl Desault revived the operation in 1801. Some time previous to this it was 
attempted by several, but its execution was found impossible on account of the extreme 
sensitiveness of the mucous membrane of the larynx and trachea. Chaussier in his 
memoirs (1780-81) proposed to use the laryngeal tube, which still bears his name, in 
the asphyxia of new-born children and in cases of dyspnoea from obstruction in the 
Upper air passages. Desault suspected for some time that this extreme sensibility of 
the mucous membrane to the presence of a foreign body could be blunted by the ha- 
bitual presence of some smooth object, and the larynx could thus be taught to tolerate 
a tube for any length of time. He obtained a convincing proof of this by accident. On 
attempting to pass an elastic tube in the oesophagus of a patient, who had received a 
transverse wound in the neck, for the purpose of feeding him, the tube slipped, by 
mistake, into the larynx. There was a sudden cough, and the patient attempted to 
vomit, but in a little while he was tranquil. However, every attempt to pass fluids 
through the tube caused a violent, convulsive cough, extreme agitation and anxiety; 
but in the intervals the patient was tranquil and comfortable. Suspecting the tube to 
be in the larynx, he brought the flame of a candle to its extremity, and it was imme- 
diately caused to vacillate by the air that escaped. Upon withdrawing the tube and 
putting it into the oesophagus, the patient wasted without difficulty. In the works of 
Desault, edited by Bichat, reference is made to six cases treated by passing long elastic 
tubes into the larynx, the upper end of the tube projecting either from the mouth or the 
nose. The first was a case of cynanche trachealis, in which the obstruction was so severe 
that brouchotomy was considered necessary and urgent. The obstruction was completely 
relieved by the tube, and, although the patient died the next day, there was no return 
of the dyspnoea. The second case was treated by a surgeon of Toulouse, and com- 
municated by one of his pupils to Desault. A boy, thirteen years old, with schirrhus 
angina of the parts surrounding the glottis, had a noisy and very difficult respiration. 
A gum elastic tube was inserted in the larynx and the upper end allowed to project 
from the mouth. This gave relief, but some time after the tube became obstructed and 
required cleaning. He repeated the operation six times, and was satisfied with the 
result, but was compelled at this juncture to neglect the patient, on account of illness. 
The next case was one of cynanche gutturalis, in which there was much swelling of the 
tongue and soft parts of the pharynx. On the fifth day all the symptoms were so 
intense that not only was the patient in imminent danger of suffocation, but he w as 
not able to swallow the smallest quantity of food. An elastic tube was passed into the 
trachea and the dyspnoea relieved. At first it excited some cough, but this soon ceased. 
The next day the tube became obstructed, and was removed, cleansed and reinserted. 
This time its presence excited scarcely any cougl). It remained in place a day and a 
half, when it was no longer needed. The patient recovered. At the hospital of Lyons, 
a soldier who had attempted suicide received food and air for fifteen days by the aid 
of two tubes, introduced one into the larynx and the other into the oesophagus. Giraud 
reports the next case, and also refers to a similar one, but has no notes of it. A man 
in a fit of madness cut his throat, dividing the trachea about an inch below the cricoid 
cartilage. The position of the head necessary to bring the edges of the wound together 
caused the most extreme difficulty in breathing. Therefore, Desault passed a gum- 
elastic tube through the nose and into the trachea. Its presence at first excited violent 
coughing, but this did not last long. The respiration became easy, and the edges of 
the w ound could be brought in exact contact without exciting either pain or dyspnœa. 
He was doing well, but in the evening, during a new paroxysm of madness, he pulled 
off the dressings, tore open the wound and caused a hemorrhage which killed him. 
Finaz of Seyssel, in a thesis presented to the Faculty of Medicine of Paris, in 1813, 
reports a case of severe laryngeal obstruction, where he urged that a gum-elastic cathe- 
ter should be passed through the larynx into the trachea. His advice was not followed, SECTION X-DISEASES OF CHILDREN. 
533 
and the patient died of asphyxia. The autopsy showed a smooth, non-inflammatory 
tumor just below the base of the epiglottis, and confirmed his opinion that catheteriza- 
tion of the larynx would have saved the life of the patient. Ducasse, in 1817, and 
Patissier, in 1820, proposed the same method in cedema of the glottis, but their advice 
was not accepted. Py (1808), Mackenzie (1825) Emile Gendron (1826), Guimier (1827), 
Liston (1827), and many others, have carried out the same idea. 
Gironard de Sancheville, in a memoir in November, 1827, advocated catheteriza- 
tion of the glottis in croup, and, by this means, the application of caustics to the larynx. 
In his early attempts he had much difficulty, but after a certain amount of practice and 
experience he could do the operation with ease and celerity. 
There have been reported many cases in which, in attempts to feed the patient by 
means of a catheter, it has passed into the trachea instead of the oesophagus. Desault's 
first case was one of this kind, and for others see a thesis by Prus, Paris, 1817, No. in, 
p. 26, and articles by Thoré and Baillarger in Annales Medico-psychologique, t. V 
and vin. Dr. John Watson reports a case of stricture of the oesophagus which it was 
necessary to cut, and to sustain life the patient was fed with a stomach tube. The 
tube frequently slipped into the larynx-in about one-fourth of the trials-and its posi- 
tion there was easily demonstrated. A similar case has come under my own notice, in 
which a large quantity of egg-nog was poured into the lungs instead of the stomach. 
The autopsy showed the bronchi filled with coagulated milk. 
Dieffenbach (1839), at the Berlin Charity Hospital, operated upon a case of croup 
by making a local application of nitrate of silver to the larynx through a curved tube 
which was passed into the trachea. The left index finger, which acted as a guide to the 
larynx, was protected by a shield of metal. In the Journal of the Soc. d. Méd. pract. d. 
Montpellier, for 1844, are found three cases of catheterization of the larynx-two by 
Lallemand and a third by Justin Benoit. In all of them the dyspnoea was relieved, 
and in one of them-a case of cedema following chronic syphilitic laryngitis-the 
recovery was complete. In 1845, Depaul, in an important memoir on insufflation in the 
asphyxia of new-born, by his researches confirmed the results then obtained by 
Duméril and Magendiè, and demonstrated that insufflation was not difficult, that it 
never caused a rupture of the pulmonary vesicles, and that it would resuscitate after 
all other means had failed. He used a modification of Chaussier's laryngeal tube. In 
the same year, Scoutetten introduced into the larynx of a baby at the point of suffoca- 
tion a gum-elastic catheter, and practiced insufflation. The relief to the dyspnoea was 
complete, but the presence of the instrument excited so much irritation-cough and 
alarming spasm-that he was compelled to remove it. The obstruction immediately 
returned, and, in spite of its inconvenience, he was forced to reinsert the catheter. 
However, after repeating this operation a number of times, the presence of the tube in 
each case causing an alarming amount of irritation, he performed tracheotomy. The 
child recovered. 
In 1852, Lestier, in a treatise on cedema of the larynx, called attention to the use of 
the laryngeal sound in this disease, and praised it above bronchotomy. He mentioned 
its use by surgeons to investigate the degree and locality of stenosis of the air passages. 
Pia devised a peculiar laryngeal cannula of wood, composed of two parts joined by a 
leather tube, so that the introduction of air could be regulated at will. Dr. Albert 
invented a copper cannula, so protected at the end as to push back mucus and prevent 
the tube from becoming obstructed by it. Leroy, Desgranges and James Curry have 
also made different modifications of the laryngeal catheter. In 1851, Didot devised a 
laryngeal tube, which resembled that of Chaussier externally, but was so arranged that 
local applications could be made through it. About this time the treatment of diseases 
of the air passages by catheterization and local applications excited widespread interest, 
and the medical journals of this period are filled with the subject. The most important 534 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
contributions were those by Horace Green, of New York, and Loiseau, of France, but 
others came from Beybard (1855), Erichsen (1855), Bowditch (1855), Roux (1856), Ben- 
nett (1858), Gros (1858), Dêlfrayssé (1858), Crégny (1858), Garin (1858), Gesenius 
(1858), Redat (1859), Clark (1859), Collin (1860), Brown-Sequard (1862), Jasche (1867), 
Löwenhardt (1867), Inderfurth (1868), Bossi (1868), Depres (1869), and many others. 
To Dr. Horace Green, of New York, belongs the credit of having made local appli- 
cations to the larynx a well-recognized therapeutical measure. His first case, one of 
follicular laryngitis, was treated in 1838. In 1848, he published a memoir " On the 
Pathology of Croup, and its Treatment by Topical Medications; " in 1856, an article on 
the injection of the bronchial tubes and tubercular cavities in the lungs; in 1859, on the 
treatment of croup by cauterization and catheterization of the larynx; and the next year, 
an article on the difficulties aud advantages of catheterization of the air passages in dis- 
eases of the chest. Green's work encountered at the New York Academy of Medicine 
and elsewhere the greatest opposition ; and the discussions on it were extremely bitter, 
and seemed more like a persecution than any attempt at an honest discussion. The his- 
tory of the S. S. Whitney case makes a very interesting chapter in the ethical history 
of the New York medical profession. 
Loiseau, imitating Dieffenbach, Depaul, Chartres and others, presented, in 1857, to 
the Paris Academy of Medicine, a paper entitled, " A simple and easy method of enter- 
ing the air passages in order to cauterize them or extract false membranes; to dilate the 
glottis; to introduce substances used in the treatment of croup, either in the form of 
liquid or powder; and finally, to take the place of tracheotomy." Loiseau used a long 
tube, one eud of which projected from the mouth. His method of operating was to 
protect the left index finger with a metal ring, which also acted as a mouth gag. to 
depress the tongue, seize the epiglottis and raise it, and pass the tip of the finger between 
the aryteno-epiglottidean folds. Then, using this finger as a guide, it is easy to pass the 
tube in the larynx and make a local application through it. The committee appointed 
by the Academy of Medicine (consisting of Trousseau and Blanche) to consider Loiseau's 
paper, returned a highly favorable report, which was unanimously adopted by the 
Academy. "This operation," says Trousseau, "is considered a very good means of 
taking the place of tracheotomy, and, at all events, should be tried before practicing 
that operation. ' ' Gros reported a successful case, and Collin, in his memoir, has collected 
twelve cases, seven of which recovered. In spite of this, he concluded that catheteriza- 
tion of the larynx is an inferior operation to tracheotomy. 
Weinlechner, in 1870, devised a long tube to be used in cases of laryngeal stenosis, 
either acute or chronic. He reports forty-six cases of croup treated by Loiseau's mêthod, 
with seventeen recoveries, and speaks very favorably of the operation. He condemns 
the use of the short tube suggested by Bouchut. Prior to this catheterization of the 
larynx was employed for the stenosis of croup by Monro and by Portal. Von Hütten- 
brenner, in 1874, discusses this operation, and in 1881 a successful case is reported 
by Paton, and another by Sanctuary. 
In the treatment of chronic stenosis appear the names of Czermak, Busch, Semelder, 
Gerhardt, Trendelenburg, Stoerk, Schroetter, McSherry, Bergmann, Sceparowicz, 
Nawratil, Richet, Gur It, Hack aud others. In most of these cases the operator passed 
the dilators through the tracheal opening upward iuto the larynx. Schroetter proposed 
dilating the larynx through the mouth by using hollow, three-cornered, vulcanized 
bougies. This method was previously suggested by Trendelenburg, who practiced it 
in one case. Hack reports a case of oedema of the glottis treated by the Schroetter 
tubes, in which the patient, when on the way to the hospital, was seized with severe 
dyspnoea and successfully introduced the tube iuto his own larynx. Rauchfass reported 
two cases in 1875, and among many other names we find Caird (1876), Labus (1876), 
Alexich (1878), Ribemout (1878), Polk (1880), Chiari (1884), etc. SECTION X-DISEASES OF CHILDREN. 
535 
The most important recent communications upon this subject are those of Macewen 
in 1880 and of Hering in 1882. Macewen's first and last case was done to prevent 
blood from entering the larynx when operating upon the mouth. His other cases, both 
successful, were for oedema of the glottis-one due to the burn of a hot potato, and 
the other following a chronic laryngeal affection. Monti, of Vienna, has resorted to 
this operation for years, and a few months ago Landgraf reported a case before the 
Medical Society of Charity Hospital at Berlin, in which there was stenosis of the left 
bronchus due to the pressure of an aneurism of the aorta. The catheterization of the 
bronchus was done a number of times, and gave so much relief that at the end of a 
month the patient was well enough to leave the hospital. Unfortunately, the cause of 
the stricture was not recognized, and in a few weeks he returned, having had a severe 
asphyxiai seizure, and shortly after died. 
In 1858 Bouchut published his memoir, and with this exception, every attempt to 
relieve laryngeal stenosis by the use of a tube passed through the mouth into the 
larynx was made with a catheter or long tube, one end of which rested in the trachea 
and the other projected either from the mouth or the nose. This method has so many 
almost insurmountable objections, that in spite of the frequent attempts it has made 
to supplant tracheotomy, it has always been an unsatisfactory operation. 
II. TUBAGE OF THE GLOTTIS. 
The whole history of tubage is represented by Bouchut's memoir and the report 
upon it by the Paris Academy of Medicine. In September, 1858, Bouchut submitted 
to the Paris Academy of Science a paper entitled "A New Method in the Treatment 
of Croup by Tubage of the Larynx. ' ' His tube was a silver, truncated, hollow cone, 
similar to a common thimble, from one and a half to two centimetres long. At its 
upper extremity were two collars, six millimetres apart, between which the vocal cords 
were supposed to rest, and it was pierced at the top by a hole for the passage of a string, 
to which it was fastened, not only to permit its withdrawal, but to prevent its slipping 
through the larynx into the trachea. The tube was fitted to the end of a curved sound 
and introduced by this means. The left index finger was used as a guide to the larynx 
and was protected by a metal ring, which also acted as a mouth gag. Bouchut operated 
in all upon seven cases of croup; five died and two recovered after having been trache- 
otomized. Upon these cases he sought to establish- 
1. Tubage is easily accomplished by means of a cannula,held in position by the 
inferior vocal cords, and it does not interfere with the functions of the epiglottis. 
2. The larynx is tolerant of the presence of this cannula. 
3. The possibility of relieving the asphyxia of croup and other laryngeal affections 
without tracheotomy. 
4. The facility with which large pieces of pseudo-membrane can be expelled 
through the tube. 
5. The advantages of this new procedure to the country physician far from assistance. 
Trousseau, who was chairman of the committee appointed to report on his paper, 
condemned the operation without mercy, as both unphysiological and impractical. 
Möller, of Koenigsberg, in 1861, made several unsuccessful attempts to use Bouchut's 
tube, and with this exception the operation has never been heard from since this report 
of the Paris Academy of Medicine, thirty years ago, until Dr. Joseph O'Dwyer, of 
New York, solved the problem. 536 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
BIBLIOGRAPHY. 
CATHETERIZATION OF THE LARYNX. 
Allexich (G.). Croup laringeo guarito col tubage della laringe. Gazz. Med. ital., pror. renete, 
Padora, 1878, xxi, 57-60. 1 pl. 
Bergmann. Ein Fall von Laryngitis hypoglottica hypertrophica behandelt mit Tubage. St. 
Peterab. Med. Wochenach., 1883, VIII, 145-147. 
Bossi. lieber die Katheterisation der Luftröhre zur Wiederbelebung scheintodter Neugeborner. 
Sitzungsb. d. Ver. d. Aerzte in Steiermark. Graz, 1867-68, v, 46-53. Also: Wiener 
Med. Preaae, 1868, ix, 869-871. 
Brown-Séquard. Possibilité d'introduire un tube dans le larynx sans produire de douleur on 
une réaction quelconque. Compte, rend., Acad. d. Se., Paris, 1882, xcv, 553-555. Also: 
France Méd., Paris, 1882, il, 461. 
Chiari (O.). Tubage des Kehlkopfes. 8°. Berlin, 1885. E. Grosser. 20 p. 
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Collin (P. V.). Du cathétérisme laryngien. 4°. Paris, 1860. Paria Thèaea, 1860, No. 7. 
[Case.] Observation d'angine diphthéritîque et de croup chez un enfant; cathétérisme laryn- 
gien ; guérison; quelques remarques sur la valeur et les indications thérapeutiques du 
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Gaz. d. hôp., Paris, 1858, xxxi, 543. 
" Deux nouveaux cas de croup guéris par le cathétérisme et la cautérisation du larynx 
(méthode de M. Loiseau). Gaz. d. hôp., Paris, 1859, xxxn, 105. 
Garin (J.). Le tubage du larynx et la trachéotomie, comme methode de traitement du croup. 
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Gesenius. Der Katheterismus des Larynx und sein Verhältniss zur Tracheotomie; nach den 
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Glück (J.). Another mode of passing catheters into the trachea. Am. Med. Monthly, New 
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Monthly, New York, 1859, xi, 81-95. Also: Reprint. 
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Gros (L.). Observation de croup traité avec succès par le cathétérisme du larynx. Bull. gén. 
d. thérap., etc., Pays, 1858, lv, 219-222. Also: Union Méd., Paris, 1858, XII, 434. 
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Jäsche (G.). Ein erfolgreicher Katheterismus der Luftröhre. St. Peterab. Med. Zeitach., 1867, 
xii, 39. 
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xxiv, 85. 
Löwenhardt (S. E.). Ueber einen Apparat zur Katheterisation der Luftröhre und Luftinhalation 
bei asphyktisch Neugeborenen. JfonafsscÄ./'. Geburtsk. u. Frauenkr., Berlin, 1867, xxx, 
265-292. 
Macewen ( W.). Croup ; tubage du larynx ; guérison ; oedème de la glotte ; introduction des 
tubes trachéaux par la bouche en place de la trachéotomie. Paria Méd., 1880, 2. S., v, 
585. 
Möller. Ueber Bouchut's Tubage beim Croup. Amtl. Ber. ü. d. Versamml. deutsch. Naturf. 
u. Aerzte, 1860. Königsberg, 1861, xxxv, 167-173. 
Orth (K.). Zwei Fälle von Kehlkopfstenose. Deutache Med. Wochenachrift, 1886, No. 29. 
Paton (J. W.). Case of croup treated bjT passing catheters into the trachea by the mouth. Brit. 
M. J., Lond., 1881, I, 803. Also: Am. Med. Bi-Weekly, N. Y., 1881, XIII, 13. Also: 
Brit. M. J., 1881, i, 1001; 1881, n, 690. 
Pollard (Bilton). Three cases illustrating the difficulties in establishing natural respiration after SECTION X-DISEASES OF CHILDREN. 
537 
tracheotomy, and their treatment by tracheal catheterization. Clinical Soc. of London. 
London Lancet (Am. Rpt.), June, 1887, p. 454. 
Prus. Thèses Paris, 1817, No. in, p. 26. 
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1875-76, n. F., v, 64. 
Reese (D. M.). Dr. Horace Green and catheterization of the bronchi. Am. Med. Gaz., N. Y., 
1860, xi, 241-249. 
Sanctuary (T.). Tracheal catheterism in Croup. Brit. Med. Jour., London, 1881, t. 1001. 
Sprague (S. L.). Catheterization of the lung. [From : Bos. Soc. Med. Observation.] Boston 
M. & S. J., 1855, un, 210-212. 
Tubage (Le) du larynx et la trachéotomie. Gaz. d. hôp., Paris, 1859, xxxn, 33. 
Von Hüttenbrenner (And.). Ueber den Katheterismus des Larynx bei der croupösen oder 
diphtheritischen Erkrankung desselben. Jahrb. f. Kinderk., Leipzig, 1874-75, vm, 
89-97. 
INTUBATION OF THE LARYNX. 
Pacific Med. & Surg. Jour., San Francisco, 1886, xxix, 65; 1887, xxx, 129; 1887, xxx, 395. 
Med. Record, New York, 1885, xxvn, 206; 1886, xxix, 214, 410, 474, 641; 1886, xxx, 280, 
487, 645, 665, 683; 1887, xxxi, 26, 70, 73, 108, 109, 161, 192, 324, 416, 608, 646, 677, 
685, 686, 687, 705, 707; 1887, xxxn, 99, 137. 
Paris Méd., 1887, xii, 97, 17; 1886, xi, 541. 
Memorabilien, Heilbronn, 1886, N. F., vi, 518, 
Medical Review, Pittsburg, 1887, I, 114. 
American Pract. & News, Louisville, 1886, in, 321 ; 1886, II, 377. 
Berliner Klinische Wochenschrift, Aug. 8, 1887. 
Jonrn. American Med. Assoc., Chicago, 1887, VIII, 9, 199, 342; 1886, VII, 35, 76; 556, 1887, 
vm, 291, 135; 1886, vi, 186, 147; July 2, 1887; 1886, vi, 426; 1887, vm, 337, 358, 701. 
Archives Pediatrics, Phila., 1886, in, 215; 1885, n, 657; 1887, IV, 154. 
Medical Journal, New York, 1887, xlv, 238; Nov. 28, 1885; 1885, xmi, 145; July 23, 1887, 
p. 95; 1887, xlv, 273, 624; 1886, xliv, 322, 373; 1886, xliii, 384. 
Medical Journ. & Examiner, Chicago, 1885, L, 475; 1885, LI, 511; 1886, Lin, 132; 1886, LII, 
351, 353, 193; 1885, li, 401; 1886, lii, 214; 1886, lui, 370; 1887, uv, 300, 407. 
Medical Age, Detroit, 1886, iv, 313; 1887, v, 15. 
Mississippi Valley Med. Monthly, Memphis, 1886, vi, 345. 
Cincinnati Lancet Clinic, 1887, LVii, 54, 97, 208; 1887, n. s. xvm, 321; 1886, N. s. xvn, 606. 
Jferf. & Surg. Rep., Philadelphia, 1886, lv, 362, 393, 586 ; 1887, LVI, 621, 525. 
Western Med. Reporter, July, 1887, p. 153. 
Albany Medical Annals, 1887, VIII, 41. 
Medical Times, Chicago, 1887, xix, 53. 
American Lancet, Detroit, 1887, N. S. xi, 92 ; 1886, N. s. x, 401. 
Med. Presse, New York, 1887, iv, 17 ; Dec. 1886, p. 40; 1887, Hl, 259. 
American Jour. Med. Science, Philadelphia, 1886, N. s. No. 184, p. 409. 
Medical Register, Philadelphia, 1887, I, 174, 42, 122, 146. 
Wiener Med. Wochenschrift, 1887, xxxvn, 2, 35, 58. 
Medical Times, New York, 1886, xiv, 55; 1887, xv, 53. 
Wiener Med. Presse, No. 12, 1887. 
Indian Medical Gazette, Calcutta, 1886, XXI, 334. 
La Independencia Médica, Barcelona, 1887, xxn, 365. 
Southern Medical Record, Atlanta, 1887, xvn, 325. 
Allgemeine Med. Central-Zeitung, May 26, 1886. 
Le Progrès Méd., June 18, 1887, p. 499. 
Gaillard's Med. Journal, New York, 1887, xlv, 101. 
Buffalo Med. & Surg. Journal, 1885, xxv, 553; 1886, xxvi, 226, 116. 
Kansas City Med. Index, 1887, vin, 148. 
Virginia Med. Monthly, Richmond, 1886, xm, 648. 
Concours Médicale, Feb. 26, 1887. 538 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Rev. Gen. d. Clin, et d. Therapeut., 1887, I, 216. 
Hahnemannian Monthly, Philadelphia, June, 1886. 
Medical Herald, Louisville, 1887, VIII, 583. 
Gazz. Med. d. Roma, Aug. 1, 1887. 
L'Union Médicale, Paris, 1887, XL, 1049. 
Maryland Med. Journ., Baltimore, 1886, xvi, 147, 67, 168, 391. 
Boston Med. & Surg. Journ., 1887, cxvi, 363; 1886, cxv, 598. 
Journal Laryngology & Rhinology, London, 1887, I, 1. 
La Riforma Medica, Napoli, 1887, No. 159, 160, 161 and 162. 
Therapeutic Gazette, Philadelphia, 1886. 
Medical Monthly, New York, 1886, I, 9. 
Pacific Record of Med. & Pharm., San Francisco, 1886, I, 68. 
Lancet, London, Dec. 19, 1885, p. 1159. 
Giornale Internationale d. scienz. med., 1886, VIII, 996. 
Weekly Medical Review, St. Louis, 1886, xiv, 171; 1887, xv, 57, 306. 
Eastern Med. Journ., Worcester, 1887, vu, 30. 
Provincial Med. Journ., 1887, VI, 225. 
Deutsche Med. Zeitung, No. 38, 1887. 
South California Pract., 1886, I, 344. 
Medical News, Philadelphia, 1887, L, 341. 
St. Louis Courier Med., 1886, xvi, 470. 
Obstetric Gaz., Cincinnati, 1887, x, 124. 
St. Louis Med. <& Surg. Journ., 1887, LU, 115. 
Canadian Pract., Toronto, 1887, xii, 1. 
Arch. Méd. Belges, Bruxelles, 1887, xxxi, 183. 
Reference Handbook of the Medical Sciences. Ed. by A. H. Buck, m.d. Vol. IV, p. 419. 
DISCUSSION. 
Dr. Pitner (Jacksonville, Ill.) questioned the correctness of the closing statement 
of Dr. Waxham, that the 249 cases of recovery following intubation were so many 
lives saved by the operation. This assumes that all cases of stenosis from croup or 
diphtheria are, without operative measures, necessarily fatal, and he had observed 
some of these cases recover under treatment without operation. He did not, how- 
ever, question the utility and great importance of this operation, which appeared 
to him to be preferable to tracheotomy in a large majority of the cases where an 
operation is indicated. 
Dr. C. Gr. Jennings (Detroit, Mich.) :-I hesitate to speak of my small number 
of intubations, and I should not do so were it not for the fact that my experience 
with tracheotomy and intubation has been directly opposite to that of the gentleman 
who has just read his paper. Too much cannot be said in praise of the efforts of 
Dr. O'Dwyer and Dr. Waxham. They have given to the profession and to the 
people a method in the treatment of croup which will save hundreds of cases. 
My own experience up to the present time includes 36 cases of tracheotomy, with 
17 recoveries, and 12 cases of intubation, with no recoveries. Dr. Waxham has given 
us the statistics of about 1000 cases of intubation, showing about 26 per cent, of 
recoveries. If compared with' the general statistics of tracheotomy, this, I think, 
is a better record than the latter operation can give. It is to be noted, however, in 
these statistics that certain operators in both operations have records far above the 
average, and I believe the successful tracheotomists have a larger proportion of 
recoveries than the physicians performing intubation who rank as the most successful. 
This would indicate that tracheotomy performed by the best operators will give better 
results than intubation performed by operators of equal dexterity. SECTION X- DISEASES OF CHILDREN. 
539 
Dr. Waxham has been unusually successful with intubation, while operators in 
the same city, and operating under the same circumstances, have been markedly 
unfortunate. I am firm in the belief that the personal equation is an important 
element in the consideration of the results of both tracheotomy and intubation. Dr. 
Waxham has caught the spirit of the operation, and he sees indications for little 
details of treatment which escape the ordinary observer, and which, although appa- 
rently insignificant, have the greatest influence over the result. Death threatens from 
so many quarters after either operation, that to be successful the most painstaking 
care is necessary. 
I must grant all the great advantages mentioned by the writers which intubation 
possesses over tracheotomy. There are some features of superiority in the latter 
operation, however, which should not be lost sight of. The accessibility of the trachea 
after tracheotomy, for the removal of membranes and desiccated mucus, and for the 
direct local treatment of the diseased mucous membrane, offers an advantage which 
can never be approached in intubation. Through a tracheal tube medicated steam 
may be almost continuously poured into the trachea. This, with the addition of 
medicated instillations and the insufflation of powders, has a great influence in the 
production of a favorable result. 
The nutrition of patients with croup who are much exhausted by diphtheritic 
toxæmia is of prime importance. After intubation, proper nutrition is almost 
impossible ; after tracheotomy, there is no such difficulty. 
In regard to the comparative difficulty of performing the operation, I would say 
that to an inexperienced operator intubation may prove fully as difficult as trache- 
otomy. When one has acquired the necessary dexterity, intubation is a very simple 
matter, while tracheotomy, even to the most expert operator, must always remain a 
difficult procedure. Physicians may become expert in intubation who never would 
attempt a tracheotomy, and herein lies one of the greatest advantages of intubation. 
It will be practiced by many more physicians, and it will bring surgical relief to 
hundreds of cases of croup which would otherwise be left to die. While I do not 
pretend to say that this should be the general rule in determining between the two 
operations, I shall in the future, in the light of my past experience, urge tracheotomy 
for all cases offering reasonable chance of success, reserving intubation for the cases 
in which operative interference will give nothing more than euthanasia and those 
patients whose parents refuse to consent to tracheotomy. 
Dr. Northrup (New York):-It seems to me the gentlemen have left a depressing 
feeling upon us. They have set up so many danger signals that I fear, if I never 
had begun on this operation, I should not have the courage to begin. They set up 
the dangers of accident so conspicuously that I fear an operator who has had one or 
two fatal cases would be wholly discouraged. I would like to say, that in an expe- 
rience of thirty-three cases I have never had any difficulty in inserting the tube and 
but little in extracting it. I never have had any accident of any kind. I have no 
doubt but many gentlemen here present could aggregate several hundred cases in 
which there has been no accident. 
There is only one drawback to the success of the tube, in my mind. This is in 
the interference with nutrition. It is many times difficult to keep up the full 
nutrition of the patient when swallowing is so interfered with. 
In reply to the question of the President, I would say the operation has never 
failed, in my experience, to fully and promptly relieve the dyspnoea. I once operated 
on a case where the physician had gone home worn out. He had told the family 
the child must die ; he could do no more He would not do tracheotomy ; he did NINTH INTERNATIONAL MEDICAL CONGRESS. 
540 
not know of intubation. A little later the case fell into my hands. I found the 
child exhausted and comatose. After putting in the tube he aroused, and ultimately 
recovered. At the end of forty hours he coughed out the tube, and it was not 
reinserted. A child in the same family became croupy, and also recovered after 
intubation. I believe it fills all the functions that tracheotomy can. 
Dr. Waxham (Chicago, Ill.):-In answer to Dr. Jennings, I would simply say 
that he has compared personal results with the total results of intubation, which 
certainly is not fair. Our brilliant and successful tracheotomists are few and far 
between. We should compare their results with the individual results of the most 
successful operators with intubation. If they would combine their results with those 
of others all over the country who have been less successful, and compare the total 
results with the total results of intubation, they will come nearer the truth of the 
matter. 
In answer to the question raised in regard to statistics, I would say that a year 
ago I collected 306 cases of tracheotomy, with 58 recoveries, or 18.95 per cent. A 
few years since Prof. Jacobi collected 1024 cases of tracheotomy, performed in various 
parts of the world, with 220 recoveries or 21.42 per cent., in contrast to 26.71 per 
cent, saved by intubation. 
Dr. O'Dwyer, in closing the discussion, referred to the question raised by one 
gentleman, that intubation being a simple operation that meets with little opposition 
will, therefore, be resorted to in a certain number of cases that would recover without 
interference. While this may be true to some extent, it should also be remembered 
that for the same reason it will be practiced in the most hopeless cases as a means 
of euthanasia where tracheotomy would not be seriously considered. 
In a large percentage of my hospital cases there was extensive catarrhal pneu- 
monia following measles, with the addition of diphtheria and nephritis at the time 
they were intubated, and of course nothing was gained except relief to the suffering, 
and nothing more was expected. I would certainly never have proposed tracheotomy 
in any of these cases, and yet they would count in the statistics of intubation as much 
as the most favorable ones. No doubt, also, many will follow the plan suggested and 
practiced by Dr. Jennings, viz., do tracheotomy on all the most favorable, and reserve 
intubation for the unfavorable cases and where consent to do the cutting operation 
cannot be obtained. 
INFANTILE CONVULSIONS IN CONNECTION WITH LATER 
NEUROTIC TENDENCIES. 
CONVULSIONS ENFANTINES PAR RAPPORT À DES TENDANCES NEVROTIQUES. 
KINDERKRÄMPFE IN VERBINDUNG MIT SPÄTEREN NEUROTISCHEN NEIGUNGEN. 
BY J. A. COUTTS, M. B. CANTAB., M. R. C. P., 
Assistant Physician to the East London Hospital for Children. 
The difficulties attached to the pathological conditions which give rise to the symp- 
tom convulsions have been frequently and ably dealt with by Dr. Hughlings Jackson 
and other writers. In adults this symptom, by itself, has been shown to afford no 
reliable indications for forming conclusions as to the brain lesions which produce or 
permit of it. The outward muscular manifestations may be the same whether the SECTION X DISEASES OF CHILDREN. 
541 
exciting cause be cerebral hemorrhage, uræmia, the yet unknown pathological brain 
states associated with idiopathic epilepsy, and numerous others. Although some assist- 
ance in forming a diagnosis may, in many cases, be afforded by a good and trustworthy 
description of the convulsive attack, yet, to arrive at a justifiable one, the past and 
family histories, the present condition of nearly all the organs of the body, and all 
concomitant circumstances, must be taken into account. A diagnosis having been 
arrived at, in most cases, a prognosis may fairly be given. Thus, a patient with dis- 
eased arteries and cerebral hemorrhage will be liable to other attacks if he recovers 
from a present one; an epileptic is not likely to pass through life and be free from 
further fits, and so on. The difficulty, then, in adults, in dealing with the symptom 
convulsions, lies mainly in the diagnosis of the associated pathological brain conditions; 
prognosis in many cases, if not in most, being fairly easy and justifiable. In marked 
contrast to this, in infants under two years of age the difficulty is chiefly concerned with 
the prognosis rather than with the diagnosis of the pathological conditions accompany- 
ing the convulsions. Infants can be but rarely the subjects of cerebral hemorrhage, 
uræmia and all the varied lesions which embarrass the question in adults. In them, as 
in adults the subjects of idiopathic epilepsy, we are dealing with a pathological condi- 
tion which seldom reveals itself to any known method of research, microscopical or 
otherwise. Post-mortem examination, in the vast majority of cases, affords no aid; all 
the changes found in the brain, that were formerly accepted as causes, are now believed 
to be rather the consequences of convulsions. All that we know with regard to the 
brain conditions accompanying most cases of convulsions in infants and epilepsy in 
adults is that, in both, we are concerned with enfeebled cerebral matter, whether this 
be brought about by occlusion of a small vessel, as a cortical vein, or due to the influence 
of a general disease, as pneumonia or an impending exanthem. Beyond this our knowl- 
edge, or rather ignorance, of the underlying brain condition does not extend. If for 
no other reason, this want of knowledge should make us cautious in predicting as to 
the future of a child who has suffered from a convulsive attack. Moreover, in many 
children the convulsive attacks continue on into adult age without remission for any 
length of time, and the conclusion gets forced upon one that they have been epilepti- 
form from the very outset. Dr. Hughlings Jackson has lately, I believe, expressed the 
opinion that lower centres are implicated in the convulsions of infancy than in the epi- 
leptic attacks of adults, owing to the non-development of these higher centres at the 
infantile age. However this may be, I would contend that the sufferers from explosive 
nerve discharges in lower centres would probably be liable to similar discharges in 
higher centres at a later period of development. There is nothing in the outward 
muscular manifestations to distinguish between the convulsive attacks that continue on 
into later life as epilepsy and those that cease with the age of infancy. Under the 
most varied circumstances of disease the convulsive paroxysms may be perfectly simi- 
lar. But little aid is gained from the outward symptoms as to the cerebral causes on 
which they depend. The fits of "so-called " eclampsia coincide in time and sequence 
with all the phenomena of typical epilepsy in an adult. All the tests that have been 
given as means of differentiating between the convulsions that are likely to be followed 
by epilepsy in later life and those of mere eclampsia have been found fallacious by 
experience. How, then, can any prognosis as to future fits or neuroses be held justifi- 
able under these circumstances? 
If we turn from the consideration of the mere paroxysm and its surroundings to the 
family history of convulsive infants, grave matter is offered for our consideration. In 
100 cases of convulsions in infants, taken consecutively from my note books, in 29 there 
was a history of neuroses in the parents or near relatives. If we might include as 
neuroses convulsions in brothers and sisters, the family neurotic percentage would rise 
to as high as 63. All are agreed as to the importance of the family history in dealing 542 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
with neuroses and of the frequency of the transmission of the neurotic taint from 
parents to their offspring. One might fairly expect, then, that a large percentage of the 
children of such parents as are dealt with in my cases would turn out neurotic in later 
life, even apart from the consideration of their having had convulsions in infancy. 
These questions as to our ignorance of the brain conditions originating convulsions, the 
similitude of the paroxysms to those in adult epilepsy, and the family history, have 
been too much ignored by most writers on the subject. So much have convulsions come 
to be regarded as normal phenomena during the age of infancy that, apart from the 
typical seizures, only too many medical men apply the term loosely to various maladies 
where there is no reason to suspect their presence. Thus have been begot the terms 
screaming convulsions and that of internal convulsions as applying to the numerous and 
vague symptoms developed, under illness, by a nervous system during process of devel- 
opment. Mothers even make a subtle distinction between convulsions and fits. With 
none of these uncertain and unsatisfactory symptoms do I propose to deal. The ques- 
tion, also, as to the association of rickets with convulsions, which will be gainsayed by 
few nowadays, is foreign to my present paper. Elsewhere {British Medical Journal, 
June 4th, 1887) I have endeavored to show that the cerebral mal-nutrition in rickets, 
which may give rise to convulsions, is the cause of frequent neuroses in later life. 
Much that is misleading as to the immediate gravity of convulsions is, I believe, to 
be found in the writings of those reported to be authorities on the subject. Dr. West 
states that the deaths due to diseases of the nervous system are 30.5 per cent, under the 
age of one year and 24.3 per cent, between the ages of one and five years, and that con- 
vulsions are responsible for these deaths in the proportion of 78.3 and 54.3 per cent, 
respectively. This would mean that nearly 23 per cent, of children under one year and 
13 per cent, of children between the ages of one and five years die from convulsions 
pure and simple. Without taking into account the other circumstances associated with 
the convulsions, this, in my experience, would seem grossly fallacious and lending a 
false importance to the immediate consequences of the symptom convulsions. One 
knows how frequently an attack of convulsions is the closing scene in the short drama 
■of the life history of an infant, but it is, as Dr. Hughlings Jackson expresses it, "only 
a mode of dying, and one incidental to the time of life," and replaces the gradual 
asphyxia or cardial failure in adults. When a child exhausted with diarrhoea or other 
disorder dies during an attack of convulsions, one is no more justified in ascribing the 
death to the latter than one would be in so doing when it was the termination of uræmic 
poisoning or tubercular meningitis. It is a non-discrimination between these cases of 
convulsions as "a mode of dying" and others that has led many to ascribe a false 
immediate gravity to the symptom itself. From this belief in the frequency and imme- 
diate danger of convulsions has, I fancy, sprung the common practice of ascribing the 
death of many, if not most, infants found dead to this cause. 
Just as the immediate dangers of convulsions pure and simple have been greatly 
overrated, so, I believe, the gravity as regards future neuroses has been vastly under- 
estimated by the general acceptance of the aphorism that convulsions in childhood are 
the equivalent of rigors in adults. It is true that in many cases of disease convulsions 
in children take the place, in time, of rigors in adults; but it is no fair inference from 
this fact that the one is of no more importance as regards the future than the other. 
That convulsions in a child with an unstable- nervous system should take place at the 
onset of severe disease is no more than one would expect. But I greatly doubt whether 
their occurrence is as frequent as is commonly supposed, or whether the percentage of 
cases in which they do occur is greater than that of children with a neurotic tendency 
to others with stable nervous systems. To illustrate the connection with, or difference 
between, rigors in adult age and convulsions in childhood, no better example can be 
taken than pneumonia. SECTION X DISEASES OF CHILDREN. 
543 
In adults, every one is agreed as to the extreme frequency of rigors at its commence- 
ment. In children, however, in my practice, although pneumonia has been common 
enough, cases complicated with convulsions at onset have been somewhat of a rarity. 
Fearing that my experience might, perhaps, have been somewhat at variance with that 
of others, I asked Dr. Eustace Smith, a great authority, about what percentage of cases 
of pneumonia in young children he found associated with convulsions at onset. He 
replied that he had never made any actual statistics on the point, but that, as far as he 
could judge generally, at least ten per cent, had convulsions. To test the matter, he 
kindly placed several of his note books of in-patients in the East London Children's 
Hospital at my disposal. From these I gathered statistics of 99 cases of pneumonia, 
but rejecting 14 cases in children above the age of seven years, the number is reduced 
to 85. Of these 85 cases 44 were diagnosed as broncho-pneumonia, the remaining 41 as 
croupous pneumonia, pneumonia or pleuro-pneumonia. Of these 41 cases of pneumonia, 
two had convulsions at the onset of the disease, or, as nearly as possible, five per cent, 
of the total. But there are significant facts about both the convulsive cases ; one, aged 
21 months, was the child of a father who was epileptic, and its maternal aunt was insane: 
the other, aged four years, had had frequent one-sided fits, from the age of sixteen 
months. As bearing on the question of convulsions with pneumonia, it is interesting 
to note that three children, aged three years, four years, and 21 months, respectively, 
had had frequent fits previously, but passed through attacks of pneumonia without con- 
vulsions, although one parent in two of the cases was an epileptic. Again, three other 
children, that had had fits before, passed through severe attacks of broncho-pneumonia 
without a seizure. Deaths were frequent, and convulsions figure prominently at the 
end, but, as I said before, can hardly be held as responsible for the result. The number 
of cases is small, but I fancy, had it been greater, the percentage of cases with convul- 
sions at onset would probably not have been materially altered. An attack of pneu- 
monia commencing with cerebral symptoms, such as convulsions, makes a much greater 
impression on the memory than many cases without such accompaniment, and has led, 
I fancy, to an exaggerated notion of their frequency. Were convulsions at the onset 
of pneumonia in children as common as many think, a possible reason for their frequent 
association might be found in the suggestion that neurotic children are possibly more 
prone than others to pneumonia. To me, I confess, the mere fact of the frequency of 
convulsions at the onset of pneumonia, were it as great as commonly believed, would 
have little weight as determining the importance of the symptom as regards the future 
of an infant. Careful inquiry as to the presence or absence of prior convulsions and 
the family history as regards neuroses are of far greater importance in my mind. If 
such inquiry were made in all cases of pneumonia with convulsions, I have a shrewd 
impression that much greater importance will come to be attached to the symptom than 
if it were merely the age's equivalent of rigor in an adult. 
Of the frequency of convulsions at the onset of exanthems, personally I have had 
but little opportunity of judging, such cases but seldom coming under the notice of 
those engaged at children's hospitals. From inquiries among friends with larger 
experience, I should judge that such cases were somewhat of a rarity. Just as in 
pneumonia, I fancy their occurrence makes a somewhat lasting impression on the mem- 
ory, and has led to a belief of their being more frequent than statistics would bear 
out. Two friends had between them about 900 cases of exanthems under their 
care, and out of all this number but three children had convulsions at the outset, one 
child at the onset of what turned out to be diphtheria, and the two others with the 
beginning of scarlet fever. The family histories, and previous histories of the children 
as to convulsions, they could not furnish me with. I have heard the question pro- 
pounded to a class of twenty qualified men, most of them in general practice, whether 
any one of them had ever seen a case of measles commencing with convulsions, and 544 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
not one of them could recollect ever having done so. Taking these circumstances into 
account, I cannot but consider convulsions at the commencement of exanthems an 
event of somewhat rare occurrence. Of course, convulsions are frequent enough in the 
later stages of measles, and also in scarlet fever without uraemia. But there are distinct 
and palpable pathological contingencies accountable for the symptom in the later stages 
of both, and convulsions in these later stages must be clearly differentiated from those 
occurring at the same period as rigors do in adults. It is matter of general acceptance 
that epilepsy has frequently its starting cause in an attack of scarlet fever, and some- 
times, but less often, in one of measles. 
From what has gone before, it will readily be surmised that I am inclined to attach 
a greater importance to the brain conditions which permit of such a symptom as con- 
vulsions than is the general custom. I cannot think that a nervous system can be so 
thrown from its balance and disturbed by the mere physiological process of a tooth 
working its way through a gum, or by the presence of undigested food in the stomach, 
or worms in the intestine. Is not such a condition of nervous system that has once 
been upset by causes, so slight, likely to remain a permanent source of weakness, and 
liable to reveal its shortcomings at times of greatest stress thrown upon it or the general 
system ? It is true that many children suffering from convulsions recover with the 
removal of the exciting cause, such as dental irritation or undigested food, and remain 
to all appearances free for a time from neuroses of any kind. But I confess that I 
should look with grave suspicion on the future of such a child, however healthy it 
might seem, and should dread a call more than ordinary upon its nervous system. 
But all, unhappily, do not get well with the removal of the exciting cause. Epilepsy 
in later life is often continuous with convulsions in infancy or separated from it by an 
interval of a few years. Dr. Gowers has shown that ten per cent, of adult epilepsies 
have a causal influence in the same brain conditions that led to convulsions in infancy. 
Where the convulsions of infancy are directly continuous into the epilepsy of later 
years, no one, I take it, doubts the similarity of the pathological brain conditions giving 
origin to both. To few, however, it occurs to associate the cerebral state giving rise to 
epilepsy at such ages as second dentition or puberty with that originating convulsions 
in infancy. If this be the case in diseases presenting such similarity in their outward 
manifestations, the association of such diseases as chorea or migraine in later life with 
convulsions in infancy must, to such practitioners, seem to verge on the fantastical and 
absurd. For some time past, nevertheless, I have made inquiries on these points, and 
have satisfied my own mind that a fairly large percentage of sufferers from chorea and 
migraine, as well as epileptics, had been the subjects of infantile convulsions, a confirm- 
ation to my own mind of the importance to be laid on the latter symptom. Such 
inquiries are easily made, and the truth of the frequency of such associations readily 
verifiable. Another problem, what percentage of children that have suffered from 
inflintile convulsions pass through life without manifest neuroses in later years, is much 
more difficult of solution. We have no statistics bearing on the question. But few 
men have the opportunity of following out the life history of many convulsive children 
into adult age, and but fewer still the time or inclination to collect statistics on such a 
subject. With a view to a partial clearing up the obscurities surrounding this matter, 
I have collected notes, with the assistance of medical friends, of sixty-eight cases of 
persons who have at least reached the age of second dentition, and who had been in 
infancy the subjects of convulsions. During the process of inquiry, the interesting fact 
seems to be brought out that a large percentage of children that had had convulsions 
died before the age of second dentition. This would mean either that such children 
were more prone to serious disease, or had constitutions less capable of resisting it when 
incurred. Of those collected, as far as could be learned from relatives' and others' ac- 
countsof events that occurred many years before, all had been the subjects of convulsions SECTION X-DISEASES OF CHILDREN. 
545 
in its most typical form ; cases of those vague and ill-defined symptoms known as inter- 
nal convulsions being rejected. Careful inquiry was made as to age of first onset, the 
number and frequency of attacks, the family history, the health of the child at the 
times, and as to the presence or absence of other disease, such as digestive or pulmo- 
nary troubles or exanthems. In these sixty-eight cases there was a history of neuroses 
in the parents in eighteen, or including cases of convulsions in brothers and sisters, in 
thirty-nine. The ages of first attack varied from three weeks to two and one-half 
years. Attacks had been frequent in nineteen cases, few in thirty-two, and in seven- 
teen the attack had been a solitary one. In thirty-nine cases no information could be 
given as to the state of the child at the times of attacks ; in nineteen cases teething 
was ascribed as the cause ; in two, teething and diarrhoea; in four, whooping cough; in 
two, bronchitis and " congestion of lungs;" in one, bronchitis and inflammation of 
lung; in one, scarlet fever; and in two, the presence of undigested food in the stomach. 
No reliable information could be gained in the majority of cases as to whether the con- 
vulsions were general or with a tendency to one-sidedness, but in seven there was a 
fairly reliable history as to one side having been affected more than the other, and of 
these five turned out neurotic. The ages to which the cases had arrived when the 
information regarding them was taken, varied from eleven to sixty-three years. Unfor- 
tunately, many of them were under the age of puberty. Now, of these sixty-eight 
cases, thirty-one were the subjects of neuroses in later life. Of these thirty-one cases, 
eight had epilepsy in its severer form; three, petit mal; four were somnambulists; three 
had melancholia; four had chorea, and seven were subject to periodical migraine. Of 
the remaining two, one was somnambulistic in early life and had severe hystero-epi- 
lepsy later on, and her only child was mentally defective; the other was also somnam- 
bulistic in early life, and at the age of twenty-two had melancholia with suicidal im- 
pulses. But of the thirty-seven who had remained as yet free from distinct neuroses, 
six were described as being eccentric in their ways and conduct and irritable in manner, 
and nearly all the rest were, in intellect, below brothers and sisters who had been free 
from convulsions in infancy. There were distinct neuroses in nine of the brothers and 
sisters who had escaped convulsions themselves, among the thirty-one cases of con- 
vulsions with after neuroses, and in fifteen of the thirty-seven cases of convulsions 
without subsequent neuroses. But besides mere statistical evidence, there is in several 
of the family histories much that is suggestive; thus, out of a family of nine, the only 
one with convulsions as an infant became epileptic at the age of fifteen, while fairly 
up in a large public school, and was finally incarcerated in a lunatic asylum, there being 
no trace of neuroses in the rest of the family. The only two convulsives out of a family 
of eight turned out melancholic, the one at seventeen and the other at twenty-two, 
the rest having no special neurotic tendencies. Many other instances like these could 
be given from the notes, did space permit, of the only neurotics in families being the 
ones that had had infantile convulsions. 
At the commencement of this paper I endeavored to show, from general grounds, 
that convulsions in infancy were likely to be followed by neuroses in later life. My 
statistics would seem to confirm what was deduced from mere theoretical bases. It is 
true that sixty-eight cases is a small number to argue from, but such cases are only 
collected together, with difficulty. Many of them, too, are subject to great disad- 
vantage, in that the ages at which the statistics were taken were under that of pu- 
berty. Nevertheless, subject as they are to this disadvantage, and small as is their 
number, my statistics would seem to prove that children who suffer from infantile 
convulsions are prone to neuroses in later life in a degree out of all proportion inci- 
dental to the more fortunate ones who escape them. 
Vol. Ill-35 546 
DE LA NATURE DE LA COQUELUCHE ET DE SON TRAITEMENT 
ANTISEPTIQUE. 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ON THE NATURE OF WHOOPING-COUGH AND ITS ANTISEPTIC TREATMENT. 
ÜBER DAS WESEN DES KEUCHHUSTENS UND SEINE ANTISEPTISCHE BEHANDLUNG. 
PAR LE DOCTEUR MONCORVO, 
Professeur de Clinique des Maladies des Enfants à la Policlinique de Rio de Janeiro ; Membre Titulaire 
de l'Académie de Médecine, etc., etc. 
Depuis bien des années et à la suite d'une observation déjà longue, j'avais remarqué 
qu'il y avait de nouvelles recherches à entreprendre au sujet de plusieurs points de 
l'histoire de la coqueluche, maladie qui sévit encore aujourd'hui à peu près avec une 
pareille intensité dans tous les pays civilisés. 
Quoique étudiée depuis la première moitié du quinzième siècle combien de contro- 
verses dominent encore de nos jours à propos de la nature, du siège, et tout particu- 
lièrement à l'égard du traitement, de cette cruelle entité morbide ! 
En ce qui touche son siège, personne n'ignore guère la variabilité des jugements 
portés à ce sujet par le grand nombre d'observateurs qui s'en ont occupé. 
C'est ainsi, par exemple, que Webster faisait siéger la maladie dans l'encéphale ; 
par contre Sanders, Pidock, Breschet la considéraient sous la dépendance d'une altéra- 
tion du pneumo-gastrique. 
Bien avant ceux-ci, d'autres comme Stoll, Browzet, Pinel, Chambon et Valdschmidt 
ont cru que la coqueluche avait son siège dans la cavité gastrique, tandis que Butter et 
Huxham la rapportaint à l'intestin. 
Padalme avait admis un siège plus complexe qui comprenait le poumon, l'estomac 
et le diaphragme. 
La majorité pourtant des cliniciens ont signalé la coqueluche comme une affection 
de l'arbre bronchique ; telle a été l'opinion de Haënnec, Walt, Vate, James Hamilton, 
Billard, Alberson, Broussais, etc. 
Ces divergences constatées par rapport au siège de la maladie se présentent égale- 
ment en ce qui regarde sa nature. 
On irait loin si on voulait rappeller toutes les théories proposées dans ce but. 
Un grand nombre de pathologistes n'ont vu dans la coqueluche qu'une simple 
névrose de l'appareil respiratoire ; cette opinion fut soutenue par Frank, Hufeland, 
Hübel, Albers, Roche, Grisolle, Blache, Schæffer, Barrier, Mattai, Jahn. 
D'autres, comme Baron, Guersant, Trousseau, Richart, Tyfe, Mayer, Flint ont admis 
que cette affection était une bronchite greffée sur une névrose. 
D'après d'autres auteurs, la coqueluche serait identique ou analogue aux fièvres érup- 
tives ; telle a été du reste la théorie soutenue par Barthez et Billiet, James Ducan, 
Neuman, Rokitansky et Valtz, Germain Sée, Roger. 
Ce coup d'œil jeté sur les théories soulevées au sujet de la nature et du siège de la 
coqueluche laisse hors de discussion le peu de solidité de ces hypothèses si variables et 
si pleines d'insertitudes. 
Cependant nous avons laissé à dessein d'énumérer parmi les précédentes la théorie 
d'après laquelle l'affection en question serait localisée à l'entrée de l'arbre bronchique. 
H y a trente-quatre ans, Gendrin, dans un de ses leçons, avait tâché de démontrer 
que la coqueluche était une phlégmasie des cryptes de la partie supérieure du tube 
aérien. 
Watson, à cette même époque, en Angleterre soutenait que la maladie était engen- 
drée par l'absorption d'un miasme toxique, agissant sur la surface respiratoire, en y 
entraînant une inflammation spécifique avec irritation des nerfs de la glotte. SECTION X-DISEASES OF CHILDREN. 
547 
Ces idées reçurent plus tard la confirmation de la part de Beau, Parrot et Wanne- 
broug. 
En 1883 et 1884, nous avons exprimé dans deux travaux sur la nature et le traite- 
ment de la coqueluche notre manière d'envisager le siège de l'affection. 
Nous étions alors, comme aujourd'hui, parfaitement convaincus de la localisation de 
cette affection à l'entrée de l'arbre aérien. 
Depuis bien des années nous avons dirigé particulièrement notre attention la plus 
rigoureuse sur l'exploration thoracique chez nos coquelucheurs, aux diverses périodes 
de la maladie, et cela nous a permis de constater, sur une large échelle, la présence de 
coqueluches d'une assez forte intensité tout-à-fait dégagées de la phlégmasie bron- 
chique; nous avons aussi été témoins d'un assez grand nombre de cas dans lesquels elle 
avait débuté par des crises spasmodiques en l'absence de toute manifestation bron- 
chique. 
C'est là un fait sur lequel nous insistons déjà depuis longtemps dans nos cours, en 
le faisant contrôler par nos élèves. 
Les examens microscopiques apportés par quelques auteurs, qui prétendent établir 
des rapports intimes entre la coqueluche et le catarrhe bronchique vulgaire, n'ont pas, à 
notre avis, la valeur qu'ils avaient voulu leur prêter. La coqueluche exempte de toute 
complication sérieuse a, sans exception, une suite heureuse, et les lésions inflamma- 
toires par les autopsies ne sont, à vrai dire, que l'expression anatomique de complica- 
tions survenues à la maladie fondamentale. 
Les données fournies par l'anatomo-pathologie pourraient venir en aide à cette pré- 
tendue localisation ; si les examens cadavériques eussent été pratiqués sur des enfants 
enlevés au cours d'une coqueluche exempte de complications thoraciques, par quelque 
maladie intercurrente ou par une autre cause accidentelle. 
Quelques cliniciens de la plus haute valeur ont prétendu que la toux quinteuse était 
provoquée par les mucosités accumulées dans l'arbre bronchique; cependant une longue 
et attentive observation nous a permis d'enregistrer un grand nombre de faits contraires 
à leur affirmation. Chez un certain nombre d'enfants, nous avons été à même de 
pouvoir contrôler cette existence préalable de la replétion bronchique à l'occasion des 
crises, mais nous devons avouer qu'il ne nous a pas été donné de la retrouver que dans 
les cas oà la maladie était compliquée d'une bronchite étendue. Le résultat de ces 
recherches fut d'autant plus clair que nous avons recours au stéthoscope de M. Consta- 
tin Paul qui a, comme on le sait, le grand avantage d'exagérer les bruits de la cage 
thoracique. 
Il ne faut point oublier que l'enfant attrape souvent sa coqueluche au cours d'une 
bronchite préalable, qui constitue par elle seule une condition prédisposante de celle-ci ; 
il peut arriver alors qu'on prenne, à un examen léger, le catarrhe bronchique comme 
la première étape de la toux convulsive. 
Dans de pareilles conditions, oui, les quintes sont quelquefois provoquées par la 
réplétion de bronches due à la sécrétion muqueuse. 
Le besoin de tousser qu'entraîne cette réplétion, amène, à son tour, la crise spas- 
modique, comme cela arrive également lorsque l'enfant avale de travers, s'effraie, etc. 
Enfin une circonstance digne de remarque c'est le défaut de parallélisme entre la 
durée et la violence des quintes, et l'intensité et l'étendue de la phlégmasie bronchique. 
Mais ce n'est pas tout, l'atténuation ou la disparition de la coqueluche à la suite 
d'une broncho-pneumonie intercurrente est encore une preuve de ce qu'aucun lien 
n'existe guère entre cette dernière phlégmasie et l'affection qui nous occupe. Ce fait 
est du domaine vulgaire. De plus, cette indépendance des deux affections est tout-à- 
fait confirmée par la physiologie expérimentale laquelle a démontré que l'excitation 
mécanique ou chimique des radicules bronchiques ou des alvéoles pulmonaires 
n'éveille absolument pas de toux. 548 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
En dernier lieu l'observation clinique rigoureuse des faits a laissé voir que la coque- 
luche, en l'absence de toute complication bronchique ou pulmonaire, n'est jamais une 
maladie fébrile. 
Cela est un argument qui plaide hautement en faveur de la théorie que nous sou- 
tenons. 
Ma longue observation m'engage à affirmer que, soit au début soit au cours d'une 
coqueluche, l'élévation de la chaleur est toujours l'indice de quelque complication du 
côté des poumons, ou l'expression de quelqu'autre maladie fébrile. 
Eu résumé, tout porte à croire que la coqueluche est en définitive une affection 
essentiellement apyrétique, siégeant primitivement à l'entrée de l'arbre aérien. 
Comment considérer la nature de la coqueluche ? 
Dès l'apparition des premières épidémies au 15éme siècle, en Europe, les observa- 
teurs avaient reconnu la contagiosité de la maladie ainsi que l'immunité créée par une 
première attaque, cependant ignoraient-ils la cause de cette transmition par contagion. 
Rosen de Rosenstein avait conçu l'idée que la coqueluche était engendrée par la 
pénétration dans les tuyaux bronchiques d'une matière étrangère ou un principe nui- 
sible qui se répand et se propage comme celui de la petite vérole, parmi les individus 
qui n'en ont pas encore éprouvé l'impression. 
Linné de son côté avait émis l'hypothèse de l'introduction dans les voies aériennes 
d'œufs infiniment petits d'une espèce particulière d'insectes. 
Ce ne fut qu'à partir de 1867, que survinrent les recherches microscopiques prati- 
quées sur les crachats des coquelucheux par Poulet, Letzrich, Henken, Tschamer, de 
Gratz et Burger de Bonn. 
Convaincus de la nature parasitaire de l'affection nous nous sommes livré à des 
recherches microscopiques, dont les premiers résultats furent publiés en 1883. 
Les examens souvent répétés jusqu'à présent n'ont donné que le même résultat. 
Voici ce que nous avons toujours observé. 
Nous avons procédé à l'examen microscopique des crachats des enfants affectés de 
coqueluche, soit pendant la période catarrhale, soit dans la période spasmodique, non 
seulement de ceux qui ne se trouvaient pas encore sous l'influence d'aucune médica- 
tion, mais aussi de ceux qui étaient soumis à l'usage de la résorcine, et dont plusieurs, 
parmi ces derniers, étaient bien près de la guérison. 
Dans les crachats rejetés immédiatement avant l'examen, la simple inspection nous 
y a permis de constater une assez grande quantité de petites masses jaunâtres irrégu- 
lièrement arrondies du volume à peu près d'une tête d'épingle plongeant dans les 
mucosités. 
Le nombre de ces corpuscules était proportionnel à la durée et à l'intensité de la 
maladie. 
Par l'examen microscopique, sans l'addition d'aucune matière colorante, nous avons 
rencontré des cellules épithéliales pavimenteuses, polyédriques irrégulières et pourvues 
d'un noyau, des globules de pus plus ou moins nombreux, des globulins et une quan- 
tité considérable de micrococci ; tous ces éléments étaient plongés dans une matière 
amorphe, fortement agglutinée que constituait la gangue de ce magma. * 
Les cellules épithéliales se montraient sous des volumes différents et formes diverses 
en étant pourvues toutes d'un noyau et d'un double contour. 
Ce qu'on y voyait de plus intéressant, c'était l'infiltration de spores infiniment 
petites et brillantes, des véritables micrococci, qui existaient en profusion dans l'inté- 
rieur des cellules, tout en y gardant la même disposition que dans la substance amorphe 
qui les entourait, c'est-à-dire la disposition en séries linéaires, en chaînes ou chapelets 
ou en groupes, qui variaient de deux, trois, quatre et plus, ou finalement elles étaient 
isolées et distinctes les unes des autres, quoique très rapprochées en raison de leur 
nombre considérable. SECTION X DISEASES OF CHILDREN. 
549 
Ces éléments se rendent plus évidents en colorant la préparation avec le violet de 
méthyle, ou mieux, avec le violet de gentiane. 
Dans d'autres points les micrococci sont groupés formant de zooglée. 
Ces spores sont plus nombreux au cours de la période spasmodique et sont en dimi- 
nuant au fur et à mesure qu'on pratique le traitement local antiseptique. 
Aussi, ce traitement fait cesser le mouvement dont ces petits éléments étaient doués 
auparavant. 
Nous avons ensemencé dans la gélatine stérilisée les micrococci contenus dans les 
crachats recémment rejétés, et nous avons pu y voir le développement du microgerme, 
en constatant la présence de mycèles entourés de petites cellules arrondies de 15 à 20 
millièmes de millimètre de diamètre, pleines de petites spores. 
En pratiquant avec cette culture des badigeonnages péri-glottiques sur des cobayes, 
nous avons observé à plusieurs reprises l'apparition de la toux quinteuse, notamment 
lorsque ces badigeonnages étaient précédés ou accompagnés d'un léger traumatisme à 
la partie supérieure du larynx en y déterminant la desquamation épithéliale. 
De tout ce qui précède, il résulte pour moi que la coqueluche a son siège primitif, à 
l'entrée de l'arbre bronchique, et est dûe à la prolifération d'un microgerme sur la 
muqueuse qui tapisse cette régipn. 
En admettant cette manière de voir, nous avons conclu que la thérapeutique devrait 
être locale et antiseptique, et nous avons recours de préférence à la résorcine tant par sa 
presque nulle causticité, sa nulle odeur, que par son extrême solubilité. 
En 1883, nous avons publié, 30 cas de guérison sur 30 enfants affectés de coqueluche 
plus ou moins grave et aux diverses périodes de son évolution. 
La résorcine fut chez tous employée dans la proportion d'un pour cent. 
En 1884, dans un nouveau travail, j'ai signalé encore 40 cas de coqueluche guéris 
dans un très-court délai par ce même moyen, mais déjà à la proportion de deux pour 
cent, ce dosage fut progressivement élevé au point que j'emploie aujourd'hui une solu- 
tion résorcinique à huit pour cent. 
Nous nous servons exclusivement pour cela de la substance chimiquement pure, la 
seule douée des propriétés ci-dessus indiquées. 
En 1885, je me suis adressé au chlorhydrate de cocaïne (10 pour 100) en badigeon- 
nages péri-glottique précédant celle de résorcine ; j'ai le premier recours à cet agent 
chez les coquelucheux dans le but de calmer l'excitabilité réflexe de la muqueuse laryn- 
gienne et de la sorte, il m'a été presque toujours possible d'amoindrir l'intensité et la 
fréquence des quintes, notammant au début du traitement, lorsque la résorcine n'a pas 
encore eu le temps d'anéantir les germes producteurs du mal. 
La combinaison de ces deux agents constitue donc, à mon avis, le meilleur moyen 
de traitement de la coqueluche. 
Postérieurement à la détaillée des 70 cas de guérison dans mes travaux de 1883 et 
de 1884, nous avons eu à soigner un très-grand nombre de cas de coqueluche selon ma 
méthode et le résultat a répondu à mon attente dans tous les cas où. j'ai pu agir con- 
venablement et pendant le temps nécessaire. 
Au bout de quelques jours, parfois même d'un jour, l'inspiration sibilante est dis- 
parue et l'intensité des quintes s'atténue sensible et progressivement. 
Dans quelques cas où il m'a été donné d'intervenir peu de jours après l'éclosion de 
la maladie j'ai pu même l'enrayer au bout de quatre à cinq jours. 
Ces remarquables succès obtenus par nous et par nos élèves, ont répandu ma mé- 
thode thérapeutique dans presque tous les pays, et nous recevons constamment de nou- 
velles confirmations de son efficacité. 
A l'étranger des contrôles aussi favorables ont eu déjà lieu ; je ferai mention toute 
particulière de celui de la part de mon éminent ami M. le Professeur W. Barlow, de 
Manchester, qui a publié sur ce rapport un long mémoire. {The Lancet, May, 1886.) 550 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Toutes les complications broncho-pneumonique survenues dans le cours de la coque- 
luche sont traitées par les moyens ordinaires sans aucune interruption du traitement 
local. 
EXPLICATION DES PLANCHES. 
PLANCHE I. 
Fig. 1. 
Fig. 2. 
Fig. 1.-Préparation de mucosité laryngienne d'un enfant atteint de coqueluche aussitôt après son 
expulsion au moment d'une quinte. 
Fig. 2.-Préparation de mucosité retirée du larynx d'un cochon d'Inde mort ä la suite d'une broncho- 
pneumonie survenue au cours d'une coqueluche expérimentalement provoquée au moyen de badi- 
geonnages périglottiques avec le germe provenant de la culture dans la gélatine. SECTION X-DISEASES OF CHILDREN 
551 
PLANCHE II. 
Fig. 1. 
Fig. 2 
Fig. 1.-Préparation de la couche profonde de la zone de culture dans la gélatine du germe de la coque- 
luche contenue dans des mucosités expulsées par un enfant au moment de la quinte. Les germes 
s'y présentent à un degré de développement moins avancé que ceux de la préparation suivante. 
Fig. 2.-Préparation de la couche la plus superficielle de la même culture précédente; toutes les deux 
faites dans la même séance quelques jours après l'ensemencement. 552 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DES HALLUCINATIONS CHEZ LES ENFANTS. 
HALLUCINATIONS IN CHILDREN. 
HALLUCINATIONEN BEI KINDERN. 
PAR LE DR. BOUCHUT, 
De Paris. 
Tous les médecins connaissent ce qu'on appelle les terreurs nocturnes chez les en- 
fants. Elles sont caractérisées par le réveil en sursaut avec frayeur, des cauchemars 
et des hallucinations engendrées par un rêve qui se poursuit chez l'enfant à moitié 
réveillé. Il s'agit de tout autre chose dans la communication que je désire faire au 
Congrès. Il s'agit des hallucinations passagères de jour et dans Vétat de veille, chez des 
enfants bien portants et en convalescence et cela sans qu'il soit question d'aliénation 
mentale. J'en ai observé 72 cas chez des enfants de deux à quatorze ans qui ont été 
publiés en 1836, dans un travail du Dr. Fernand Bouchut, et ce sont ces faits qui 
doivent me servir dans cette communication. 
Mais avant tout, il est bon de dire ce que c'est qu'une hallucination, et quelles divi- 
sions il faut établir dans leur étude, si on tient à ne pas laisser pêle-mêle des phéno- 
mènes semblables en apparence et dont la cause est absolument différente. 
L'hallucination est, comme l'a dit Van Helmont, le rêve de l'homme éveillé. 
C'est, dans l'état de veille, un trouble de l'intelligence et de la sensibilité caracté- 
risé par la perception anormale, imaginaire et passagère des choses extérieures qui 
n'existent pas. Les mêmes phénomènes chez l'homme endormi constituent le rêve. 
Ainsi, l'apparition d'images agréables ou terrifiantes de fantômes et d'animaux fan- 
tastiques, la perception de voix aimées ou menaçantes, de sons mélodieux, la sensation 
d'odeur agréables ou désagréables, les sensations douloureuses ou- voluptueuses des dif- 
férentes parties du corps qui surviennent pendant le sommeil, forment le rêve, et elles 
s'évanouissent au réveil sans avoir troublé l'intelligence et sans laisser dans la cons- 
cience la conviction intime de leur réalité. 
Tout au contraire, les mêmes perceptions ou sensations, dans l'état de veille, sont 
rapportés à des objets extérieurs qui n'existent, pas et elles engendrent des connexions 
erronées qui annoncent un trouble de l'intelligence et caractérisent l'hallucination. 
L'homme donne alors un corps au produit de son entendement, il rêve tout éveillé. 
Les hallucinations se présentent sous deux formes admises par Esquirol :- 
1. L'hallucination proprement dite, caractérisée par la perception imaginaire d'un 
objet extérieur, d'une odeur, d'un fumet ou d'une sensation qui n'a aucune réalité exté- 
rieure. 
2. L'illusion sensoriale dans laquelle la perception s'exerce sur un objet du dehors 
dont la configuration se transforme, et fait par exemple : qu'un chapeau parait être 
une figure grimaçante ; qu'une odeur agréable est infecte ; qu'à cheval sur un bâton, 
le sujet se figure être sur un coursier fantastique. 
Elles ont pour siège les différents organes des sens et affectent la vision, l'ouïe, l'odo- 
rat, le goût et le toucher. 
Chez les enfants, ces perceptions anormales occupent surtout le sens de la vue, tan- 
dis que chez l'adulte, d'après Esquirol, Lelut, Parchappe, Baillarger, Delassiauve, 
Motet, etc., elles occuperaient le sens de l'ouïe. 
C'est là une différence importante à noter. 
D'après ce que j'ai vu il est nécessaire d'admettre que les hallucinations chez les 
enfant sont : 
1. Idiopathiques et Suggestives. 
2. Sympathiques ou réflexes. SECTION X-DISEASES OF CHILDREN. 
553 
3. Toxiques. 
4. Organiques. 
Mais toutes dépendant d'une modalité pathologique des cellules cérébrales de leur 
imbibition sanguine variable, et de la composition du sang qui les nourrit. 
HALLUCINATIONS IDIOPATHIQUES. 
Les hallucinations idiopathiques sont celles dont la cause occasionnelle est encore 
peu connue et résultent de la surexcitation cérébrale, de l'intelligence de l'imagination 
et des facultés affectives. On en voit chez les enfants très-jeunes que l'on effraie par 
des contes terrifiants et des histoires fantastiques, que l'on mène à des fééries, à des 
spectacles de bataille et chez des enfants plus âgés dont on excite mal à propos la terreur 
religieuse. 
HALLUCINATIONS DIUBNES ESSENTIELLES PAR SUITE DE FRAYEUR. 
Un enfant de 12 ans qui faisait sa première communion à Montmartre fut si effrayée 
des terreurs de l'Enfer nées dans son esprit par l'influence du prédicateur qu'elle per- 
dit connaissance et eût quelques mouvements convulsifs ainsi que plusieurs de ses com- 
pagnes. 
Le lendemain, les attaques se reproduisirent et en même temps, pendant la journée, 
il y eut l'hallucination d'un crucifix rouge de feu au milieu de l'espace. 
Cette hallucination se montra plusieurs jours de suite. Des lavements d'eau chlo- 
roformée la guérirent de ses attaques et de ses hallucinations. 
J'ai observé trente cas de ce genre, dans lesquels la terreur religieuse, une frayeur 
ou des émotions morales de différentes natures ont produit des résultats semblables. 
Dans tous ces cas, l'hallucination a eu lieu dans le jour, a été passagère et n'a pas 
eu de suite comme trouble de l'intelligence, de la raison ou de la santé. 
HALLUCINATIONS SUGGESTIVES. 
Mais, à côté de ces faits cliniques tirés de la pathologie infantile ordinaire, il y a des 
faits nouveaux, qui depuis les pratiques du magnétisme animal, de l'hypnotisme et de 
la suggestion hypnotique, attestent la facilité qu'il y a à provoquer des hallucinations 
passagères et très variées dont il serait bien difficile d'établir la cause anatomique 
autrement que par une modalité d'action et d'imbibition variable des cellules céré- 
brales. 
Ces hallucinations suggestives faciles à déterminer chez l'adulte, se produisent égale- 
ment chez les enfants lorsqu'on .peut les hypnotiser, les anesthésier et produire les phé- 
nomènes de transfert. J'en ai publié deux exemples. 
HALLUCINATIONS RÉFLEXES, SYMPATHIQUES. 
Les convulsions sont le phénomène nerveux le plus habituellement observée au 
début des maladies aiguës fébriles de l'enfance telles que la pneumonie, l'angine ton- 
sillaire et les fièvres éruptives ; mais de temps à autres on voit avant la convulsion ou 
après elle, des hallucinations passagères visuelles qui ne viennent qu'une fois, rarement 
d'avantage. Ce phénomène est quelque chose d'analogue au délire du début de la pneu- 
monie et de la variole chez l'adulte, alors que rien n'est déclaré et qu'il est impossible 
de faire un diagnostic. 
Il annonce le commencement d'une maladie, dont la localisation ne sera peut-être 
possible que deux ou trois jours après. L'organisme est atteint subitement et réagit 
aussitôt par le nerf sympathique, pour produire soit des convulsions, soit des hallucina- 
tions, soit du délire selon l'âge des sujets et leur idiosyncrasie naturelle ou acquise. 
Chez les jeunes enfants, on n'observe guère dans l'état fébrile que les hallucinations 
ou les convulsions, ce que témoignent les vingt observations que j'ai recueillies. Chez 554 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
l'adulte, au contraire, c'est du délire et quelquefois du délire furieux, hallucinatoire, 
si le sujet est alcoolique. 
Que se passe-t-il alors dans l'intérieur du cerveau et dans le fonctionnement des 
cellules cérébrales qui fout la perception, l'intelligence et la motilité? Je ne veux rien 
préciser pour ne pas faire du roman scientifique, mais il est permis de croire que ces 
troubles étant passagers dépendent également d'un trouble passager de la circulation 
vaso-motrice cellulo-cérébrale et que l'hypérémie peut être considérée comme étant la 
cause de ces accidents. Ce qui peut autoriser à dire qu'il en est ainsi, c'est qu'un autre 
épisode de début des maladies fébriles, le frisson n'est qu'une convulsion partielle et 
la sensation prononcée du froid qui n'est qu'une illusion sensoriale, est accompagnée 
d'une élévation de température, 40 degrés, qui révèle un trouble vaso-moteur profond 
amenant la paralysie vaso-motrice passagère. 
Sensation du froid malgré l'élévation thermique, perception d'images qui n'existent 
pas ou hallucinations, convulsion et délire à la première heure d'une maladie aiguë 
fébrile innommée sont des perturbations nerveuses de même ordre ; ce sont des acci- 
dents réflexes jadis appelés sympathiques, dont la constriction ou la paralysie vaso-mo- 
trice peuvent seules rendre compte. 
Rech a observé quatre cas d'hallucination survenue à la suite du froid. 
Quatre enfants après avoir été exposés plusieurs heures à un froid très vif, passèrent 
brusquement dans un appartement très chauffé. Immédiatement ils devinrent anxieux 
en proie à des hallucinations. Le visage vultueux, le poux rapide, la température était 
normale. 
Au bout de quelques jours, tout était rentré dans l'ordre, mais tous les quatre 
eurent une assez forte amygdalite avec bronchite. 
Ces hallucinations je les ai observées dans vingt et un cas de pneumonie ; d'angine 
de stomatite, de dentition, de scarlatine, et une fois l'accident passé, ainsi que la maladie 
provocatrice, il n'est resté aux enfants aucun trouble de l'intelligence et de la raison. 
HALLUCINATIONS TOXIQUES. 
Chez les enfants, on observe chez eux que des hallucinations toxiques accidentelles, 
par la belladone, le datura ou n'importe quelle autre solanée vireuse, empoisonnements 
dûs à une erreur de pharmacien, comme dans l'observation ci-jointe, ont causé par la 
gourmandise de petits enfants qui prennent dans les jardins des baies de belladone dont 
ils se régalent jusqu'à en mourir. 
Ici la cause anatomique semble assez facile à indiquer, car, si l'on a vu des sujets 
soumis à des doses toxiques de belladone, on voit chez eux une telle turgescence des 
capillaires du visage des yeux, qu'il est impossible de méconnaître une paralysie vaso- 
motrice considérable, et puisqu'on même temps se produisent de terribles hallucina- 
tions et un violent délire, il n'y a rien de hasardeux à soutenir que ces troubles du sys- 
tème nerveux se rattachent à l'hyperhémie cérébrale. Les autopsies, le microscope et 
la physiologie sont là qui prouvent l'exactitude de cette assertion. 
HALLUCINATIONS D'ORIGINE CÉRÉBRALE. 
A côté de ces troubles vaso-moteurs passagers de la circulation cérébrale et de leur 
action sur les cellules cérébrales, il y a, chez les enfants comme chez l'adulte, des hallu- 
cinations qui dépendent d'une légion organique du cerveau et de néoplasme (gliome) 
ou tubercules plus ou moins volumineux. 
Ces néoplasmes amènent d'une façon intermittente des perturbations vaso-motrices 
de voisinage qui se révèlent par des hallucinations passagères ou qui engendrent un 
état aigu dans lequel les hallucinations sont le phénomène dominant. J'en ai vu un 
bel exemple dans lequel le diagnostic fort incertain a été tout-à-coup éclairé par l'exa- 
men de l'œil qui a fait découvrir un tubercule de la choroïde. SECTION X-DISEASES OF CHILDREN. 
555 
Dès lors il n'y eut plus de doute ; les hallucinations résultaient de l'hyperhémie 
cérébrale voisine d'un tubercule du cerveau. L'autopsie a permis de vérifier ce dia- 
gnostic. 
HALLUCINATIONS DE LA FIÈVRE TYPHOÏDE, DE L'iCTÈRE DE LA CHORÉE. 
Les hallucinations se rencontrent aussi, chez les enfants, dans les cas de fièvre 
typhoïde au début ou dans le cours de la maladie, dans l'évolution de la jaunisse, et 
enfin nous les avons vues dans la chorée soit au début, soit dans l'évolution de cette 
névrose congestive de la moelle. 
THÉORIE ET MÉCANISME DES HALLUCINATIONS. 
Les théories de l'hallucination sont nombreuses, et elles relèvent de l'ordre swrnaï«- 
rel, de l'ordre psychologique et de l'ordre anatomique, c'est-à-dire, de l'état cellulaire du 
cerveau. 
Le rôle du surnafureZ dans l'explication des hallucinations a été longtemps en faveur. 
C'est la théorie du mysticisme et des esprits dominés par les croyances religieuses de la 
démonologie ; de la sorcellerie et des possessions démoniaques, mais cette intervention 
des démons familiers des génies, des fées, des anges, de satan, de Dieu dans les hallu- 
cinations, si considérable dans l'antiquité et au moyen âge, n'a plus rien de scienti- 
fique. Rien dans la surnaturel ne peut satisfaire les exigences de la physiologie et de 
la pathologie moderne. Les inspirations de l'extase religieuse, les visions célestes, les 
voix divines et les illusions sensorielles de la possession démoniaque, de la magie, de la 
sorcellerie sont des manifestations de mysticisme religieux ou profane, et de la foi 
divine qui se rattachent à la nervosité morbide, et c'est à ce point de vue qu'il faut se 
placer si on veut se rendre compte des phénomènes hallucinatoires. 
Le théorie psychologique qui dans la première moitié du siècle, a joui d'une certaine 
faveur, n'explique pas grand'chose, car elle se contente d'hypothèses hasardeuses ren- 
dant compte du fait par ce fait lui-même. Ainsi que veulent dire à côté de ce qu'on 
appelle les conceptions normales de l'intellect, ces autres conceptions intérieures dites 
anormales par M. Garnier, constituant les fausses perceptions, ou les hallucinations qui 
sont l'expression dans un langage diiférent du fait à analyser. 
Pour être complet, il faudrait ajouter que ces conceptions anormales de l'halluciné 
s'accompagnent d'une perception imaginaire d'images extérieures, de bruits étranges 
de sons musicaux, de paroles bizarres, de contact cutané agréable ou douloureux, ce que 
la conception normale ne produit jamais. 
Ainsi les yeux fermés, j'ai la conception d'un paysage, de la figure d'un ami, mais 
je n'en ai pas l'image ; ceci c'est un rappel mental d'une perception antérieure, tandis 
que chez l'halluciné ce rappel mental prend la forme extérieure d'un acte sensoriel dé- 
terminé entraînant la conviction d'un fait réel. 
Le Dr. Peisse considère l'hallucination comme l'exagération du rappel mental ordi- 
naire de la perception des sons et des images. C'est-à-dire, comme un acte de mémoire. 
Mais chez un sujet bien portant, les yeux ouverts ou fermés, le rappel mental ne donnent 
que des images confuses des objets et des couleurs de la nature sans perceptions réelles; 
que des mélodies sans bruit, que des souvenirs gustatifs, tactiles, sans aucune sensa- 
tion réelles. Et, si forte que soit la tension de la mémoire dans l'évocation d'une 
forme idéale que l'on voit et que l'on pourrait prendre, ce sujet n'est pas dupe de la 
conception anormale imaginaire, tandis que l'halluciné est dupe de la conception visu- 
elle, auditive ou autre. 
C'est là une différence absolue. 
Un autre philosophe, dont le nom est resté célèbre, Bûchez a soutenu la même 
théorie du rappel mental donnant la conviction d'une extériorité qui n'existe pas, mais 556 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cette explication est encore de celles qni rendent compte du fait par le fait lui-même et 
ne peuvent pas faire beaucoup avancer la science. 
Pour Letut, l'auteur du démon de Socrate, les hallucinations sont la transforma- 
tion des idées en sensations, chose contraire et opposée au fonctionnement normal de 
l'intellect qui s'élève de la sensation et de la perception à la formation des idées. 
Ce sont, dit-il, des sensations fausses prises pour des sensations véritables; cela n'est 
pas exact, car chez les hallucinés, il n'y a que des conceptions anormales donnant lieu 
à des sensations véritables ce qui est bien différent. 
Dans son traité des hallucinations, on voit que, pour Brière de Boismont, le rappel 
mental et la conception qui en résulte peuvent, dans leur exagéiation, donner lieu 
à de véritables sensations, ce qui amène l'hallucination physiologique qu'on peut 
observer chez les sujets nerveux et de haute intelligence par la force d'attention et 
de volonté. 
Sans quelques différences dans le langage, Delasiauve, Parchappe, Fahret et d'autres 
aliénistes ont donné à ces théories le secours de leur talent et de leur expérience, mais 
comme on le voit par ces courts extraits, tout en restant ou à peu près à cette idée que 
l'exagération du rappel mental produit les fausses sensations, on tourne dans le même 
cercle, et il n'en sort rien de bien satisfaisant. 
La théorie anatomique tirée de l'état cellulaire du cerveau, des troubles passagers qui 
s'y produisent a donné et donnera les meilleurs résultats. 
Sandras a émis cette idée que l'hallucination est une manifestation pathologique à 
part dans les désordres dont le système nerveux nous montre une étrange collection. 
C'est un fait entièrement distinct de la pensée, de la réminiscence, de la sensation 
normale. 
Sandras, qui avait eu de nombreuses hallucinations et qui les avait bien étudiées 
sur lui-même, était un médecin distingué de l'hôtel-Dieu dont la raison et l'intelligence 
étaient appréciées de ses collègues. 
Il avait eu une petite hémorrhagie cérébrale avec hémiplégie et dont il avait guéri, 
c'est à la suite de cet accident qu'il avait de fréquentes hallucinations, qu'il distin- 
gusit très-bien de ses sensations normales. 
Bourdier dans le même ordre d'idées, a soutenu que l'hallucination était toujours 
une opération pathologique et jamais physiologique. 
Cela est vrai, mais il est allé trop loin en disant que raison ou hallucination s'ex- 
cluaient réciproquement et que si l'hallucination était compatible avec l'intégrité de la 
raison. 
Il est évident que c'est là une affirmation sans valeur démontre par le nombre des 
hallucinés célèbres jouissant d'une intelligence supérieure atteignant le génie. 
La même pensée de localisation se trouve dans le mémoire de Baillarger sur les 
hallucinations qu'il attribue. 
1. A l'exercise involontaire de la mémoire et de l'imagination. 
2. A la suspension des impressions internes. 
3. A l'excitation interne des appareils sensoriels. C'est là que se trouve la pensée 
localisatrice; les deux autres expliquent aussi bien le rêve que l'hallucination et confon- 
dent ces deux phénomènes qui doivent être séparés. 
D'après tout ce que nous savons sur la physiologie du cerveau dans ses rapports avec 
le fonctionnement de l'intelligence de la mémoire, du langage, avec la détermination 
du siège de la sensibilité et de la motilité, il semble qu'on ne puisse séparer l'origine 
des troubles de l'intelligence, de la sensibilité et du mouvement, des modifications 
petites ou grandes passagères ou permanentes de l'état cellulaire du cerveau et en par- 
ticulier des centres. 
La psychologie, dans ses applications métaphysiques peut chercher autre chose, mais 
la médecine clinique ne doit pas avoir la prétention de s'élever si haut. SECTION X-DISEASES OF CHILDREN. 
557 
Elle doit se borner à la recherche des modifications de texture d'imbibition sous 
forme des cellules qui correspondent aux différentes fonctions du système nerveux. 
En effet, à côté des grosses lésions d'un traumatisme, d'une rupture, d'une oblitéra- 
tion vasculaire, du développement d'un néoplasme ou de quelques entozoaires, il y a 
des modifications partielles de texture cellulaire cérébrale, hyperhémie, anémie par 
imbibition sanguine variable, résultant d'une insolation de l'action du grand sympa- 
thique, de son influence vaso-motrice. Est-ce qu'un homme frappé d'insolation qui 
déraisonne momentanément, qui a des hallucinations pendant une journée n'a pas eu 
de modification si légère qu'elle ne soit dans l'imbibition des cellules cérébrales corres- 
pondantes aux fonctions troublées? Deux jours après, tout rentre dans l'ordre, mais si 
l'insolation a été plus forte et les lésions plus accentuées, si ces lésions sont considé- 
rables et permanentes, l'intelligence peut être plus sérieusement troublée ou à tout 
jamais perdue. 
C'est aussi dans cette voie que M. Luys et M. Ritti se sont engagés pour rendre 
compte de la formation des hallucinations. 
Ainsi, pour eux, ce sont les vibrations des cellules de la couche corticale produite 
par les stimulations de la couche optique qui engendrent les perceptions sensorielles. 
Mais, à l'état pathologique, le contraire à lieu, et les vibrations naissent spontané- 
ment dans les cellules des couches corticales produisent des perceptions anormales par 
suite d'automatisme, comme le dit Baillarger. 
Le même phénomène d'automatisme pourrait avoir lieu également dans les cellules 
de la couche optique comme si une sensation réelle venait de les mettre en mouvement. 
Et M. Ritti (Théorie de Vhallucination, page 50) dit : 
"A l'état normal, les objets extérieurs amènent l'excitation des nerfs sensoriels. 
Dans l'hallucination, au contraire, une excitation interne, celle des ganglions sensoriels, 
amène des représentations perçues par le malade, et qu'il objective comme si une 
impression sensorielle venait irriter le nerf sensoriel. 
Puis il se résume en disant que les phénomènes du processus morbide de l'halluci- 
nation sont :- 
1. L'activité spontanée des cellules de la couche optique provoquée par des causes 
variables. 
2. L'irradiation de cette activité fictive vers les cellules de la substance corticale. 
3. L'entraînement consécutif de ces mêmes cellules corticales qui mettent en œuvre 
ces matériaux erronés avec la même logique que s'ils étaient réels (page 51). 
Quand on est bien au courant de la physiologie actuelle du cerveau, cette théorie de 
l'ébranlement et de la vibration spontanée des cellules du cerveau satisfait bien l'esprit. 
Mais on peut se demander qui a vu la vibration des cellules du cerveau? Evidemment, 
c'est là une brillante hypothèse. 
Dans cette étude qui repose sur ces infiniment petits et sur des éléments invisibles, 
n'est-il pas préférable d'attribuer à un désordre anatomique cellulaire passager, sur un 
petit territoire cellulaire de la couche corticale, le trouble fonctionnel hallucinatoire que 
M. Ritti attribue à,la vibration cellulaire ? Sans rien affirmer à cet égard, il nous sem- 
ble que cela pourrait être plus exact. 
A la suite d'une grande surexcitation du cerveau par la religion, la politique, l'amour 
contrarié, l'ambition de la fortune ou des honneurs, une grande frayeur, il est bien évi- 
dent que tous les actes de certains individus révèlent un fonctionnement cérébral irré- 
gulier qui résulte d'une modalité pathologique des cellules correspondant aux facultés 
en désordre. 
Sans pouvoir déterminer la nature exacte de cette altération il est difficile de ne pas 
en admettre l'existence. 
Les hallucinations extatiques ou démoniaques, les substitutions de personnalité qui 
font croire à un politicien du bas étage qu'il est empereur ou roi ; les illusions senso- 558 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
rielles de celui qui, comptant des cailloux dans sa main, assure qu'il entasse des milli- 
ons ; les ennemis que croit voir et entendre un homme qui a échappé à un grand péril ; 
les propositions deshonnêtes qu'une femme croit entendre derrière elle dans la rue; ne 
sauraient exister sans une modalité cellulaire pathologique au cerveau. 
Les lésions ophthalmoscopiques trouvées dans ces cas font croire à la congestion céré- 
brale qui se traduit par la flexuosité des veines, la turgescence des artères et quelque- 
fois par des hémorrhagies de la rétine. 
A la première heure des maladies aiguës fébriles et des fièvres éruptives de l'en- 
fance, alors que l'on ignore ce qui va se produire, si le grand sympatique par ses actions 
réflexes et vaso-motrices, détermine des hallucinations ou une convulsion, tous les phy- 
siologistes et les médecins admettront bien que, si l'état morbide fébrile agit sur le sys- 
tème nerveux central pour produire de tels désordres fonctionnels, cet état morbide a 
modifié l'état du cerveau, c'est que les cellules cérébrales directrices de la fonction 
troublée ont subi l'influence constrictive ou paralysante des nerfs vaso-moteurs, et 
qu'il en est résulté une maladie pathologique passagère à'iaquelle on peut attribuer les 
perceptions anormales de l'hallucination. 
Le problème est plus délicat, plus difficile à résoudre aujourd'hui pour les halluci- 
nations suggestives de la vue, de l'ouïe, du goût, de l'odorat, du toucher. 
Comment ces hallucinations, de même que les paralysies de la sensibilité et du 
mouvement peuvent-elles se produire au commendement de l'expérimentateur et dis- 
paraître à sa volonté. 
Nous n'avons aucune donnée certaine pour répondre à cette question et pour for- 
muler l'explication de ces phénomènes morbides. Il est bien probable qu'il y a une 
influence morale agissant sur l'état physique et psychique. 
Or, on sait depuis longtemps combien, en dehors de l'hypnotisme, cette influence est 
considérable et les traités de pathologie renferment les observations les plus curieuses à 
cet égard, montrant les troubles de la circulation générale ou vaso-motrice qui amènent 
la perturbation ou l'arrêt des fonctions nerveuses. Il est probable qu'il en est de même 
dans les hallucinations et les paralysies suggestives par hypnotisme. 
La sensibilité du système vaso-moteur est telle qu'il n'est pas impossible que, sous 
l'influence morale exercée par l'hypnotiseur, il y ait des phénomènes de perturbations 
fonctionnelles nerveuses, phénomène d'arrêt ou autre, et qu'il survienne, en consé- 
quence, des modalités cellulaires cérébrales amenant les troubles passagers de percep- 
tion de sensation et de mouvement. 
C'est là du moins ce que la réflexion peut inspirer quand on désire se rendre compte 
des phénomènes dont je viens de parler. 
Hors de là il n'y a que des hypothèses peu satisfaisantes. Il est bien plus facile de 
se rendre compte des hallucinations toxiques par les solanées vireuses, les papavéracées, 
le haschisch, l'alcool. 
Là, il y a un élément connu et certain, c'est le poison qui circule dans les vaisseaux 
et vient imprégner les cellules cérébrales et tant que le poison n'est pas éliminé il y a 
une modification des cellules cérébrales par le sang toxique qui vient les nourrir et qui 
trouble leur fonctionnement physiologique ; nous ne savons pas ce qui se passe dans les 
cellules autrement que par les troubles hallucinatoires ou délirants des malades, mais 
nous sommes sûrs qu'un des deux facteurs de l'exercice régulier, normal de ces cellules, 
est altéré et qu'il est certainement la cause des désordres nerveux. 
L'observation des malades et l'expérimentation qui peut renouveller le phénomène 
à volonté en sont la preuve. 
Quand aux hallucinations de cause organique cérébrale il semble que leur méca- 
nisme soit des plus faciles à exposer et à comprendre. Il n'en n'est rien ; qu'il y ait 
tubercule, gliome, ancienne hémorrhagie, ou n'importe quel néoplasme dans un point 
quelconque du cerveau ou de la moelle, cela n'explique point l'origine des hallucinations. SECTION X-DISEASES OF CHILDREN. 
559 
En effet, les différences, les variétés, de siège de la lésion cérébrale excluent toute 
idée localisatrice chez les enfants. 
Pour se rendre compte des hallucinations dans ces cas, il faut réfléchir que la lésion 
apparente n'est peut-être pas la cause directe du phénomène morbide et qu'elle n'en 
est que la cause occasionnelle, au même titre qu'elle est cause de la céphalalgie, du ver- 
tige et des vomissements. 
En effet, par leur présence dans le cerveaux et la moelle épinière les néoplasmes 
entretiennent ou peuvent entretenir dans tout l'organe des troubles circulatoires et nu- 
tritifs qui engendrent différents désordres du système nerveux dans l'intelligence, la 
sensibilité générale et spéciale et le mouvement. 
Elles peuvent aussi bien troubler l'exercice régulier des perceptions normales pour 
produire des perceptions anormales ou hallucinations. 
Il suffit pour cela que, dans le centre d'origine des perceptions, l'état des cellules 
cérébrales soit modifié par une influence de voisinage éloignée, et alors on comprend 
que des hallucinations puissent se produire au même titre qu'elles se produisaient sous 
l'influence d'une irritation sympathique lointaine, viscérale ou autre. 
On comprend aussi la possibilité des hallucinations avec des tumeurs placées en 
avant ou en arrière des hémisphères cérébraux, dans les noyaux centraux, la couche 
optique, dans le cervelet ou le moelle. 
C'est moins la lésion elle-même que son retentissement sur les cellules du centre des 
perceptions. 
De cette façon, quelle que soit la cause occasionnelle des hallucinations, leur véri- 
table origine peut être rapportée à une modalité pathologique toujours la même, 
et cette modalité peut être considérée comme une lésion vaso-motrice des cellules 
cérébrales du centre des perceptions. 
OBSERVATIONS SUR LA PNEUMONIE FRANCHE INFANTILE. 
OBSERVATIONS ON TRUE INFANTILE PNEUMONIA. 
BEOBACHTUNGEN ÜBER DIE ECHTE PNEUMONIE BEI KINDERN. 
PAR LE PROFESSEUR ADOLPHE D'ESPINE. 
De Genève 
INTRODUCTION. 
Messieurs-Pour répondre à l'appel de votre Président, j'ai rédigé quelques obser- 
vations tirées de ma pratique hospitalière et privée, qui ont trait à la pneumonie 
franche. S'il est un sujet de la pathologie infantile, qui semble connu dans ses moin- 
dres détails, c'est assurément celui-là. Aussi n'ai-je point la prétention de vous entre- 
tenir aujourd'hui de choses nouvelles et me bornerai-je à attirer votre attention sur 
certains points spéciaux qui m'ont paru avoir une réelle importance pratique. 
Je diviserai mon travail en trois parties :- 
1. Observations sur la forme centrale ou congestive. 
2. Observations de pneumonies franches mortelles. 
3. Considérations sur le traitement de la pneumonie. 
I. FORME CENTRALE OU CONGESTIVE. 
Pneumonia Vera Levissiona.-Il existe chez l'enfant une forme de pneumonie franche, 
qu'on peut appeller centrale ou congestive, forme difficile à reconnaître, parce que les signes 560 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
physiques sont peu accentués ou incertains, et que les signes fonctionnels (au point de 
certains crachats) sont absents ou de peu d'importance. Cette forme est souvent mécon- 
nue ou peut-être prise pour une autre affection (début de fièvre continue, éclampsie, 
fièvre de croissance ou de dentition). 
Grisolle* la connaissait déjà et l'a parfaitement caractérisée en ces termes: "La 
pneumonie peut être latente, soit parce qu'elle occupe un trop petit espace, soit que 
située à une grande profondeur et au centre du poumon, elle se trouve enveloppée de 
toutes parts par une portion du poumon complètement intacte." 
Parmi les auteurs plus modernes, la plupart d'entr'eux ont signalé l'apparition tar- 
dive ou le peu d'importance des signes physiques dans certaines formes de la pneumo- 
nie infantile ; je n'en citerai que deux. Meigs et Pepperf distinguent la forme lobaire 
qui est caractérisée peu l'infiltration classique et la forme partielle " dont les symp- 
tômes, disent-ils, sont beaucoup plus obscurs et incertains que dans la forme lobaire." 
Cadet de Gassicourt £ distingue la pneumonie à signes stéthoscopiques dès le début, à 
signes stéthoscopiques tardifs et sans signes stéthoscopiques ; ce qui revient à dire sui- 
vant lui ; pneumonie atteignant dès le début les parties superficielles du poumon, ne 
les atteignant que plus tard, restant centrale jusqu, à la fin. Cet éminent observateur 
relate l'histoire d'une pneumonie centrale chez un garçon de 10 ans, qui présenta tous 
les signes rationnels de la maladie, mais sans expectoration et sans signes physiques 
appréciables. 
On peut à ce sujet distinguer deux catégories de faits. Dans la première, la durée 
de la fièvre est semblable à celle de la pneumonie classique, c'est la forme centrale pro- 
prement dite. Dans la seconde, la durée de la fièvre est raccourcie, c'est la forme abor- 
tive. On pourrait donner aux deux catégories réunies le nom commun de forme conges- 
tive ou bien encore de pneumonia vera levissiona. 
(a) Pneumonie Centrale.-C'est à la première catégorie de faits, qu'appartient indu- 
bitablement l'observation suivante: 
Observation 1.-Pneumonie centrale du sommet droit-Herpès labial-Pneumo- 
coccus de Fraenkel dans un crachat-Fièvre modérée de huit à neuf jours. 
G. M. 16 ans garçon, encore enfant par son développement physique, d'une bonne 
santé habituelle, tombe malade et s'alite le 28 Mars, 1887, après s'être senti légèrement 
indisposé le 25 Mars et avoir ressenti quelques frissons le 26 et le 27. 
Température axill. le 28 Mars, au soir, 38.6°. Le 29 Mars (deuxime jour), tempé- 
rature au matin, 38.1°, au soir, 40°. 
Sauf la fièvre et l'état saburral des premières voies, rien de particulier à noter, ni à 
la gorge, ni au ventre, ni aux poumons. L'apparition d'un groupe d'herpès labial me 
fait chercher une pneumonie que j e ne trouve pas. 
Hentederioni. Le 30 Mars (troisième jour), température au matin, 38.9°, au soir, 
39.9°. 
Rien de nouveau, sauf un léger toussotement. 
Le 31 Mars (quatrième jour), temperature au matin, 38.7°, au soir, 39.8°. 
Un épistaxis dans la matinée. Un peu de vertige, quand le malade est sur sou séant. 
Rate normale, ventre non balloné, pas de diarrhée. État subjectif, bon. 
Le 1er. Avril (cinquième jour), température au matin, 38.5°, au soir, 39.6°. 
La toux a un peu augmenté ; il n'y a aucun point de côté. Après une exploration 
minutieuse, j'arrive à constater aujourd'hui dans la fosse sus-épineuse droite une sub- 
matité dont les limites inféro-externes dessinent celles du lobe supérieur. Dans cette 
étendue, diminution considérable du murmure vésiculaire et dans un point très limité 
* Traité Pratique de la Pneumonie, 1841, page 436. 
f Practical Treatise, 1874, 5th edition, page 875. 
J Traité Clinique, 1880, tome I, page 66. 561 
SECTION X-DISEASES OF CHILDREN. 
situé à la partie interne du triangle sus-épineux, j'entends un peu de respiration bron- 
chique aux deux temps, ainsi que du retentissement de la voix avec timbre légèrement 
bronchique. Pas de râles. 
Potion avec cinq grammes de benzoate de soude. 
Le 2 Avril (sixième jour), température au matin, 38.5°, au soir, 39.4°. 
Mêmes lignes. 
Le 3 Avril (septième jour), température au matin, 38.5°, au soir, 38.5°. 
Le matin, quelques crachats verts un peu collants sont examinés au microscope après 
coloration au bleu de gentiane. J'y constate uu nombre considérable de pneumococcus 
de Fraenkel, ce qui confirme le diagnostic pneumonie franche. 
La journée a été beaucoup meilleure depuis un lavement qui a provoqué une toux 
naturelle. La toux a diminué. La matité au sommet droit est moins nette aujour- 
d'hui qu'hier. On entend encore un peu de timbre bronchique dans la respiration et 
dans la voix. 
Le 4 Avril (huitième jour), température au matin, 38°, au soir, 38.5°. 
Le 5 Avril (neuvième jour), température au matin, 37.7°, au soir, 38.1°. 
Pour la première fois la nuit a été bonne et la toux a entièrement disparu. A la 
percussion de la fosse sus-épineuse droite, encore légère diminution dans l'intensité du 
cou en comparaison avec le côté sain. À l'auscultation, pas de râles ; on ne trouve 
plus qu'un léger retentissement de la voix. 
Je constate par contre, pour la fin fois, une sub matité avec son plus élevé (high- 
pitched), et de l'expiration prolongée dans le triangle susdemiculaire droit. 
L'urine est encore foncée. L'enfant a essayé de faire quelques pas, la marche est 
titubante. L'herpès existe encore sous forme de croûte, sur la lèvre, plus de fièvre. 
Ce n'est que le 7 Avril (onzième jour), que les signes physiques sont redevenus absolu- 
ment normaux et que l'enfant a repris tout son appétit. Il est probable que cette affec- 
tion aurait pu passer dans la litérature sous le nom de fièvre synoque ou de fièvre her- 
pétique, si la pneumonie n'avait pas été démasquée. 
Il est bon d'insister peut-être ici sur le mode d'exploration physique à suivre en 
pareil cas. 
(a) Fosse Sus-épineuse.-La percussion de la fosse sus-épineuse doit se faire en enfon- 
çant profondément le doigt plessimétrique et en percutant doucement ; la percussion 
doit être faite de même des deux côtés pour apprécier les différences. Il y a de nom- 
breuses chances d'erreur, qui proviennent de la position asymétrique de l'enfant, de la 
tension plus ou moins grande des muscles par le cri, etc. Aussi faut-il contrôler à plu- 
sieurs reprises le résultat avant de l'admettre comme certain. Si la limite de la matité 
obtenue dessine exactement celle du lobe supérieur, on peut la rapporter avec beaucoup 
de probabilité à un lésion du poumon. 
Il faut ausculter en fermant l'oreille libre. Ce précepte donné par Ziemssen* dans 
sa monographie sur la pneumonie est important surtout pour saisir le timbre bronchique 
qu'accompagne le retentissement de la voix ou du cri. Le premier signe sthéthosco- 
pique et souvent le seul dans les parties du lobe supérieur éloignées des bronches, c'est 
Vabsence du murmure vésiculaire sous l'oreille. Comme on peut entendre facilement 
chez les petits enfants du murmure vésiculaire propagé des parties voisines ou les 
petites dimensions de la fosse sus-épineuse par rapport à l'étendue de l'oreille du 
médecin, le signe stéthoscopique habituel sera une diminution notable du mwrmure vésicu- 
laire, en comparaison avec le côté sain. 
(&) Triangle Sus-claviculaire.-Il ne faut jamais oublier d'explorer chez l'enfant le 
triangle sus-claviculaire. La percussion eu est plus facile, que celle de la fosse sus-épi- 
Vol. Ill-36 
* Berlin, 1862. 562 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
neuse, pourvu qu'elle soit faite avec douceur et révélera souvent une matité très nette 
dans la forme dite contrôle de la pneumonie. 
L'auscultation peut en être faite avec un stéthoscope binauriculaire à petite embou- 
chure, dit stéthoscope américain, qui permettra d'apprécier surtout la diminution du 
murmure vésiculaire. 
Comment peut-on se représenter l'état antiseptique du poumon dans les formes 
légères de la pneumonie, telles que celle de notre observation ? L'infiltration solide, 
fibrineuse, doit être réduite à son minimum. Son siège est en général assez fixe ; il 
correspond à la partie profonde et interne de la fosse sus-épineuse, c'est-à-dire, à l'ori- 
fice des grosses ramifications de la bronche supérieure. C'est peut-être le fait que vou- 
laient exprimer Meigs et Pepper, par le nom de pneumonie partielle. Cette solidifica- 
tion doit être centrale au début, comme le prouve dans certains cas l'existence d'un 
peu de murmure vésiculaire superficiel, à travers lequel l'oreille perçoit déjà le reten- 
tissement à timbre bronchique de la voix et du cri. Le reste du lobe supérieur est 
atélectasié par la congestion inflammatoire, il est engoué ou plutôt englué ; l'air n'y 
pénètre plus, d'où absence des râles crépitants habituels chez l'adulte, disparition de la 
respiration et subinatité, comme les, résultat de l'exploration physique. L'extension 
et l'intensité du-souffle expriment probablement assez exactement l'extension de l'in- 
filtration fibrineuse. Il est assez fréquent d'entendre dans cette variété de pneumonie 
infantile l'intermédiaire entre la vraie respiration bronchique et le murmure vésiculaire 
auquel Austin Flint a donné avec beaucoup d'à-propos le nom de respiration broncho- 
vésiculaire (Unbestimmtes Athmen des Allemands). 
(6) Pneumonie Abortive.-Le nom de peumonie abortive a été donné pour la première 
fois, à notre connaissance par M. Picot et moi * à cette forme de pneumonie franche 
avec infiltration légère qui évolue plus rapidement que la forme ordinaire, c'est-à-dire, 
au moins de cinq jours. Cette manière de voir a été adoptée aussi par d'autres auteurs, 
en particulier par Baginsky f qui lui consacre un paragraphe spécial. Elle a été com- 
battue par Cadet de Gassicourt qui distrait son histoire de celle de la pneumonie franche 
et en fait une maladie nouvelle sui-generis, sous le nom de congestion simple du poumon. 
C'est l'opinion soutenue par Hieué f qui a donné la première description de cette affec- 
tion en 1876. Nous ne voulons pas rentrer ici dans la discussion de ce point de doc- 
trine. Je me borne à constater qu'en démontrant l'existence de la même preuve anato- 
mique avec la durée classique de la pneumonie franche et la présence des microbes 
caractéristiques dans ces crachats, je crois avoir donné un argument décisif en faveur 
de votre manière de voir. 
Nous sommes disposés à croire que la pneumonie abortive est très fréquente dans la 
première enfance et qn'on peut lui rapporter un grand nombre de convulsions fibriles, 
de fièvres dites dentition, mais que les signes physiques sont souvent peu accusés, 
c'est-à-dire, que la pneumonie abortive reste souvent centrale. 
Si nous ne comptons dans nos notes que les observations dans lesquelles les signes 
physiques étaient évidents, nous n'en trouvons que six, qui se répartissent comme suit, 
au point de vue de la localisation : - 
Sommet droit, 3. 
Sommet gauche, 1. 
Lobe inférieur gauche, 2. 
La durée de la fièvre a été dans deux cas de deux jours, et dans les autres cas de 
trois jours. 
Manuel Pratique des Maladies de l'Enfance, second edition, page 548, Septembre, 1879. 
j" Praktische Beiträge zur Kinderheilkunde, I. lieft, page 17, 30 Avril, 1880. 
J Thèses de Paris, 1876. SECTION X-DISEASES OF CHILDREN. 
563 
L'observation suivante a été choisie parmi les six cas, comme exemple de la pneu- 
monie abortive, à cause des particularités intéressantes de sa symptomatologie : 
Observation 2.--Pneumonie abortive du sommet gauche-Convulsions tétaniformes 
-Rash morbilliforme chez un enfant d'un mois et demi-Durée de la fièvre : trois 
jours. 
Enfant de M., âgé d'un mois et demi, né à terme et robuste (poids à la naissance 
3.470 grammes), nourri exclusivement au sein le premier mois, allaitement mixte 
depuis 15 jours. 
Le 24 Février, 1886, le médecin de la famille, le Dr. Ferrière, de qui je tiens ces 
renseignements, est appelé à 3 heures de l'après-midi. Il apprend que l'enfant n'est 
pas bien depuis la veille au soir, à la suite d'une promenade où il aurait pris froid ; il 
a eu un vomissement dans la soirée, la nuit a été agitée, le matin, il vomit continuel- 
lement et refuse le sein. La figure est très-pâle, les traits sont contractés, la respiration 
est rapide et saccadée. 
A 4 heures, l'enfant a une convulsion tonique avec bouche serrée et écume surtout 
des lèvres. 
Appelé en consultation avec le Dr. Ferrière à 7 heures du soir, je constate une forte 
fièvre (40.2 dans le rectum), une submatité avec résistance au doigt dans la fosse sus- 
épineuse gauche avec respiration bronchique dans la partie interne. Sous la clavicule 
gauche, le son n'est pas aussi plein qu'à droite. Il n'y a pas de toux. Je diagnostique 
une pneumonie franche et porte nu pronostic plutôt favorable. 
Ordonnance :-Ne donner comme nourriture que le sein. Compresses de priessuites 
autour du front. Enveloppement ouaté des extrémités inférieures. Un peu de rhum 
dans de l'eau à boire. Bains tièdes, si l'agitation ne cède pas aux compresses. 
Le soir à 11 heures, respiration vague, avec arrêts complets de 3 à 4 minutes ; sorte 
de Cheyne-Stokes, température 40°, 25 Février (deuxième jour), à 9 heure du matin, 
température 39.1°. 
La nuit a été plus calme que la précédente, maisl a respiration est encore irrégulière. 
Matité diminuée un peu dans la fosse sus-épineuse gauche, mais plus nette qu'hier en 
avant où elle s'est étendue à toute la région sus- et sous-claviculaire. Respiration 
bronchique en cet endroit. 
L'enfant n'a pas encore toussé depuis le commencement de la maladie. 
I. Bain tiède ce matin, suivi d'une sorte de syncope ou faiblesse. 
Je revois l'enfant en consultation à 3 heures de l'après-midi, après une nouvelle 
«rise de convulsions toniques, qui a été moins forte que celle de hier. Température 
39.6°, ù 6 heures du soir. 
L'enfant a mieux pris le sein qu'hier, on continue les compresses de Priessuites. 
Le 36 Février (troisième jour), température 38.8° à 9 heures du matin. 
Le Dr. Ferrière constate l'existence d'un exanthème rubéoliforme sur le tronc, les 
jambes, les bras et la nuque ; il n'existe presque pas à la figure. 
La matité est encore marquée en avant à gauche. Souffle près de l'angle sterno- 
■claviculaire. 
On cesse les compresses et les bains. Consultation à 3 heures de l'après-midi : 
L'exanthème s'est généralisé, mais il a déjà pâli depuis le matin, c'est un rash. 
À 7 heures du soir température 37.5°, l'enfant est calme. 
Le 27 Février (quatrième jours), au matin le rash a disparu. La fosse sus-épineuse 
gauche est' redevenue normale. Encore un peu de matité en avant, mais il n'y a plus 
de souffle. 
Température au matin, 37.6°, au soir, 38°. 
Depuis lors, l'enfant s'est bien porté. 
Remarques-J'attire l'attention dans cette observation 
1. Sur l'absence totale de toux. 564 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
2. Sur la durée exacte de trois jours de fièvre, continue avec défervescence caracté- 
ristique. 
3. Sur le caractère tonique des convulsions, qui a été déjà indiqué comme un 
caractère spécial de l'éclampsie des premières semaines de la cei, par Soltmaun. 
4. Sur l'apparition du rash, qui a été signalé déjà dans le cours de la pneumonie 
infantile, soit par Rilliet et Barbthez, soit par Cadet de Gassicourt.* 
II. PNEUMONIES FRANCHES MORTELLES. 
La pneumonie franche chez l'enfant est de l'avis de tous les auteurs une maladie 
essentiellement bénigne, qui a une tendance naturelle à la guérison. Néanmoins, il ne 
faut pas aller trop loin dans ce sens et il peut être utile de publier tous les cas mortels, 
afin d'être renseigné plus exactement sur les causes qui aggravent le pronostic et faire 
faire un pas en avant, si possible, à la thérapeutique de cette maladie. 
Depuis mon établissement à Genève, c'est-à-dire, pendant 14 ans de pratique, sur 
un nombre très-considérable des pneumonies franches infantiles que j'ai soignées, je ne 
crois avoir eu que deux cas mortels. J'ai pu dans ces deux cas me rendre compte par 
l'autopsie de la cause prochaine de la mort. Je les rapporterai ici très brièvement. 
Observation 3.-Pneumonie franche multé le bain droite terminé par gangrène- 
mort le onzième jour. 
Cette observation a été déjà relatée en quelques mots dans notre manuel.f 
Il s'agissait d'une fillette de trois ans et demi, d'une bonne santé habituelle. Le 
pronostic nous avait paru inquiétant dès le début à cause de l'élévation considérable 
de la température, de la prostration des forces et de l'extension rapide de l'inflamma- 
tion du lobe supérieur au lobe inférieur. 
La fièvre fut combattue par les bains tièdes, par la quinine et le salicylate de 
soude. Ce dernier médicament fut donné à la dose journalière moyenne d'un gramme. 
Au bout de deux jours, il avait déterminé une diminution notable delà fièvre. Ce 
jour-là, le cinquième de la maladie, nous trouvons dans l'observation les signes sui- 
vants: " Peau fraîche, l'enfant parait très-fatiguée. Figure pâle, légèrement bouffie." 
Le salicylate est supprimé le lendemain et remplacé par une portion tonique à l'extrait 
de quinquina et à la liqueur ammoniacale anisée. 
La fièvre reprend de plus belle le soir du sixième jour et persiste jusqu'à la fin. 
Le huitième jour, la fièvre et la dyspnie étant considérables, on ordonne des bains 
tièdes et un lavement de 0.50 de sulfate de quinine. 
Le neuvième jour l'enfant prend un bain sinapisé et la potion au salicylate en 
alternant avec la potion excitante. 
Le dixième jour, la fièvre a diminué, mais il n'y a pas d'amélioration réelle. L'an- 
goisse respiratoire est grande. On se borne à prescrire un uni généreux à doses fré- 
quemment répétées. 
Le onzième jour, l'état va en empirant. Le pouls est extrêmement rapide et faible. 
L'enfant meurt dans l'après-midi sans avoir présenté à aucun moment de la fétidité 
ou de l'haleine et sans avoir expectoré. L'exploration physique avait seulement permis 
de constater une inflammation pneumonique du poumon droit qui s'était étendue du 
sommet à la base. 
L'autopsie confirma le diagnostic de pneumonie franche, fibrineuse, mais elle révéla 
en outre, ce que je n'avais point soupçonné, la présence de trois infarctus cunéiformes 
gangréneux occupant la superficie du lobe supérieur. L'un d'entr'eux n'était pas 
encore ramolli et était nettement hémorragique ; les autres étaient déjà affectés, 
ramollis et excavés à l'intérieur et d'une couleur pis noirâtre sans fétidité aucune. 
Mon collègue M. le Professeur Lalen qui a bien voulu examiner la pièce, a constaté 
* Loe. cit. p. 85. 
f D' Espine et Picot, troisième edition, p. 653. Disseminated centers of Pulmonary Gangrene 
following true Hepatization. Phlebitis of the Pulmonary Veins 
I) E spin e . SECTION X DISEASES OF CHILDREN. 
565 
une phlébite des veines pulmonaires dans les rameaux qui provenaient de ces foyers 
gangréneux. La paroi de la veine était jaunâtre ; l'une d'elles contenait un thrombus 
adhérent, ramolli, qui pouvait être suivi jusque dans le foyer. 
La figure enjointe peinte après la pièce représente le lobe supérieur incisé par le 
milieu au niveau des trois foyers de gangrène. On voit dans la partie gauche un throm- 
bus adhérent et à droite la paroi vasculaire rouge et enflammée. 
Observation 4.-Pneumonie franche terminée par hépatisation grise de tout le pou- 
mon droit. Mort le dix-huitième jour. Antopsie (résumée). 
La jeune Marie A., âgée de 11 ans, entre dans mon service à l'Hôpital Cantonal le 
18 Juin, 1885, au dixième jours d'une pneumonie que j'avais soignée en ville depuis le 
11 Juin (troisième jour de la maladie). Un peu de délire les premiers jours avec fièvre 
très élevée, oscillant entre 40.3° et 40.7° (R). J'avais constaté une pneumonie massive 
du lobe inférieur droit, qui s'étendit le dixième jour au lobe supérieur du même côté. 
L'enfant fut traitée par les bains tièdes et les compresses de Priessnitz sur la poi- 
trine, qui parurent les premiers jours amener une amélioration sensible. Le douzième 
jour, l'état subjectif était bon et la fièvre avait diminué. Mais elle reprit de plus 
belle le quatorzième jour, en même temps que la pneumonie s'étendait et devenait plus 
massive dans le lobe supérieur. 
L'état général grave et les râles humides éclatants firent soupçonner un instant 
qu'il s'agissait d'une tuberculose aiguë à forme pneumonique. L'examen des crachats 
révéla la présence de nombreux pneumobacilles encapsulés de Friedländer, mais fut 
négatif pour les bacilles de Koch. 
Dans les derniers jours, la fièvre fut très élevée, la dyspnie s'accompagna d'asphyxie 
et l'enfant succomba, malgré une médication au cognac et l'application de ventouses 
sèches, le 26 Juin (dix-huitième jour). 
A V autopsie, hépatisation complète de tout le poumon droit avec passage au troisi- 
ème degré hépatisation prise. Epanchement modéré séro-purulent dans la cavité 
pleurale droite, contenant des flocons fibrineux et beaucoup de pneumobacilles encap- 
sulés. Un peu de liquide séreux dans la cavité pleurale gauche. Le poumon gauche 
est acclimatié. 
Dégénérescence graisseuse du foie et des reins (épithélium cortical). 
Les autres cas de-pneumonie franche infantile mortels, que j'ai observés ont été vus 
par moi seulement occasionellement, en consultation avec des confrères et n'ont pas 
été suivis d'autopsie. Quoiqu'on en soit réduit à des probabilités sur les causes de la 
mort, j'en donnerai un court résumé pour être complet. 
Observation 5.-Enfant A., fillette de 16 mois, atteinte d'une pneumonie massive 
du sommet droit, avec hyperpyrexie. Vue en consultation avec son médecin le Dr. 
Solay, le 31 Janvier, 1786, le neuvième jour de la maladie. 
L'enfant est dans le coma, les membres sont en résolution. Néanmoins, il n'y a 
pas de signes de méningite, c'est une pneumonie à forme cérébrale. L'enfant suc- 
comba dans la soirée. 
Observation 6.-Alice M., belle fillette de deux ans, tomba malade le 9 Mars, 1882. 
Le Dr. G-œtz qui la soigne, a constaté une hépatisation massive du lobe inférieur 
gauche, qui s'est étendue le 16 Mars (sixième jour), au lobe supérieur du même côté. 
La température ce jour est montée à 41°. 
Je la vois en consultation avec le Dr. G-œtz le 17 Mars, au soir (septième jours); 
Perte de connaissance ; souffle énorme et matité absolue au sommet gauche ; la 
sonorité commence à revenir à la base. Néanmoins, la température est encore élevée 
40.2°, malgré plusieurs vésicatoires appliqués les jours précédents. Nous prescrivons 
des bains tièdes qui ramènent un peu de connaissance. Néanmoins, le lendemain, 18 
Mars (huitième jour), la température était encore à 39.8° et l'enfant succomba dans la 
soirée. 566 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dans ces deux dernières observations, il ne semble pas y avoir eu de complication, et 
l'on ne peut attribuer la terminaison fatale qu'à l'intensité de la fièvre et de l'infection 
pneumonique. Dans ces deux cas l'infiltration a été massive et étendue à tout le pou- 
mon. Nous en tirons la conclusion, qu'il faut être réservé dans son pfonostic, quand 
chez l'enfant on voit apparaître de bonne heure une matité considérable et un souffle 
tubeuré, surtout quand cette hépatisation massive s'étend à plusieurs lobes. 
Nous résumons une dernière observation, dans laquelle la mort a été aussi pen 
une embolie artérielle, provenant probablement d'une thrombose cardiaque ; nous 
n'avons jamais vu citer cette complication dans le cas de la pneumonie franche 
infantile. 
Observation 7.-Anna L., deux ans. Bronchite et pneumonie du sommet droit qui 
a débuté vers le 9 Juin, 1886, et s'est étendue le 16 Juin à toute la partie postérieure 
du lobe inférieur droit. 
Le 17 Juin (neuvième jour), l'amélioration est très sensible, la toux est devenue 
grasse. Tout fait espérer une convalescence prochaine, quand dans la nuit du 17 au 18, 
l'enfant est prise d'angoisse respiratoire et d'une grande agitation. Le Dr. Jeanneret 
qui est son médecin, constate le 18 au matin que la jambe et le pied droit sont froids, 
insensibles et couverts de taches bleues ecchymotiques. 
Je vois l'enfant à midi en consultation avec le Dr. Jeanneret, nous constatons une 
action tumultuense, quoique régulière, du cœur, avec dilatation considérable des cavi- 
tés droites, ainsi qu'une pneumonie massive avec souffle amphorique dans toute la par- 
tie postérieure du poumon droit, surtout dans le lobe inférieur. Nous formulons un 
pronostic absolument grave. 
Le 20 Juin (douzième jour), les taches ecchymotiques sont plus nombreuses sur la 
jambe droite, qui est douloureuse au toucher. On constate aussi quelques ecchymoses 
moins nombreuses sur le pied gauche. 
La fièvre continue et le poult est extrêmement fréquent. 
Le 23 Juin (quinzième jour), le pied droit et la jambe droite jusqu'au milieu du 
du mollet sont froids et d'un bleu violet. Sur les orteils du pied gauche, il s'est formé 
des pustules qui ont conflué en phlyctènes jaunes opaques, se détachant sur un fond 
violet ecchymotique. 
L'enfant est très affaiblie, tantôt somnolente, tantôt agitée. Les lèvres sont 
cyanosées. Elle meurt dans la soirée. 
III. CONSIDÉRATIONS SUR LE TRAITEMENT DE LA PNEUMONIE FRANCHE. 
On peut diviser les méthodes de traitement employées contre la pneumonie franche 
des enfants en méthodes nuisibles, inutiles et utiles. 
(a) médications Nuisibles.-Il ne faut pas oublier, avant d'ordonner une médication 
énergique contre la pneumonie franche, qu'il s'agit d'une maladie à forme cyclique, 
qui guérit dans l'immense majorité des cas par les seuls efforts de la nature. 
Primum, Non-nocere.-Il n'est plus besoin aujourd'hui de faire les procès des émis- 
sions sanguines générales et de l'émétique ; ils sont proscrits par tous les médecins 
d'enfants. 
Il n'en est pas de même de la classe chaque jour plus nombreuse des antipyrétiques 
internes et je serais heureux si mon modeste travail donnait l'occasion aux sommités 
médicales de présenter dans le sein de la Section for Children Diseases de se prononcer 
au sujet de leur utilité dans la pneumonie. 
Je mets à peu les sels de quinine, qui ne sont point dangereux à moins qu'on n'en 
hausse les doses et que j'ai employés occasionnellemnt avec avantage, soit en lavement, 
soit par la bouche, mais sans pouvoir leur attribuer dans le traitement de la pneumonie 
le même succès que dans celui de la fièvre typhoïde des enfants. 
Quant an salicylate de soude, je l'ai abandonné, n'ayant pu m'empêcher de lui attri- 567 
SECTION X-DISEASES OF CHILDREN. 
buer une influence hyposthénisante dans l'observation de gangrène pulmonaire que j'ai 
relatée plus haut (Obs. 3.). 
L'antipyrine a un certain vague dans le traitement de la pneumonie infantile, qui 
je crois, est actuellement en voie de décroissance. Ce médicament, comme l'ont prou- 
vé des expériences physiologiques récentes, a une action déprimante sur le cœur et je 
n'ai jamais pu me résoudre à l'employer à dose efficace contre la fièvre de la pneumonie 
franche. 
L'antifibrine n'a pas tout-à-fait le même inconvénient, mais mon expérience n'est 
pas suffisante dans la pneumonie franche pour pouvoir me prononcer à son égard. 
Quant à la digitale, dont l'usage est encore très répandu dans le traitement de la 
pneumonie, je ne puis m'expliquer son emploi. Quand on l'ordonne à faibles doses, 
ce médicament n'a aucune action appréciable sur la fièvre pneumonique et les accidents 
nerveux qui en dépendent ni sur la résolution de l'exsudât. Il a par contre souvent le 
grave inconvénient d'irriter l'estomac et de gêner l'alimentation, qui joue un rôle 
important en soutenant les forces jusqu'à la crise. À hautes doses, la digitale est dan- 
gereuse chez l'enfant. 
(&) Médications Inutile.-Je range sous ce titre les vésicatoires qui sont sans action 
aucune sur la marche locale de la pneumonie et ont le grave inconvénient de rendre 
impossibles les bains et autres applications externes. Ils augmentent souvent l'agitation 
pendant la période fébrile et doivent être réservés pour les cas où l'induration du pou- 
mon persiste après la défervescence ou bien contre les complications pleurales et péri- 
cardiques. 
(c) Médications Utiles.-Je n'en connais que deux, les applications réfrigérantes 
externes et les excitants diffusibles à l'intérieur. 
Les premières peuvent être employées dès le début de la fièvre pneumonique sous 
la forme de compresses de Priessnitz sur le tronc et de bains tiècles administrés deux ou 
trois fois dans les 24 heures, au moment des exacerbations. Si elle ne suffisent pas pour 
ramener la température normale, elle combattent efficacement les symptômes ner- 
veux de la fièvre, l'insomnie, l'agitation, le délise, l'adynamie et les convulsions. 
Nous avons pu constater, dans un cas de pneumonie cérébrale à forme typhoïde d'une 
extrême gravité chez une fillette de quatre ans, une amélioration passagère après chaque 
bain et la disparition définitive du coma après quelques jours de traitement. 
Nous avons eu la conviction, que dans ce cas, nous avons dû. le salut de notre malade 
au traitement balnéaire employé avec persévérance et associé à quelques lavements de 
quinine ; la fièvre tombe le septième jour. 
Les excitants diffusibles sont d'un usage si répandu contre la faiblesse cardiaque dans 
la pneumonie, que nous n'avons pas besoin d'insister sur leur utilité. Nous mettons 
au premier rang les alcooliques et le musc associé au benzoate d'ammoniaque. 
Nous n'avons pas d'expérience chez l'enfant sur les injections sous-cutanées d'éther 
qui rendent de si éminents services dans les pneumonies asthéniques d'un autre âge. 568 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ÜBER DIE IM KINDESALTER VORKOMMENDEN GESCHWULST- 
BILDUNGEN, UND SPECTELL ÜBER MEDIASTINALTUMOREN 
NICHT CONGENITALER NATUR BEI KINDERN. 
ON THE FORMATION OF TUMORS OCCURRING DURING INFANTILE LIFE, 
ESPECIALLY ON MEDIASTINAL TUMORS OF NON-CONGENITAL 
NATURE IN CHILDREN. 
SUR LA FORMATION DES TUMEURS CHEZ LES ENFANTS, SPÉCIALEMENT, SUR LES 
TUMEURS MÉDIASTINES D'UNE NATURE NON-CONGÉNITALE. 
VON PROFESSOR DR. OSCAR WYSS, 
Dirig. Arzt des Kinderspitals zu Zürich. 
Unter den seit Eröffnung des Züricher Kinderspitals, anno 1874, bis heute in diese 
Anstalt aufgenommenen 2768 Spitalspatienten fanden sich 16 mit Neubildungen im 
engem Sinne des Wortes, d. h. nach Ausschluss aller Angiome, ferner der auf tuberku- 
löser oder syphilitischer Basis beruhenden Geschwulstbildungen, aller Missbildungen 
oder mit solchen im Zusammenhänge stehenden Geschwülste. Nach dem Geschlecht 
vertheilen sich diese Geschwülste so, dass neun dem männlichen, sieben dem weib- 
lichen angehörten, und auf die verschiedenen Altersjahre vertheilen sich die Fälle in 
folgender Weise : Es kamen auf das 
1. Lebensjahr (0-1) 3 Fälle, nämlich 1 Knabe, 
2 Mädchen, 
2. 
4 4 
1 Fall, 
44 
1 
0 " 
3. 
44 
1 " 
4 4 
0 " 
1 
4. 
44 
1 " 
44 
1 " 
0 " 
5. 
44 
1 " 
44 
0 " 
1 
6. 
44 
2 Fälle, 
44 
2 Knaben, 
0 " 
8. 
44 
2 " 
4 4 
2 
0 " 
9. 
44 
1 Fall, 
ll 
1 Knabe, 
0 " 
12. 
44 
1 " 
0 " 
1 
14. 
44 
2 Fälle, 
a 
0 " 
2 " 
15. 
44 
1 Fall, 
44 
1 " 
0 " 
Summa 
.... 
.. 9 Knaben, 
7 Mädchen. 
Auf die verschiedenen Körperorgane vertheilen sich diese Neoplasmen in folgender 
Weise : Es war der Sitz der Geschwulstbildung zweimal im Gehirn, zweimal im 
Darm, zweimal im Oberschenkelknoten, zweimal im Ovarium, je einmal im Mediasti- 
num anticum, im Beckenknoten, Pharyngolaryngealraum, im Muskel, Axilla, subu- 
tanen Bindegewebe und Lymphdrüsen. Der anatomischen Structur nach handelte es 
sich um Sarkome, Lymphosarkome, Osteosarkome, Kystosarkome, Fibrosarkome, 
Myxosarkome und Kystome. Zu diesen Geschwulstbildungen fügen wir kurz noch 
einige, die wir ausserhalb des Kinderspitals zumeist in der Consultativ-Praxis zu sehen 
Gelegenheit hatten. Es handelte sich um zwei Fälle von diffuser sarkomatöser Dege- 
neration des Peritoneums ; um zwei Fälle von primärem Lebersarkom, und um einen 
Fall von Sarkom am Schädel in der Stirngegend, wohl ausgegangen vom Periost. 
Unter allen diesen Geschwulstbildungen, die wir bei Kindern beobachtet haben, bot 
mit das meiste diagnostische Interesse der von uns anno 1882 beobachtete und diagno- 
sticirte Fall von Mediastinaltumor, theils wegen seiner grossen Seltenheit, theils auch 
der klinischen Symptome wegen. Es handelte sich um einen vierzehnjährigen Knaben, 
Fritz M., der wegen " Compression der Trachea durch Struma " in's Züricher Kinder- 
spital geschickt wurde und nach Kurzem auch wegen Erstickungsaufällen tracheoto- 
rnirt werden musste. Da in der That eine erheblich vergrösserte Glandula thyreoidea 
vorhanden war, schien jene Diagnose plausibel. Aber nachdem die Trachealkanüle SECTION X DISEASES OF CHILDREN. 
569 
eine kurze Zeit gelegen hatte, kehrte die Dyspnoe, kehrten die Symptome der Tracheo- 
stenosis wieder ; eine längere König'sche Kanüle beseitigte die Dyspnoe. Aber 
wiederum nur f ür eine kurze Zeit lang ; dann musste wieder eine längere, tiefer in die 
Trachea hinabreichende Kanüle eingelegt werden, um die Respiration wieder frei zu 
machen. Die Tracheostenose, die also anfänglich etwa in der Mitte der Trachea Statt 
hatte, rückte allmählig weiter nach unten, an eine Stelle, wo allem Anscheine nach die 
Struma nicht mehr auf die Trachea einen Druck ausüben konnte. Um diese Zeit 
traten auch anderweitige neue Symptome auf : die Lungenränder wurden von oben 
hinter dem Sternum auseinander gedrängt ; es entwickelte sich eine zwischen Jugulum 
Sterni und oberer Herzgrenze befindliche, oben breitere und nach unten etwas schmäler 
werdende, die obere Hälfte des Sternums und die angrenzenden Partien des Thorax 
einnehmende Dämpfung des Percussionsschalles. Dann kamen neuralgiforme Schmer- 
zen in der linken Schulter und im linken Arm, Lymphdrüsenanschwellungen über 
und unter der linken Clavicula. Es bildeten sich sodann Oedeme und Cyanose im 
Gesicht aus, Oedeme des linken Armes, Venenectasien, namentlich in der Gegend 
des Brustbeins : Symptome von Compression der Vena cava, während am Herzen, 
abgesehen von etwas pericarditischem Reiben im Beginn, das aber späterhin vollständig 
verschwand, und auf den Lungen, äusser etwas catarrhalischen Geräuschen, keine 
Anomalie sich nachweisen liess. Es bildete sich späterhin, nachdem schon vorher 
Schlingbeschwerden bestanden hatten, gegen das obere Ende des Sternums eine Verwöl- 
bung der obern Hälfte des Brustbeins in seiner Nachbarschaft aus, die Dyspnoe nahm 
wieder zu, der Patient musste beständig sitzen, und er starb nach neun Monate dauernder 
Krankheit. Die Section ergab einen kindskopfgrossen, von der Thymus ausgehenden 
Tumor mediastini mit Compression der Trachea in grosser Ausdehnung; etwa die untere 
Hälfte war comprimirt ; Compression der grossen Venen, zumal der Vena cava supe- 
rior, der Speiseröhre. Die Neubildung hatte übergegriffen auf die Bronchealen und 
peritrachealen Lymphdrüsen, auf die Drüsen unter und über der linken Clavicula ; sie 
setzte sich auch auf den Herzbeutel fort, hatte diesen an seiner Basis infiltrirt und 
zudem eine hämorrhagische, eitrig fibrinöse Pericarditis herbeigeführt. In beiden 
Pleurahöhlen etwas Hydrothorax mit nachfolgender Lungencompression. 
In der Literatur haben wir nur eine geringe Zahl ähnlicher Fälle von Mediastinal- 
tumor, bei Kindern beobachtet, verzeichnet gefunden. Unter den zwischen den Jahren 
1742 und 1870 publicirten Fällen fand sich nach Riegel keiner aus dem Kindesalter. 
Es sind bis zur Zeit nur etwa neun oder zehn solcher Fälle beschrieben, und die Mehr- 
zahl derselben nicht so eingehend, dass man ein klinisches Bild aller dieser Fälle 
zusammenfassen kann. Wir sehen hierbei gänzlich ab von jenen congenitalen Thymus- 
geschwülsten (resp. Hypertropien der Thymus), über die vor Kurzem Dr. G. Somma in 
Neapel im Archiva di Pathologia infantile, anno li, fase. 4, 1884, eine vortreffliche 
Abhandlung schrieb. Diese bilden eine besondere Krankheitsgruppe für sich, ver- 
schieden von der in Rede stehenden Affektion. 
Die neun genauere Angaben bietenden Fälle, inch der unsrige, lassen Folgendes 
über die Mediastinaltumor en der Kinder, die von der Thymus ihren Ausgang nehmen, fest- 
stellen. Bezüglich Aetiologie. Unter 9 Patienten befanden sich 7 Knaben und bloss 
2 Mädchen. Auf die Altersjahre kommen : ein Fall auf das 1. Lebensjahr ; auf das 
6. zwei Fälle, auf das 7. ein Fall, auf das 9. zwei Fälle, auf das 12., 13. und 15. Jahr 
je ein Fall. Es sind also die ersten fünf Lebensjahre viel seltener von dieser Krank- 
heit heimgesucht, als die zwei folgenden Lustren. Andere ätiologische Momente waren 
keine zu eruiren. Dass aber möglicherweise auch bei der Aetiologie der Neubildungen 
des Kindesalters die Heredität eine Rolle spielt, das deutet die Erfahrung an, die wir 
neulich machten und die darin bestand, dass bei zwei Kindern, die Geschwisterkinder 
waren, maligne Unterleibsgeschwülste vorkamen. 
Pathologische Anatomie. Ihrer anatomischen, resp. histologischen Beschaffenheit 570 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
nach sind die Mediastinalgeschwülste der Kinder nicht wie heim Erwachsenen meistens 
Carcinome, sondern Lymphosarkome. Einzig Prof. Vogel in Dorpat hat einen seiner 
Fälle als Carei nom taxirt, zwar ohne genauere Details anzugeben. Nur in ganz weni- 
gen Fällen liegen genauere Angaben über die histologischen Verhältnisse vor ; so von 
Grützner und von Steudener. Die von uns untersuchte Geschwulst zeigte ein an 
verschiedenen Stellen des Tumors verschieden mächtiges, bindegewebiges Stützgewebe 
von alveolarem Bau. In den festeren, derberen Theilen der Geschwulst war dieses 
Bindegewebsgerüste dicker, derber, reichlicher, zeigte lockiges, welliges Bindegewebe, 
auch glänzende, festere, aus elastischen Fasern, sowie nach den Rändern der Geschwulst 
hin vielfache andere, im Zustande der Atrophie befindliche Gewebspartien (Muskeln- 
fasern, Fettgewebe etc.), eingeschlossen. Manchenorts waren in dasselbe auch Rund- 
zellen eingelagert, theils isolirte, theils in Reihen augeordnete, theils gruppenweise 
zusammengelagerte. Wo die Geschwulst von weicherer, markschwammartiger Beschaf- 
fenheit war, war das Bindegewebsgerüste sparsam, zarter, die Maschen grösser und die 
Septa sehr dünn ; aber doch überall deutlich nachweisbar, auch mit Farbstoffen imbi- 
birbar. In den Alveolen, den kleinen wie den grösseren, lagen, dicht nebeneinander 
gelagert, anscheinend ohne Kittsubstanz, doch leicht zusammenhängende Rund zellen 
von der Grösse etwa der weissen Blutkörperchen. An einigen Stellen (wohl bei 
gewisser Richtung der Schnittführung) war die Dimension der Alveolen so sehr gross, 
dass dieselben als schlauchähnliche oder drüsenähnliche, mit Rundzellen ausgestopfte 
Gebilde neben einander gelagert erschienen. Der Bau der Geschwulst war somit derje- 
nige eines Lymphosarkoms. Unzweifelhaft haben alle diese Tumoren der Thymus (resp. 
des Mediastinum anticum des Kindes) einen ähnlichen Bau; und wenn auch die Lymph- 
drüsen des Lungenhylus, diejenigen an der Bifurcation, an der Trachea durch tuber- 
kulöse oder andere Entartung zu Geschwulstbildung Veranlassung geben können, so 
müssen doch bei diesen sowohl die anatomischen als auch die klinischen Erscheinungen 
ganz andere sein. Freilich gibt es ja auch noch andere pathologische Vorgänge in der 
Thymus, die klinische Symptome machen können : die Hypertrophie (vgl. die Arbeit 
von Somma), Abscesse etc. ; aber diese sind in gewisser Beziehung doch different von 
denen bei unserer Affektion. Wir ziehen deshalb diese Thymusaffektionen nicht in den 
Kreis unserer Betrachtung, sondern halten uns an die Symptome des Lymphosarkoma 
thymicum infantum. 
Symptomatologie. Die Mediastinalgeschwülste, die bei Kindern beobachtet wurden, 
machten sämmtlich in der ersten Zeit ihrer Entwicklung keine Symptome. Ja, einmal 
wurde eine solche Geschwulst zufällig bei einer Section eines an Pneumonie gestorbenen 
Kindes beobachtet (von Steudener), ohne dass intra vitam darauf bezügliche Erschei- 
nungen beobachtet worden wären. Ist jedoch das Wachsthum der Geschwulst bis zu 
einer gewissen Grösse gediehen, so übt sie auf die Nachbarorgane einen Druck aus und 
es stellen sich Erscheinungen ein, 1. Seitens des Respirationsapparates, und 2. Seitens 
desjenigen der Circulation. Die Respiration wird behindert, beengt ; die Athemzüge 
werden hörbar. Beim Laufen oder Springen, beim Abliegen im Bett steigern sich diese 
Erscheinungen ; erst vorübergehend, später bleibend, werden die Athemzüge, In- und 
Exspiration, doch namentlich die erstere, verlängert, keuchend und pfeifend. Die 
Kranken müssen eine ganz bestimmte aufrechte Position einnehmen ; nicht zu weit 
nach vorn übergebeugt, nicht zu stark nach hinten ; und oft auch in einer bestimmten 
Richtung im Sinne von Rechts nach Links oder mit einer bestimmten leichten Rota- 
tion der Wirbelsäule : offenbar so, dass die Stellung der comprimirten Trachea so ist, 
dass ihr Lumen noch so weit als möglich offen erhalten wird durch die entsprechende 
Körperposition. Besonders in der Nacht treten heftigere Attaquen von Dyspnoe bis 
Orthopnoe auf. Bei dem von uns beobachteten Patienten steigerte sich dieser quäl volle 
Zustand so, dass man sich eines Tages genöthigt sah, die Tracheotomie vorzunehmen 
(ex indicat. vitali) und eine König'sche Kanüle einzulegen. Dies hatte günstigen 571 
SECTION X-DISEASES OF CHILDREN. 
Erfolg, aber nach einiger Zeit kehrte die Dyspnoe wieder und konnte nur dadurch 
gehoben werden, dass man eine noch längere, d. h. noch weiter in die Trachea hinab- 
reichende Kanüle einlegte. Offenbar rückte die Verengerung der Trachea, die zuerst 
höher oben ihren Sitz hatte, weiter nach unten. In keinem der in der Literatur ver- 
zeichneten Fälle von Mediastinaltumor bei Kindern musste die Tracheotomie, die bei 
unserem Kranken mit Erfolg in Anwendung kam, gemacht werden ; dass bei Neuge- 
borenen mit Hypertrophie der Thymus, Tracheostenose und Erstickungstod vorkommt, 
ist zwar längst bekannt, neuerdings aber durch Somma's zwei sehr werthvolle Beobach- 
tungen wiederum constatirt. Dass bei Erwachsenen mit Mediastinaltumor zwar 
Compression der Trachea vorkommt, jedoch sehr selten, hat Riegel ("Krankheiten der 
Trachea und der Bronchien," in Ziemssen's Pathologie und Therapie, p. 201) hervorge- 
hoben. Husten, Tracheabronchialcatarrh, auch durch objective Symptome, Rhonchi 
etc. nachweisbar, kommt zu einer gewissen Zeit des Leidens begreiflicherweise vor. 
Auch Hämoptoe ; zwar in unserem Falle wegen der vorausgegangenen Tracheotomie 
und geringen Quantität des entleerten Blutes ohne Bedeutung ; in einem andern Falle 
aber spontan und reichlicher : wohl doch mit der beträchtlichen venösen Stauung im 
Zusammenhang. Ferner wurde bei unserem Kranken hinten, rechts oben, in der Fossa 
supraspinata lautes Bronchialathmen in grosser Ausdehnung constatirt : ein Symptom, 
das wir gleichfalls auf den, die Lunge nach aussen verdrängenden und nach hinten 
gegen die Wirbelsäule hin wachsenden Tumor und die Drüsendegeneration der über 
dem rechten Bronchus und an der Bifurcation liegenden Lymphdrüsen beziehen müs- 
sen. Hydrothorax und Compression der unteren Lungenpartien durch letztere, wieder- 
holt beobachtet, waren Terminalalterationen. 
Von den Störungen von Seiten des Circulationsapparates sind in erster Linie die 
Oedeme im Gesicht, sowie in den oberen Extremitäten hervorzuheben. Sie sind ent- 
weder nur auf der einen Körperhälfte oder, wenn beiderseitig, auf der einen Seite 
stärker vorhanden. Es ist nicht immer die gleiche Seite stärker afficirt ; in dem 
von Gützner (1869 Berlin, Diss.) mitgetheilten Falle waren die Oedeme auf der rechten 
Seite, bei unserem Patienten stärker links, im Gesicht sowohl, als auch später am Arm 
und der linken Hand, und ähnlich in den Fällen von Gamgee und Vogel. Die Oedeme 
waren bei unserem Patienten jeweilen stärker am Morgen und nahmen im Laufe des 
Tages ab. Auffälliger noch als die Oedeme waren Venenectasien, theils auf der Brust, 
wie sie namentlich in der eben citirten Beobachtung von Grützner und in unserem 
Falle, theils aber auch an Hals, Gesicht und Arm auf der einen Seite stärker sich be- 
merkbar machten. Und ebenso die Cyanose des Gesichtes, der Lippen und Schleimhäute 
sowohl, wie der äussem Haut. Am Herzen constatirte Vogel bei dem einen seiner 
Kranken ein systolisches Blasen; bei unserm Patienten war im Beginne der Beobachtung 
ein pericarditisches Reibegeräusch vorhanden, das später verschwand. Sonst war am 
Herzen in den übrigen Fällen nichts Abnormes constatirt worden. 
Einmal, von Dr. Gamgee in Edinburgh, war das Blut microscopisch untersucht wor- 
den und eine Vermehrung der weissen Blutkörperchen gefunden worden. Gleichzeitig 
bestanden in diesem Falle an den unteren Extremitäten Petechien, die bei keinem andern 
Patienten notirt worden sind. 
Störungen im Bereiche des Nervensystems wurden wiederholt gesehen. In unserem 
Falle bestanden neuralgische Schmerzen in der linken Schulter, ausstrahlend in den Arm 
und in die Hand. Wir führten sie auf die secundären Lymphdrüsentumoren über und 
unter der linken Clavicula zurück. Wahrscheinlich waren diese auch der Grund, 
warum bei unserem Kranken die Oedeme auf der linken Gesichtshälfte und im linken 
Arm so beträchtlich waren. Grützner beobachtete analoge neuralgische Schmerzen 
wie wir. 
Der Verdauungsapparat bot in ein paar Fällen bestimmte Störungen. In Folge 
directen Druckes der Geschwulst auf die Speiseröhre kamen Schlingbeschwerden vor, bei NINTH INTERNATIONAL MEDICAL CONGRESS. 
572 
Grützner's Kranken und bei deni unsrigen, so dass feste Dinge gar nicht mehr genossen 
werden konnten. In einem Falle bestanden zudem noch heftige Schmerzen im Gaumen. 
Ob Recurrenslähmungen bei Kindern mit Mediastinaltumoren vorkamen, wissen wir 
leider nicht, da in keinem der Fälle die laryngoscopische Untersuchung vorgenommen 
wurde. 
Die Vorwölbung des Sternums an der Stelle des Tumors wurde wiederholt beobachtet 
und ist natürlich ein äusserst wichtiges Symptom. Sie entwickelt sich langsam und 
spät ; ist schmerzhaft, anfänglich ohne Veränderung der Haut, später mit ausgedehnten 
Venen, auch eventuell geröthet, aber ohne Pulsation und ohne Fluctuation. 
An den Abdominalorganen wurde meist wenig oder nichts Abnormes beobachtet. 
Einige Male Ascites ; bei unserem Kranken war der untere Leberrand, mehr in Folge 
venöser Hyperämie der Leber als in Folge des Hinabgedrängtseins durch Tumor und 
pericarditisches Exsudat, nach unten verdrängt. Die Milz war geschwellt. 
Abmagerung bestand meistens in Folge der Kachexie ; auch terminale Oedeme an 
den unteren Extremitäten. Nur einmal, von Steudener, wurde bei der Section der 
Ernährungszustand noch als ein guter notirt. 
Dauer der Krankheit. Prognose. Die Krankheitsdauer genau zu bestimmen, ist 
geradezu unmöglich, weil sie eine Zeit lang bestehen kann, ohne Symptome zu machen. 
Die am längsten dauernde Krankheitsdauer von über zwei Jahren wurde von Dr. Kosen- 
berg in Göttingen notirt ; doch wurde diese Beobachtung nicht usque ad finem durch- 
geführt. Zweimal war die Krankheitsdauer nur wenige Wochen (Vogel) ; zweimal 
4 Monate, einmal 5| Monate und einmal ca. J Jahre. Die Prognose ist nach unserem 
heutigen Wissen immer eine infauste, lethale. 
Diagnose. Die Diagnose wird sich auf die oben geschilderten Symptome zu stützen 
haben : den langsamen fieberlosen Verlauf ; die Symptome von allmählig zunehmen- 
dem Druck auf die Trachea, die grossen Gefässe, zumal die Vena cava superior, später 
auf den Oesophagus und das Sternum ; die Verschiebung der Lungenränder, die eigen- 
thümliche Dämpfungsform der Geschwülste im Mediastinum anticum. Von Wichtig- 
keit f ür die Diagnose eines malignen Tumors ist sodann der Nachweis der secundären 
Lymphdrüsenerkrankungen. Gegen die einfache Hypertrophie der Thymus und die 
damit im Zusammenhänge stehenden Respirationsbeschwerden wird das Alter des 
Patienten sehr iu's Gewicht fallen : jene tritt in einer viel früheren Zeit des Lebens auf, 
innerhalb des ersten Lebensjahres, als die bei uns in Rede stehende Affektion. Gegen 
Abscesse in der Thymus, syphilitische Vorgänge daselbst : die Anamnese, wie auch der 
objective Befund. Gegen anders woher stammende Abscesse im Mediastinum, Con- 
gestionsabscesse von der Wirbelsäule her, von Lymphdrüsenvereiterung her : die genaue 
Berücksichtigung der Temperaturverhältnisse, sowie der objective Thatbestand ; und 
ebenso dürfte die Diagnose von tuberculösen Drüsenpaqueten an der Bifurcation und im 
Lungenhylus, um die grossen Bronchien herum keine Schwierigkeit haben, da auch 
hier Temperaturverlauf, Anamnese und objectiver Befund entscheidende Anhaltspunkte 
geben werden. 
Therapie. Ist die Diagnose auf Lymphosarkoma thymicum gestellt, so wird die 
Therapie allerdings kaum mehr grossen Erfolg aufzuweisen haben. An eine operative 
Beseitigung der Geschwulst ist wohl bei der grossen Nähe der wichtigsten Organe : 
Herzbeutel, Herz, grosse Gefässe, Pleuren, kaum zu denken ; immerhin, sofern die 
Geschwulst blos auf die Thymusdrüse noch beschränkt wäre, nicht absolut undenkbar. 
Aber da ist wohl die Diagnose noch nicht möglich oder noch unsicher ! Von internen 
Mitteln wird in erster Linie Arsen in vorsichtig, langsam, allmählig zu steigender 
Dosis und in seinen Wirkungen streng überwacht, zu empfehlen sein. Wir ordiniren 
ihn bei Kindern selten anders als so : Solutionis arsenicalis Fowleri 5. Aquä Cinna- 
momi 10. M. Detur ad Vitr. Compte gouttes. Dt. Drei Tage lang Morgens, Mittags, 
Abends, J Stunde nach der Mahlzeit einen Tropfen auf einem Stückchen Zucker zu SECTION X DISEASES OF CHILDREN. 
573 
nehmen. Am 4., 5. und 6. Tage Morgens 1, Mittags 2, Abends 1 Tropfen. Am 7., 8. 
und 9. Tage Morgens 1, Mittags 2, Abends 2 Tropfen zu nehmen. Am 10., 11. und 
12. Tage Morgens 2, Mittags 2, Abends 2 Tropfen zu nehmen. Am 13., 14. und 15. Tage 
Morgens 2, Mittags 3, Abends 2. Am 16., 17. und 18. Tage 2, 3, 3, und so wird lang- 
sam und sehr allmählig jeweilen erst Mittags, dann Abends, dann zuletzt Morgens die 
Tagesdosis jeweilen nach drei Tagen um einen Tropfen gesteigert, und kann im Laufe 
der Zeit bis auf 15 Tropfen dreimal pei- Tag gestiegen werden. Das Aussetzen der 
Tropfen für einige Tage wird ungeordnet, wenn Digestionsstörungen sich einstellen ; 
das Aufhören dieser Therapie darf nicht plötzlich geschehen, sondern muss langsam 
und allmählig stattfinden. Jodkali, Jodeisen wird weniger wirksam sein. 
Unter bestimmten Indicationen, bei Suflbcationsgefahr durch Compression der 
Trachea, wird die Tracheotomie und das Einlegen einer König'schen Kanüle indicirt 
sein, und dadurch dem Patienten sein Dasein bedeutend erleichtert, sein Leben, wie 
in unserem Falle, um viele (6) Wochen verlängert werden können. Wir bezweifeln, 
dass hier die Tubage an die Stelle der Tracheotomie treten kann : die grosse Länge und 
relativ beträchtliche Enge des Rohres würde kaum die Respiration lange ungehindert 
gestatten. Dass Narkotica nicht immer werden vermieden werden können, begreift 
sich aus der Schilderung der Symptome und des Krankheitsverlaufs, und zwar glauben 
wir hier unter Umständen nicht blos Morphium, oder Opium, Chloral Hydrat etc., 
sondern wegen der oft momentan heftigen Dyspnoe auch auf kurze Inhalationen mit 
kleinen Mengen von Aether, Chloroform oder anderen ähnlichen Präparaten hinweisen 
zu wollen. Eine zweckmässige Lagerung, so dass die Kranken mit fast aufrechtem 
Körper auch schlafen können, ist für diese armen Patienten mit eine grosse Wohlthat. 
Und was resultirt aus dieser Betrachtung ? Dass es gewisse unheilbare Krankheiten 
bei Kindern gibt ? Allerdings. Aber sie lehrt uns auch, dass offenbar diese äusserst 
seltenen Erkrankungen dennoch nach einem gewissen Typus verlaufen, dass ihnen ein 
bestimmtes Krankheitsbild zukommt, das wir kennen müssen. Sie lehrt uns, dass 
dieses Krankheitsbild ein anderes ist beim Erwachsenen, ein anderes im kindlichen 
Alter. Und wenn auch viele Symptome die gleichen oder sehr ähnliche sind, so sind 
andere wiederum bedeutend abweichend und für Den, der die Sachlage nicht ganz 
genau kennt, irreführend. Sie beweist von Neuem, dass die Pädiatrie eine ihrer Exi- 
stenz berechtigte Tochter der Medicin im engern Sinne des Wortes ist ; dass es aber 
auch unsere Pflicht ist, mit aMem Fleiss und aller Energie dies Terrain zu bebauen, 
das zwar bereits manche schwere Errungenschaft aufweist, aber doch noch unendlich 
viele Lücken besitzt. Daher auch von Alt-Europa her der Wunsch den Herren Col- 
legen jenseits des Atlantischen Oceans : möge dort die Pädiatrie eine glückliche und 
für das Menschengeschlecht segensreiche Entfaltung gewinnen und ihr manche Heim- 
stätte wissenschaftlichen Ringens und Strebens gegen Krankheit und Leiden der lieben 
Kinderwelt beschieden sein ! 574 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SUR LE TRAITEMENT DE LA DIPHTHÉRIE PAR L'ESSENCE DE 
TÉRÉBENTHINE ET LE SULFURE DE CALCIUM, DANS UNE 
épidémie en l anneé isss, cas nombreux 
DE GUÉRISON. 
ON THE TREATMENT OF DIPHTHERIA BY OIL OF TURPENTINE AND SUL- 
PHITE OF CALCIUM, IN AN EPIDEMIC OF THE YEAR 1885; 
NUMEROUS CASES OF CURE. 
ÜBER DIE BEHANDLUNG DER DIPHTHERIE DURCH TERPENTINÖL UND SCHWEFEL- 
CALCIUM, IN EINER EPIDEMIE DES JAHRES 1885; ZAHLREICHE FÄLLE 
VON HEILUNG. 
PAR LE DOCTEUR ÉMILE POUSSIÉ, 
De Paris, France. 
J'ai l'honneur de faire une communication sur une épidémie de diphthérie que nous 
avons observée le Dr. Michaut Alfred, de Blandy, et moi dans l'arrondissement de 
Melun, Seine et Marne, France. 
Une jeune femme de Paris dont les parents habitent Moisenay a été prise de 
diphthérie dont elle est morte. Le 4 Août les parents rapportent son linge à la cam- 
pagne et ramènent sa petite fille âgée, de 10 mois. 4 jours après c'est-à-dire le 8 Août, 
1885, le père la mère et une jeune fille de 13 ans, sœur de la morté, sont pris eux 
mêmes d'angine diphthéritique. Traitement : pilules de térébenthine, 5 centigrammes, 
8 par jour, gargarisme phénique 2%, toucher les plaques diphthéritiques avec solution 
acide citrique Le mieux au bout de 5 jours. Alimentation substantielle tonique, 
vin généreux, alcool. Le 16 Août dernière visite ; les 3 malades sont guéries. 
Voyant ces personnes atteintes de diphthérie j'ài fait renvoyer le 9 Août à Saint 
Germain, à une lieue de là, l'enfant de 10 mois chez des parents qui ne sont jamais 
entrés dans la famille contaminée. Dans cette maison il y a 6 enfants dont 2 jumelles de 
8 ans ont été prises de diphthérie le 13 Août, c'est-à-dire 3 jours après l'arrivée de 
l'enfant dans la famille, preuve que la maladie a été amenée par cette enfant qui n'étant 
pas contaminée elle même n'apu transporter les germes par ses vêtements. Le même 
traitement est institué pour ces 2 nouvelles malades qui guérissent l'une bien, l'autre 
est atteinte de leucocythémie, de paralysie du voile du palais et même du coté du 
pneumogastrique, car elle présentait de l'orthopneé, de l'arythmie du cœur et de plus 
de l'albuminurie. Après avoir institué un traitement tonique cette enfant finit par 
guérir au bout d' 1 mois et demi. 
Trois jours après que ces 2 petites filles tombaient malades, c'est-à-dire le 16 Août, 
un garçon de la famille, âgé de 12 ans, était pris â son tour et était guéri au bout de 
8 jours mais il lui est resté une paralysie du voile du palais et une paralysie presque 
complète du nerf optique pendant 6 jemaines. 4 jours après, c'est-à-dire le 20 Août, son 
frère âgé de 6 ans était atteint de diphthérie, mais rebelle à toute espèce de traitement 
succombait le 24 Août. 
Une amie de la première malade en contact continuel avec elle est tombée également 
malade le 9 Août atteinte de diphthérie dont elle guérit au bout de 8 jours, même 
traitement. 
Nous avons eu en quelques mois 54 cas de diphthérie dont 48 malades dans la 
même commune. Aussi l'école dut-elle être fermée pour circonscrire cette épidémie et 
empecher la propagation dans le voisinage. Sur ces 54 malades nous avons obtenu 46 
guérisons grâce croyons-nous à notre traitement. Beaucoup d'enfants eurent des 
paralysies du voile du palais ; 5 enfants eurent en plus de la Surdité qui chez un garçon 
de 12 ans dura plus de 6 semaines. 3 enfants eurent un écoulement sanieux du nez, SECTION X DISEASES OF CHILDREN. 
575 
dont une fille ayant de fausses membranes énormes. Enfin un garçon de 10 ans eut de 
la paralysie du nerf optique et une fille de 8 ans de la leucocythémie, Paralysie du voile 
du palais, albuminurie arythmie pendant 6 semaines. L'épidémie n'était donc pas 
bénigne. Le traitement que nous avons institué fut : Traitement externe, injection 
nasale, eau phéniquée à 2 pour cent. 4 fois par jour. 
Toucher les fausses membranes avec l'acide citrique au toutes les 4 heures. 
Gargarisme, eau phéniquée 2% Si le gargarisme était impossible lavage au pinceau 
trempée dans la solution d'acide phénique. 
Traitement interne. Adultes. Essence de Térébenthine, Capsules gélatineuses de 5 
Centigram et même de 10 centigr.-8 caps, par jour en 4 fois, nos 9 adultes malades 
supportèrent très bien ce traitement. Enfants. Chez eux nous avons toujours commencé 
par l'essence de térébenthine, en émulsion 30 centigrammes en émulsion dans jaune 
d'œuf No. 1. Sirop simple et eau de fleurs d'oranges 120 gr. par cuillereés à bouche 
toutes les heures. 
Si les enfants éprouvaient de la répulsion ou de la fatigue d'estomac nous donnions 
des pilules de Sulfure de Calcium de 1 centigramme No. 20 toutes les 3 heures 2 ou 3 
pii. Toutes les habitations ont été laveés a 1'hypochlorite de chaux, les murs et les 
escaliers avec un lait de chaux. 
Ses linges ont été trempés dans l'eau de Potasse et les crachats ont été brûlés, jetés 
au feu. 
Grâce au traitement institué assez facile a faire suivre aux enfants à partir de 1' 
âge de 2 ans, nous n'avons eu que 8 morts. Toutefois je ferai observer que ces cas se 
décomposent ainsi. 
3 enfants complètement rebellés à tout traitement. 
2 enfants morts de paralysie intestinale survenue chez l'un au 9e jour, alorsque tous 
les symptômes diphthéritiques étaient notablement amendés, et chez une autre environ 
8 jours après disparition des plaques. 
2 enfants étaient âgés de 8 jours, on sait toute la gravité de la diphtherie à cet âge. 
Enfin une fille de 8 ans était mourante à notre arrivée "Cette épidémie était carac- 
térisée par le manque des symptômes habituels de strangulation du croup à pas un des 
enfants morts, à l'exception de ceux rebelles à tout traitement, au nombre de 3, n'est 
mort par obstruction des voies respiratoires. La plupart de ces enfants sont forts mais 
lymphatiques, pas toujours très bien nourris. 
La relation de cette épidémie nous a paru intéressante à noter en ce que l'étiologie 
est nettement démontreé par le transfert d'habits contaminées et de plus le traitement 
institué par le Dr. Michaut et moi nous a donné des résultats tels que nous croyons 
devoir les soumettre à votre appréciation dans ces grandes assises de la science tenues 
en ce pays delibre discussion. 
DE L'HÉRÉDO-SYPHILIS ET DU RACHITISME AU BRESIL. 
ON HEREDITARY SYPHILIS AND RACHITIS IN BRAZIL. 
ÜBER DIE HEREDITÄRE SYPHILIS UND RACHITIS IN BRASILIEN. 
PAR LE DOCTEUR MONCORVO. 
Professeur de Clinique des Maladies de l'Enfance à la Policlinique de Rio de Janeiro. 
La syphilis fat avec toute probabilité introduite au Brésil par les premiers portugais 
qui sont venu l'habiter. La majorité de ces colons était représentée par des individus 
tirés des prisons ainsi que par d'autres condamnés au bannissement en ces lointains 
parages. Or, rien n'admet à croire qu'aucune mesure prophylactique fût prise depuis 576 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
dans le but de restreindre en quelque sorte la dissémination de la syphilis et sa transmis- 
sion par la voie de l'hérédité. Même plus tard, tant sous le domaine colonial qu'après 
la fondation de l'Empire Brésilien (1822) jusqu'à l'époque actuelle, aucun règlement 
de la prostitution ne fut décrété. Enfin pas une seule mesure hygiénique ne fut 
encore prise au Brésil dans le sens de mettre obstacle aux ravages de la syphilis. 
Dans de telles conditions tout doit porter à croire au prime abord à la fréquence exa- 
gérée de l'hérédo-syphilis au Brésil. En me bornant à mon observation faite à Rio de 
Janeiro et à la province du même nom, je me crois autorisé à affirmer que dans le 
tableau de la pathologie infantile la syphilis héritée figure au chiffre de 60 pour 100. 
Elle contribue puissamment à la déchéance physique, chaque fois plus accusée, de la 
majorité de la population brésilienne. Après l'impaludisme aigu ou chronique, c'est la 
syphilis héréditaire qui représente le rôle le plus important au milieu des causes de la 
mortalité de l'enfance, soit directement soit par la gravité qu'elle imprime à presque 
toutes les maladies qui affectent les jeunes sujets. Enfin elle constitue, à mon avis, le 
plus grand facteur qui entrave l'accroissement de la population au Brésil, soit par la 
mortalité des enfants, soit par les fausses-couches et les morts-nés dont le nombre pro- 
digieux est démontré par les statistiques. 
Aucune race n'est plus que l'autre à l'abri de la syphilis au Brésil. Toutes les 
manifestations caractéristiques de l'hérédo-syphilis soit récentes, soit tardives y sont 
sous tous les points de vue identiques à celles décrites par les auteurs européens et 
américains du nord. 
Le rachitisme se montre dans mes statistiques à la proportion de 45 pour 100, sur 
les enfants malades que j'ai eus sous mon observation. Cela montre l'improcédence de 
l'assertion de l'illustre Prof. Ch. West, au Congrès de Londres en 1881, lorsqu'il affirma 
que, tandis que la syphilis était fréquente au Brésil, le rachitisme par contre y était 
inconnu. Cette affection revêt au Brésil les mêmes formes que celles observées par les 
auteurs anglais, français, allemands et américains du nord. 
Plus de deux tiers des rachitiques que j'ai observés tant à Rio qu'aux différents 
endroits de la province du même nom, portaient les signes actuels ou anciens de l'héré- 
do-syphilis. D'autre part il est assez rare de trouver un enfant hérédo-syphilitique 
qui ne présente pas de la déformation rachitique des os, encore même qu'elle ne soit 
que trop légère. 
Le rachitisme au Brésil n'est point le privilège des enfants des classes pauvres; rien 
au contraire plus commun que de le retrouver chez ceux appartenants aux familles du 
rang même le plus élevé. 
Un examen approfondi des conditions étiologiques du rachitisme au Brésil, m'a 
fait voir que l'alimentation ne joue qu'un rôle secondaire pour sa production. Il est 
fort commun d'y voir un enfant sujet dès le début au régime le plus irrégulier sans la 
moindre trace de rachitisme, tandis que d'autres soumis à l'allaitement maternel, dans 
les meilleures conditions possibles, deviennent rachitiques. 
Sans la moindre prétention de vouloir trancher la question encore si litigieuse de 
Pétiologie du rachitisme, basée sur une observation déjà longue et attentive sur près de 
trois mille enfants rachitiques, je m'incline à voir dans l'hérédo-syphilis, sinon la cause 
invariable de cette affection osseuse, du moins celle qui contribue à la majorité des cas à 
sa production. 
Dans le traitement de la syphilis héréditaire précoce je donne la préférence à l'em- 
ploi de la liqueur de Van-Swieten et aux frictions avec l'onguent napolitain. Chez les 
enfants plus âgés je m'addresse au sirop de Gibert, au protoiodure et au tannate 
d'hydrargyre. Les iodures de potassium ou de sodium s'ajoutent avec le plus grand 
profit à ces derniers notamment dans les cas de complications de lésions viscérales. 
Pour ce qui concerne la thérapeutique spéciale du rachitisme j'ai essayé dans un 
certain nombre de cas aux diverses périodes de son évolution le traitement par le phos- SECTION X-DISEASES OF CHILDREN. 
577 
phore proposé par M. Kassowitz, et, à l'exception d'une modification favorable du côté 
de la nutrition générale, je n'ai pu constater jusqu'ici aucune modification aussi 
prompte ni aussi appréciable des conditions osseuses, comme l'a fait observer le savant 
Prof. Viennois. 
TRAITEMENT DES TUMEURS ÉRECTILES PAR L'ÉLECTROLYSE. 
TREATMENT OF ERECTILE TUMORS BY ELECTROLYSIS. 
BEHANDLUNG DER ERECTILEN GESCHWÜLSTE DURCH ELECTROLYSE. 
Chirurgien du Dispensaire Furtado-Heine. 
PAR LE DR. P. REDARD, 
Un nombre considérable de méthodes ont été proposées pour le traitement des 
tumeurs érectiles et cirsoïdes. Après avoir expérimenté les différents procédés théra- 
peutiques recommandés, nous sommes convainçus que V électrolyse est la méthode de 
choix qui présents sur ses concurrentes une supériorité incontestable. 
Si l'on cherche cependant des observations sur ce sujet, on voit que depuis 1882, 
époque à laquelle Ciniselli de Crémone publia sa première observation de guérison de 
tumeur érectile par l'électrolyse, très peu de chirurgiens ont eu recours à ce puissant 
procédé. 
Quelques spécialistes électriciens ont toujours recours à l'électrolyse, la majorité des 
chirurgiens se servent de preuves rares qui sont quelquefois insuffisants et dangereux. 
Les causes de l'abandon de l'électrolyse sont multiples : la méthode paraissait com- 
pliquée, les appareils électriques étaient imparfaits, d'un prix élevé, les galvanomètres 
d'intensité ne permettaient pas d'apprécier exactement l'intensité des courants. On 
accusait l'électrolyse d'être un traitement très long et surtout très douloureux, on 
pensait qu'elle pourait produire des eschares, des cicatrices vicieuses, des suppurations 
prolongées. 
Les auteurs n'étaient pas fixés sur la pratique de l'opération et à l'exemple de 
Ciniselli appliquaient la méthode d'une façon empirique tantôt plongeant deux aiguilles 
dans la tumeur, tantôt une seule, se servant de courants trop faibles ou trop forts, pro- 
duisant de véritables destructions des tumeurs traitées au lieu de décomposition des 
tissus avec atrophie vasculaire. 
Le but de cette communication est de démontrer que l'électrolyse est la méthode 
de choix pour le traitement de toutes les tumeurs érectiles qui permet grâce à une 
technique opératoire reguliere, d'obtenir, et sans aucun accident, des guérisons rapides. 
Nons voulons surtout démontrer que l'électrolyse est pratique et que tous les médecins 
peuvent l'exécuter avec facilité et sécurité. 
Nous avons déjà traité plus de soixante cas de tumeurs érectiles par l'électrolyse soit 
dans notre service du Dispensaire Furtado-Heine soit dans notre clientèle. Plusieurs 
des tumeurs présentaient un volume considérable, avec dilation vasculaire très 
notable, quelques unes des tumeurs avaient déjà été traitées sans succès par d'autres 
procédés. M. le Dr. Dubois de Gonzae qui avait assisté à nos opérations de l'hôpital 
nous a adressé de très importantes observations sur ce sujet. 
Nous regrettons de ne pouvoir donner ici ces observations en détail. Nous citerons 
seulement le cas d'une tumeur érectile très volumineuse de la face interne de la joue 
gauche, traitée sans succès par des cautérisations ignées répétées et que nous avons 
guérie par 8 séances d'électrolyse. 
Vol. Ill-37 578 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
L'appareil instrumental nécessaire pour la pratique de l'électrolyse est des plus 
simples. Une pile à courants continus fonctionnant régulièrement, particulièrement 
celles de Gaiffe, de charderi, un galvanomètre d'intensité bien gradué, des aiguilles en 
or ou en platine de | millimètre de diamètre et de 8 à 10 centimètres de long les 
aiguilles doivent être acérées, afin de s'introduire facilement et sans résistance, dans 
la tumeur. 
L'enfant doit être soigneusement immobilisé. L'emploi du chloroforme ne nous 
paraît pas nécessaire. La durée des séances ne devra pas être prolongée, l'opération 
étant moyennement douloureuse. 
Trois procédés peuvent être employés pour l'introduction des aiguilles :- 
1° A l'exemple de Ciniselli et de la plupart des auteurs, les deux aiguilles sont 
introduites dans la tumeur à peu de distance l'une de l'autre (Ciniselli, Bœckel, Lin- 
coln, Knott, Duncan, Delore, Voltolini) ; 
2° L'aiguille positive seule est plongée dans la tumeur, l'autre pôle sous forme de 
plaque étant placé sur un point quelconque du corps (Monoyer, H. Pitoy) ; 
3° L'aiguille négative seule est placée dans la tumeur (Altbaus). 
Le choix du procédé d'introduction des aiguilles a une influence considérable sur le 
résultat opératoire et nous désirons insister sur cette partie de notre communication. 
Une connaissance plus parfaite des actions électrolytiques nous permet d'apprécier 
exactement aujourd'hui l'action produite par les aiguilles sur les tissus vasculaires. 
Nous savons qu'au' pôle positif se produit une action chimique intense que des 
caillots durs, résistants, adhérents aux parvis se forment dans les vaisseaux et les obli- 
tèrent, les tissus se rétractent et se décomposent, il ne se produit pas d'eschares, la 
peau est respectée. 
Au pôle négatif au contraire, il y a véritable destruction et cautérisation des tissus 
avec eschare consécutive, les caillots formés sont mous et diffluents. 
D'après cela, il est facie de comprendre les avantages et inconvénients suivant que 
l'on plonge une ou les deux aiguilles dans la tumeur. 
Au début de nos opérations nous nous servions des deux aiguilles placées dans la 
tumeur. Les résultats étaient certainement satisfaisants, mais nous avions souvent 
des hémorrhagies au niveau des piqûres, et des eschares avec des cicatrices consécu- 
tives. 
Dans le procédé l'aiguille négative doit être changée plus souvent de place que 
l'aiguille positive, sous peine de voir se produire une eschare quelquefois assez impor- 
tante avec suppuration consécutive. Les courants employés doivent être plus intenses 
que lorsque l'on emploie l'aiguille positive seule. 
Les eschares ne peuvent être évitées, l'emploi d'aiguilles spéciales permettant l'isole- 
ment au niveau de la peau ne nous a jamais donné de bons résultats. 
Les inconvénients de l'introduction des deux aiguilles doivent faire rejeter ce 
prouvé dans la plupart des cas surtout lorsqu'il s'agit de tumeurs siégeant sur la face, 
ou les cicatrices doivent être soigneusement évitées. Nous conservons cependant le 
prouvé dans quelques cas exceptionnels de tumeurs voluminaires, ne siégeant pas sur 
la face, lorsque nous désirons obtenir une destruction rapide, la rétraction produite 
à la chute des eschares accompagne des guérisons souvent rapides. 
La piqûre au moyen de l'aiguille positive seule nous paraît surtout devoir être 
recommandée. Le pôle négatif sons forme de plaque doit être placé aussi près que 
possible de la tumeur, quelquefois à la partie supérieure du bras. 
L'aiguille doit être plongée obliquement à la périphérie de la tumeur, nous recom- 
mandons de placer quatre aiguilles à la fois reliées par de courts fils au fil principal de 
la pile. On obtient ainsi une action simultanée et rapide en plusieurs points de la 
tumeur. Les aiguilles doivent être laissées en place deux à quatre minutes et réappli- 
quées ensuite en d'autres points. Le courant employé doit être de 12 à 20 milliam- 
pères. SECTION X DISEASES OF CHILDREN. 
579 
Les séances qui doivent être de cinq à six minutes peuvent être rapprochées et faites 
tous les huit jours. 
Le temps nécessaire à la guérison varie nécessairement suivant l'étendue de la 
tumeur, dans les cas oh la tumeur avait le volume d'un petit œuf, quatre à cinq séances 
nous ont suffi pour obtenir une guérison parfaite. Une à deux séances suffisent pour 
les petits nævi-vascul aires. 
Dès la première séance, surtout si l'on emploie quatre aiguilles à la fois, la tumeur 
blanchit, durcit très notablement, la circulation diminue, et à la deuxième séance les 
modifications obtenues sont déjà très importantes. Dans les cas de tumeurs cirsoïdes, 
lorsque des vaisseaux volumineux s'observent à la périphérie delà tumeur, l'aiguille 
doit être plongée obliquement dans l'axe des vaisseaux et laissée en place une à deux 
minutes. 
Au début de nos recherches nous avions presque toujours un écoulement sanguin au 
moment où nous retirions notre aiguille. Le caillot adhérait, en effet, à l'aiguille posi- 
tive, une partie de ce caillot déplacé et arraché permettait au sang de la tumeur de 
s'écouler par la figure extérieure. 
Plus tard nous avons pu éviter à coup sûr toute hémorrhagie. Il suffit, en effet 
avant de retirer l'aiguille, de renverser le courant pendant quelques secondes et de ra- 
mener à zéro. 
L'aiguille ne doit être enlevée que lorsque l'on n'éprouve plus aucune résistance. 
La peau qui recouvre la tumeur conserve son apparence à peu près normale, dans 
les tumeurs érectiles de la face, ou n'observe jamais de cicatrices. 
La douleur notée au moment du passage du courant est supportable. En se servant 
de courants modérés on évite les mouvements des courants traversant une partie sacrée 
du corps. Il faut éviter, surtout si l'on opère au voisinage du crâne, de dépasser 25 à 
30 milliampères. 
Avec le procédé de figure avec deux aiguilles, ces chiffres peuvent être très notable- 
ment dépassés. 
On doit dans tous les cas diminuer progressivement l'intensité du courant et éviter 
toute secousse. 
La durée des séances ne doit pas dépasser cinq à huit minutes. 
Nous recommandons enfin de désinfecter avec grand soin les aiguilles, avec de l'éther 
ou par le flambage. 
Comme conclusion nons dirons : 
L' electrolyse est la méthode de choix dans le traitement des tumeurs érectiles. Elle réussit 
toujours, là où d'autres méthodes ont échoué. 
Grâce à une technique opératoire régulière, Vélectrolyse met à l'abri de tout accident 
d'eschare, de suppuration, de cicatrice, etc. 
Elle permet d'agir avec sûreté et précision. La monopuncture positive doit être employée 
dans la grande majorité des cas. 580 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
NOTE SUR L'IMPALUDISME CHEZ LES ENFANTS AU BRÉSIL. 
NOTE ON THE MALARIA OF CHILDREN IN BRASIL. 
BEMERKUNG ÜBER DIE MALARIA BEI KINDERN IN BRASILIEN. 
PAR LE DOCTEUR MONCORVO. 
Professeur de clinique des maladies de l'enfance à la Policlinique de Rio de Janeiro. 
Dans le tableau pathologique de la ville de Rio de Janeiro, capitale de 1'Empire 
du Brésil, l'une des affections qui dominent d'une façon plus accusée et qui contribuent 
de beaucoup à l'augmentation de la mortalité à de certaines époques de l'année, c'est 
sans contredire l'infection malarique. 
Mon observation personnelle faite sur plusieurs milliers d'enfants de cette ville 
m'autorise à affirmer que ce fléau sévit d'une façon plus accusée tant par sa fréquence 
que par sa gravité pendant toutes les périodes de l'enfance. De fait la malaria atteint 
les enfants de tous les âges, sa gravité étant à la raison inverse de ceux-ci. Les nou- 
veau-nés sont eux-même les victimes les plus communes de l'infection, car chez eux, 
bien plus souvent qu' à toute autre époque de la vie, la malaria se cache très souvent 
sous des formes bizarres et insidieuses aux yeux de l'observateur peu expérimenté. 
D'une façon générale toute élévation de la chaleur cutanée qui ne dépasse guère 
38° ou 38.5°, reste aisément inaperçue chez les petits sujets qui sont encore emmail- 
lotés dans des langes. Des légers accès se présentent et se succèdent parfois plusieurs 
jours de suite sans que la mère ou la nourrice s'en rendent compte, notamment lorsqu' 
ils survienent dans la nuit, ce qui est très fréquent. Bref un accès grave éclate, la 
chaleur monte à 39°, 40° et même plus, le système nerveux central se prend et le 
petit malade ne résiste guère à la majorité des cas à l'explosion très bruyante de cette 
infection qui minait en cachette sa santé depuis un temps plus ou moins long. Cette 
méprise devient fort commune dans les familles qui ne font point usage du thermom- 
ètre aussitôt que quelque altération de la santé de l'enfant est soupçonnée. Rien de 
plus trompeur que le cortège des symptômes ou mieux les formes que revêt la malaria 
chez les petits enfants qui n'ont pas encore atteint la première année. Dans un grand 
nombre de cas tout se borne à un changement de caractères du petit patient qui pâlit, 
a des selles grumeleuses et catarrhales plus ou moins fréquentes, perd l'appétit, vomit 
souvent le lait, mais la température de la peau semble normale notamment aux parties 
ordinairement examinées, c'est à dire, la face et les extrémités. Mais si on tâche de 
prendre à plusieurs reprises la température rectale, on la trouve augmentée soit dans la 
journée, soit dans la nuit. Dans le premier cas cette augmentation de la chaleur coïn- 
cide d'habitude avec un abattement général plus ou moins accusé, voire même du 
sommeil anormal, le refroidissement (pas constant du reste) des extrémités et finit très 
souvent par l'apparition de sueurs à la tête, au cou, parfois au tronc et bien plus rare- 
ment généralisées. C'est là le tableau symptomatologique qui précédé ordinairement 
de quelques jours et parfois de quelques semaines l'éclosion d'un accès pernicieux si on 
ne parvient pas à temps de l'empêcher en soumettant dès le début le petit malade à 
l'usage de la médication spécifique, c'est à dire, la quinine. 
Rien de plus irrégulier que le type de la fièvre paludéenne chez les tout petits sujets ; 
les types classiques ne s'observent que rarement chez eux. Ces accès se répètent souvent 
plusieurs fois dans les vingt-quatre heures et ne gardent point de l'uniformité dans 
quelques jours consécutifs. Aussi lorsque la fièvre est franchement intermittente il est 
rare qu' on observe la suite classique des trois états, de frisson, chaleur et sueur. 
Un des éléments les plus utiles dans d'autre pays pour le diagnostic de la malaria à 
toutes les périodes de la vie, l'hypertrophie de la rate, s'observe ici bien plus rarement, SECTION X-DISEASES OF CHILDREN. 
581 
chez les adultes, que celle du foie ; chez les tout jeunes enfants au contraire, l'augmen- 
tation du foie constitue la règle, notamment dans le cas d'infection aiguë. Ceux donc 
qui veulent se baser sur ce signe pour établir chez les tout jeunes sujets le diagnostic de 
la malaria aiguë, tombent presque souvent en erreur ne la reconnaissant point et 
exposant de la sorte la vie de leurs petits malades. 
Lorsque l'enfant a dépassé les cinq ou six premiers mois les mères au temps que les 
médecins peu expérimentés veulent souvent voir dans les manifestations sus-indiquées 
l'expression d'une dentition pénible, ce qui est bien peu acceptable aujourd'hui, alors 
que la presque majorité des cliniciens s'accorde sur l'exagération du rôle qu' on avait 
fait jouer jusqu' ici à cette fonction naturelle par rapport aux maladies du premier âge. 
Dans d'autre circonstances la malaria s'accompagne d'une inflammation viscérale 
laquelle masque tellement son origine qu'elle est souvent prise par une maladie pure- 
ment locale et protopathique. La bronchite aiguë ou subaiguë, la broncho-pneumonie, 
la méningite, l'entérite reconnaissent très fréquemment pour cause à Rio l'intoxication 
paludéenne. Les symptômes de ces phlegmasies là s'imposent fort à l'attention du clin- 
icien pour la détourner de leur nature infectieuse. Cette méprise entraînera les plus 
fâcheuses conséquences, car en l'absence du traitement spécifique il est rare de voir une 
terminaison heureuse. 
Beaucoup d'autres formes peuvent être encore observées, quelques unes tellement 
bizarres et même bénignes en apparence, qu' une très grande sagacité devient nécessaire 
de la part du médecin pour les rattacher à leur cause vraie. Sans l'intervention 
prompte et active de la quinine la mort peut survenir parfois au bout d'un jour et de 
quelques heures même. La forme syncopale, celle congestive cérébrale ou pulmonaire, 
celle cholériforme, l'algide, tels sont les types les plus communs de l'impaludisme 
aigu larvé. 
L'intoxication malarique chronique domine plus particulièrement chez les sujets qui 
ont déjà dépassé la deuxième année. Elle compromet fort la nutrition et l'évolution 
de l'organisme de l'enfant en l'exposant par cette déchéance physique à une extrême 
réceptivité morbide. 
Dans ces conditions la malaria agit d'une façon toute particulière sur l'appareil 
digestif ; depuis la plus légère dyspepsie jusqu' aux diarrhées les plus graves et les 
plus réfractaires (séreuses, bilieuses ou lientériques) on peut observer toutes les nuances 
des phlegmasies gastro-intestinales chroniques. Parfois celles-ci s'accompagnent de 
légers accès fébriles survenus à des intervalles fort variables. 
Dans la majorité des cas les diarrhées chroniques encore même qu' elles soient pré- 
cédées de fièvre à type intermittent ou rémittent n'engendrent plus à la suite la moindre 
élévation de la chaleur, mais elles offrent souvent ceci de particulier : qu' elles 
surviennent à un certain moment du jour ou de la nuit étant quelquefois précédées ou 
suivies d'évacuations tout à fait normales. Ces sortes de diarrhées maremmatiques 
suivent d'ordinaire une marche très lente et résistent presque invariablement à tout 
autre traitement que celui par les sels de quinine. 
Dans une communication faite à l'Académie des Sciences de Paris en 1884 sur la 
température de la paroi abdominale dans les cas de diarrhée chez les enfants, je fis voir 
la coïncidence et la corrélation qu' il y avait entre la marche du flux et la chaleur du 
ventre, celle-ci montant de 35° à 37.5° et s'abaissant parallèlement avec le retour des 
selles à ses conditions physiologiques. 
Bien plus communément que dans les cas aigus l'impaludisme à marche lente 
s'accompagne de la congestion du foie, mais il n'est pas aussi fréquent de retrouver la 
sclérose hépatique chez les jeunes sujets infectés que chez les adultes dans des pareilles 
circonstances. Dans les endroits marécageux pas très éloignés de Rio où la malaria 
sévit endémiquement, le sang des enfants qui y restent subit bientôt une profonde altéra- 
tion, consistant notamment dans la destruction des hématies. L'œdème partiel ou 582 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
généralisé, l'ictère, la pâleur extrême de la peau et des muqueuses sont les consé- 
quences de l'hydrémie et de l'hypoglobulie. Ces enfants présentent un aspect très 
caractéristique de la dystrophie malarienne. Chez eux il est d'ailleurs très commun de 
retrouver l'ectasie gastrique consécutive à une gastropathie due parfois exclusivement 
à cette infection. Ce fait que j'ai été le premier à signaler en 1882, à été largement 
observé par moi et par mes élèves. 
Une circonstance que je ne pourrai manquer de signaler par rapport à l'impaludisme 
aigu chez les enfants, c'est sa fréquente coïncidence avec les fièvres exanthématiques, 
de façon à en obscurcir la marche cyclique. Dans d'autres cas la fièvre palustre éclate 
pendant la période terminale de l'exanthème lui prêtant en apparence une marche 
irrégulière et inattendue ; de sorte qu' à une fièvre éruptive bénigne et à marche régu- 
lière dont la terminaison favorable est justement prévue, survient parfois une nouvelle 
et brusque ascension thermique avec d'autres symptômes graves, et le petit malade 
succombe souvent à cette rechute apparente, qui n'est en réalité qu'un accès pernici- 
eux greffé sur la maladie antérieure. Il faut être prévenu contre cette possible coïnci- 
dence pour sauvegarder la vie de ces petits malades au moyen du traitement quinique 
employé à temps. Dans le traitement de l'impaludisme chez les enfants, l'agent vrai- 
ment spécifique est, comme pour celui des adultes, la quinine. 
Pour ce qui concerne les fièvres malariques, mon guide pour le dosage de cette 
substance est non seulement l'âge de l'enfant, mais surtout l'intensité de la fièvre ou 
la gravité des symptômes qui l'accompagnent. Tout d'abord je dois signaler que les 
enfants (au Brésil du moins) présentent une très grande tolérance pour la quinine, 
relativement bien plus accusée que chez les adultes ; c'est donc sans raison d'être la 
crainte qu 'ont les médecins peu expérimentés en pathologie infantile d'administrer à 
leurs petits malades des doses quelque peu élevées. C'est ainsi que je ne reste presque 
jamais au deçà de 25 centigrammes par jour dans les cas les plus bénins, et je monte 
à plusieurs grammes dans les cas graves, sans m'inquiéter beaucoup de l'âge de mon 
petit patient. Quand le cas est pressant par sa gravité actuelle ou attendue, je 
m'adresse presque invariablement à la méthode hypodermiqne pour l'administration 
du sel de quinine, car il ne faut compter que trop rarement dans ces conditions sur la 
tolérance gastrique et encore moins sur celle de l'intestin. Je dois ajouter que les 
injections faites profondément et avec tout le soin antiseptique n'engendrent presque 
jamais le moindre accident. J'en ai fait cinq mille environ et c'est à peine si dans 
quelques cas assez peu nombreux, de petits abcès se sont succédé ; même dans ces cas 
le traitement a réussi. 
Parmi les sels de quinine j'emploie de préférence le chlorhydrate, tant par sa solu- 
bilité que par sa plus grande proportion d'alcaloïde. 
Dans les cas d'hyperthermie je m'adresse à l'emploi simultané de l'antipyrine dont 
j'ai constaté les effets remarquables sur plus de 200 enfants avec la plus parfaite 
tolérance. 
Dans les cas d'impaludisme chronique je recours aussi à l'emploi de l'arsenic, auquel 
je m'adresse également comme le complément du traitement quinique de l'intoxication 
aiguë. Enfin, mon observation personnelle m'engage à voir dans l'arsenic un très bon 
moyen prophylactique contre l'empoisonnement malarien. SECTION X-DISEASES OF CHILDREN. 
583 
SCARLATINAL NEPHRITIS. 
NEPHRITE SCARLATINE. 
DIE SCHARLACHNEPHRITIS. 
BY HENRY ASHBY, M.D., M.R.C.P., 
Physician to the Hospital for Sick Children, Manchester, and Lecturer on Diseases of Children, Owens 
College. 
> 
There is no disease which presents so many complications and sequelæ as does scarlet 
fever, and no one of these is of greater interest and importance than the albuminuria 
which so frequently attends its febrile stage or follows on during the weeks of conva- 
lescence, when the fever itself has spent its force. Much has been written on the sub- 
ject, and many observations have been made, both in the wards and the dead-house, 
which have helped to elucidate it, but notwithstanding this, it appears to me that most 
of the recent writers have ignored some of the principal points and confused together 
forms of the disease which are essentially distinct. Some confusion has also apparently 
arisen by keeping the clinical and pathological observations too much apart, the work 
in the laboratory being done in ignorance of the symptoms presented during life. 
It would be out of place for me to attempt to present to the International Congress 
an exhaustive paper on scarlatinal albuminuria which shall include an account of the 
work done by all observers who have made the subject their study. All I hope to do 
is to present as concisely as I can an account of my own observations; in short, a picture 
of scarlatinal nephritis as I have seen it, both in the wards and in the post-mortem room. 
That it must be short and concise, must be my excuse for many errors of omission and 
for much being omitted which I would gladly have found a place for. My own expe- 
rience has been gained in the fever ward of the Hospital for Sick Children, Pendlebury, 
Manchester, where, during the past eight years, upwards of 1500 cases of scarlet fever 
have been under my care. 
Following Friedlander, we may divide the subject into three divisions, in the follow- 
ing way:- 
1. The "initial albuminuria," which is frequently present during the first few 
days when the fever is high, and which, in uncomplicated cases, disappears as the fever 
subsides. 
2. The albuminuria which is often present during the second and third weeks 
(though it may have existed from the first), in those cases where the fever is maintained 
in consequence of the foul state of the fauces and the presence of glandular inflamma- 
tion. In these cases the albumen in the urine is associated with changes in the kidneys 
of a septic character. 
3. The albumen which comes on during convalescence-usually after an interval of 
apyrexia-though it may supervene in cases where the fever has been maintained in 
consequence of various complications. The usual time is from the sixteenth to the 
twenty-fourth day; in its typical form it is accompanied by oedema, with blood casts 
and epithelial débris in the urine. 
(1) Concerning the initial albuminuria there is but little to be said; albumen is 
absent in the urine of mild cases with but slight or transient fever, and often present 
in traces or moderate quantities in the deeply colored, highly concentrated urine of 
those cases where the fever (103°-105°) runs high. It is, however, absent in some 
rapidly fatal cases, just as it is absent in some malignant cases of diphtheria. I have 
never seen blood in sufficient quantities to give the urine a red or smoky appearance in 
the early stages. This "febrile albumen" is present in typhoid fever, pneumonia, 
erysipelas, as well as in the early stages of scarlet fever, and is probably due to the 584 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
same cause in all these instances, whether to changes in the nutrition of the epithelium, 
consequent on the febrile state, or in some changed pressure in the capillaries. An 
examination of the kidneys in fatal cases of scarlet fever during the first few days or 
week does not show, according to my experience, any gross changes. The cortex and 
surface of the kidneys are pale, resembling in this respect the pallid appearance of the 
liver and heart muscle, due to the cloudy condition of the epithelial cells, which appear, 
under a high power, to be more granular than usual. The microscope also shows con- 
gested capillary vessels, coagulated albumen in the tubules, a slight extravasation of 
leucocytes here and there around the capillary veins, and an increase of the nuclear ele- 
ments in the glomeruli and capillaries. 
2. During the second and third weeks, in those cases where there are sloughy throats, 
cellulitis and adenitis, albumen is mostly present in the urine in variable quantities, 
though often there is not more than a distinct trace present and never in quantities 
approaching to what is sometimes seen in post-scarlatinal nephritis. I have not seen 
blood present in sufficient quantities to tinge the urine, but that blood is not infre- 
quently present is shown by the careful testings of Stevenson Thomson, and the micro- 
scopical examination of the kidneys in fatal cases shows that minute hemorrhages take 
place into the tubules. Epithelium, fibrinous or blood casts are not, or only exception- 
ally, present in such cases. (Edema or puffiness about the face is likewise absent, unless 
the post-scarlatinal variety to be described shortly supervenes. The post-mortem 
changes found in the kidneys in these cases varies considerably, being least marked in 
those dying early in the disease, and best marked in those who have died toward the 
end of the third week, where the fever has been high, the fauces sloughing, and there 
has been much suppuration and inflammation of the glands and the tissues around. In 
the former case the kidneys do not appear much changed to the naked eye, except 
some pallor and injection of the vessels, and the microscopical changes found are those 
already mentioned, namely, effusion of leucocytes around the capillary vessels and glo- 
meruli, some exudation of albuminous matters into the capsular space, cloudy swelling 
of the epithelium and increased nuclei in and around the glomeruli. In the latter case 
the changes are often very striking. The kidneys are enlarged; thus in a girl of 2| 
years, who died on the twentieth day, they weighed 14 ounces (heart, 3| ounces; spleen, 
3 £ ounces); in a boy of 5J years, 9| ounces; in another of 3 years, 8 J ounces. They are limp 
and flabby, pale or of a cream color, the surface is mottled with minute hemorrhages and 
injected capillary vessels. On section the cortex is increased in width and of the same 
mottled appearance as the surface; the pyramids show marked injection of their vessels. 
In some cases minute abscesses or cheesy spots are seen at the base of the pyramids and 
extending along the interlobular vessels into the cortex. These abscesses vary in size 
from a pin's head to a split pea. On examining sections microscopically under a low 
power, the most striking features are the masses of leucocytes which surround an inter- 
lobular vein or artery and the glomeruli supplied by it. Sometimes whole tracts of 
kidney are infiltrated with leucocytes, and the glomeruli which are surrounded have 
undergone hyaline degeneration. The capillaries are often dilated, tortuous and gorged 
with blood; small hemorrhages have taken place between and into the tubes; often there 
are some leucocytes and amorphous-looking matter in the capsular space around the 
glomeruli. The epithelium is notably changed, being coarsely granular. In a few 
cases micrococci-laden emboli are present in the vasa recta or capillary vessels. All these 
changes are undoubtedly septic in character, being the result of the inflammatory 
lesions taking place about the throat, septic materials being transferred from the pri- 
mary source, by means of the circulation, to the kidneys. The inflammation starts from 
a number of foci, and is not a general inflammation, as is the post-scarlatinal variety; as 
a consequence, the kidneys rarely become choked and entirely obstructed, and, more- SECTION X-DISEASES OF CHILDREN. 
585 
over, death usually takes place in consequence of the general septicæmic state, perhaps 
independently of or only assisted by the kidney lesion. 
I have already referred to the albumen in the urine during life being usually mod- 
erate in quantity and unaccompanied by blood to any extent, casts or epithelium. Are 
there ever any definite and distinctive symptoms of kidney disease apart from the pres- 
ence of albumen ? In connection with the urine, it must be said that children so suffer- 
ing are acutely ill, and, especially in the younger ones, it is impossible to measure the 
quantities passed; often the whole of the urine is passed in bed and cannot be saved for 
examination. 
It is well in all cases where septic kidneys are suspected to test the urine daily for 
the coloring matter of the blood, by means of tincture of guaiacum and a solution of 
peroxide of hydrogen, for blood may be present in quantities too small to be detected 
by the eye, and if present, it is exceedingly probable that a septic nephritis exists. 
While death in the majority of such cases appears to be due less directly to the kid- 
ney lesion than to the general state of septicaemia, the kidney lesion being part only of 
a general septicæmic state, yet in exceptional cases symptoms of irritation of the kid- 
neys may be present, to be followed by complete suppression of urine and death from 
a choked kidney. In a few cases I have known the temperature to be maintained dur- 
ing the second week, in consequence of excessive glandular inflammation, but the tem- 
perature has continued elevated after the subsidence or improvement of the lesions 
about the neck, without any local cause being discovered. The fauces, the cervical 
glands, the middle ear, the lungs may be searched in vain for the cause of the fever, 
and the event may prove that a septic inflammatory condition is in progress in the 
kidneys and leads to a fatal result. In such cases I have noted excessive quantities 
of urine passed, 40-90 ounces, of low specific gravity 1004-1008, and containing small 
quantities of albumen, but no deposits of either coloring matter of blood or casts, to be 
followed suddenly, at the end of the third week, by almost complete suppression of urine, 
death following in a few days, with uræmic phenomena. Dr. Dreschfeld tells me his 
experience has been somewhat similar. 
Case I.-In one of my cases somewhat similar to the above, which died on the 
twenty-first day, the death was immediately brought about by suppression of urine, 
though the sloughy condition of the throat and septic pneumonia present made it clear 
that life would not have been long prolonged in any case. The kidneys were enlarged, 
pale and flabby, whole tracts of the kidney were infiltrated with leucocytes, and minute 
hemorrhages had taken place, both inter- and intra-tubular, apparently effectually chok- 
ing the kidney and preventing its normal function. 
In the vast majority of cases, however, septic inflammation of the kidneys gives no 
symptoms which can be differentiated from those of the general septic infection. There 
is no general inflammatory congestion, but rather numerous points of inflammation, 
sufficient fairly normal kidney structure being left to carry on the functions, and con- 
sequently there is no general oedema, diminished urine or uræmic symptoms. It is 
only when the inflammatory lesions are more than usually extensive, or some sudden 
hemorrhage takes place, that suppression of urine arises. 
3. Post-Scarlatinal Nephritis.-It is the nephritis which occurs during convalescence 
which is best known, and surpasses all the forms in interest and importance. Septic 
nephritis accompanies and is practically lost in a general septicæmia; post-scarlatinal 
nephritis either supervenes in an apparently healthy individual, or sets in as the last and 
fatal complication in a patient who has had a severe attack, and is apparently just over 
the worst. This form of nephritis has been described as 1 ' tubal, " " acute desquamative, ' ' 
or ' ' catarrhal nephritis, ' ' but the term post-scarlatinal sufficiently identifies it without 
committing to any notion as to its pathology. The term " desquamative " is especially 
bad, inasmuch as the shedding of the epithelium is a purely mechanical act, the result 586 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
of the fibrinous cylinders being forced along the tubules by the force of the urine 
behind. The albuminuria usually conies on from the fourteenth to the twenty-sixth 
day, i.e., during the third or fourth weeks, or at least appears in larger amounts than 
before, as albumen is frequently present, as already considered, during the first and 
second weeks, and the post-scarlatinal variety is apt to supervene in cases of a mild septic 
character, which are on their way to recovery. There can hardly be a doubt that 
during the attack of scarlet fever, even in mild cases, the kidneys undergo irritation in 
separating the poison from the blood, and are left, like the lungs after measles, in a condi- 
tion in which they readily take on inflammation of a fibrinous or croupous type. In both 
cases the pneumonia or nephritis may follow mild attacks, but the experience of hospital 
practice shows that where reasonable care is taken, the mild cases rarely suffer from 
nephritis, at least in its severer forms; the worst and most fatal cases are those where 
the nephritis supervenes on a severe and prolonged attack of the primary fever, where 
there has been much exudation about the fauces and glandular inflammation. The 
severity of the attacks vary immensely ; sometimes they are so mild that they might 
easily escape the attention of a casual observer. A slight puffiness of the face and a 
small quantity of albumen in the urine may be all there is to notice, both disappearing 
in the course of a few days or weeks. On the other hand, the attack may be sudden- 
an acute inflammatory congestion taking place, to be quickly followed by uræmic symp- 
toms. In the majority of cases, the two earliest and most characteristic symptoms are 
puffiness of the face, and a diminished quantity of urine; these may be present before 
any albumen can be detected in the urine. I have often noticed, in passing round the 
wards, a slight pallor or puffiness of the face in children who had no albumen, but in 
whom albumen appeared in a few days. The gradually diminishing amount of urine 
passed has frequently called my attention to a case of commencing nephritis. An 
evening rise in the temperature is often present, to become normal again in the morning; 
a rise in the temperature is frequently followed by the passage of bloody urine, as if a 
temporary congestion of the kidneys had taken place, which was relieved by the transu- 
dation of blood into the urine; the following evening, perhaps, a repetition takes place, 
the blood disappearing or is in diminished quantity during the period in which the tem- 
perature is normal. The temperature becomes sub-normal in uraemia. The amount of 
albumen present varies considerably; there may be none, or the urine may set solid on 
•boiling; the specific gravity is apt to vary also; it is mostly from 1010-1020. Nephritic 
urine on standing usually deposits a precipitate which resembles the flocculent deposit 
of beef tea, and which consists of epithelial débris, blood corpuscles, and fibrinous casts 
of the tubes. The urine diminishes still more, perhaps only a few drops to a few ounces 
being passed; oedema of the face and extremities, vomiting and other uræmic symptoms 
follow, when suddenly a crisis like that of pneumonia takes place; large quantities of 
smoky urine (2000 to 4000 cc.) of low specific gravity are passed, the oedema quickly 
disappears and the patient is convalescent again. 
The following case illustrates such attacks:- 
Case ii.-Scarlet Fever, Nephritis Uraemia.-B. 92, Frank B., aged eight years. First 
day, sore throat; second day, rash; admitted August 1st, 1882. Third day of illness, 
pulse 120; temperature 102°-104°; moderate rash; tonsils congested and covered with 
secretion; rash disappeared seventh day; temperature remained 100°-101° till sixteenth 
day, rose to 102.8°, and the urine became dark brown with much deposit, and contained 
blood corpuscles and fragments of epithelial casts; passed 250 cc., averaged 800 cc. pre- 
vious week. Seventeenth day, pulse 80 ; temperature 99°-l02°; urine 350 cc.; spe- 
cific gravity 1015; dark brown; about one-third albumen; many casts; vomited three 
times; pulv. jalapse co. mist. pot. citr. Eighteenth day, temperature 98°-100°; urine 
100 cc.; ext. jaborandi liq., ifi, xx, and packs at 110° repeated several times; pulv. 
fol. jaborandi, gr. v. st. ; moderate perspiration. Nineteenth day, pulse 68; temperature SECTION X-DISEASES OF CHILDREN. 
587 
98°-99°; urine 175 cc. ; smoky, with dark-brown flocculi; specific gravity 1015; one- 
third albumen; two packs at 110°, preceded by pulv. fol. jaborandi, gr. x. ; fair per- 
spiration. Twentieth day, 300 cc. of urine; specific gravity 1013; one-third albumen; 
jaborandi and packs. Twenty-first day, much headache; sweated profusely after 
jaborandi; passed 450 cc. ; specific gravity 1010, and one-fourth albumen; systolic bruit 
at apex. Twenty-second day, temperature 98°-102°; much headache; no sleep; 
vomited; urine 750 cc. ; specific gravity 1008. Twenty-third day, uraemic convulsions; 
muscular twitchings; foaming at mouth; convulsions arrested by chloroform. Twenty- 
fourth day, urine 250 cc. ; specific gravity 1012; still smoky, but less blood; no return 
of convulsions. Twenty-fifth day, urine 150 cc. Twenty-sixth day, urine 1000 cc.; 
after this date gradually improved, passing 1000-2000 cc. daily for next week or two. 
Discharged fifty-seventh day, with trace of albumen; a month or two after his urine 
was free. (Has remained quite well since August, 1887.) 
Occasionally such attacks are fatal in the early stages, being very acute from the first 
in the following case:- 
Case hi.-Scarlatinal Nephritis.-B. 192, Mary Ann N., aged nine and a half years; 
father died of phthisis, a sister of scarlet fever; always a delicate child; first com- 
plained of sore throat a fortnight ago; rash appeared soon after. Admitted November 
3d, 1884. November 4th, general oedema; face anaemic and puffy; pulse 60; tempera- 
ture 99°; cardiac sounds normal, except second accentuated, apex beat normal; no des- 
quamation; urine passed 700 cc. during night, specific gravity 1014, clear, not smoky, 
no deposit, much albumen, one-third. November 5th, pulse 84, temperature 98°; face 
puffy; urine 750 cc., no blood or deposit, less albumen, one-sixth. November 7th, tem- 
perature rose suddenly, pulse 136; temperature 104.6°; is tossing about and slightly 
delirious; pulse high tension; urine 1400 cc. passed; frequent micturition; urine 
opaque, dark, with much deposit; albumen about one-third; vapor bath; cupping to 
loins; vin. ant. m. v. t. d. s. November 8th, pulse 132; temperature 103°-105°; much 
oedema of face; semi-delirious, muttering to herself; tongue coated and dry; constantly 
vomiting; urine specific gravity 1012, dark red, opaque, much deposit; 200 cc. only; 
about half albumen; pilocarpine nitr. gr. one-eighth and packed; tr. digitalis and 
ammonia. -November 9th, pulse 140; temperature 105°-105.6°. Is drowsy and dull; 
frequent vomiting; heart's impulse diffused; no crepitation in lungs, but respiration is 
slightly impaired at both bases, and vesicular murmur is weak. Not possible to save 
urine from fæces ; apparently very little passed. Some diarrhoea, bowels acted five to 
eight times daily for last three days, without medicine. Died early November 10th. 
Post-mortem.-Only possible to procure one kidney, weight 4 oz. Surface dark 
red; vessels intensely injected; capsule strips. On section much blood exudes; cortex 
dark red; Malpighian bodies injected; pyramids chocolate color. The whole organ is 
in a state of acute congestion. 
Microscopical examination shows the kidney to be in a state of acute inflammation. 
There has been a transudation of leucocytes from the vessels and glomeruli ; and whole 
tracts of the kidney, especially near the capsule, are occupied by leucocytes; while the 
contorted tubes are distended with blood. No micrococci were discovered. 
In the two foregoing cases there can hardly be a doubt that there was an acute in- 
flammatory congestion of the kidneys, of the type of a croupous pneumonia ; in the one 
case the engorged vessels are relieved by the exudation of liquor sanguinis into the 
air vesicles of the lungs, in the other case into the tubules of the kidneys. The plugs 
of fibrine which are thus formed in the tubes, are forced down by the pressure of the 
fluid behind them, stripping off the epithelium, and thus damaging the secreting pow- 
ers of the kidney. Death rarely takes place in this stage, inasmuch as sufficient urine 
is secreted, and the fibrinous plugs expelled in sufficient numbers to relieve the blocked- 
up tubes. It is only in extreme cases, like the one just referred to, where the kidneys 588 
NINTH INTERNATIONAL MEDICAL CONGRESS 
are acutely engorged and appear to secrete blood instead of urine for the time being, 
that death ensues from the completely choked condition of the organs. In other cases, 
instead of the congestion being relieved and recovery taking place, as in the first case 
related, secondary changes take place in the kidneys, which gradually interfere more 
and more with the secreting powers of the kidneys, and death results directly or indi- 
rectly in consequence of the retention in the blood of the waste products which it is the 
office of the renal organs to separate. These changes are the result of the chronic con- 
gestion of the kidneys. These consist in- 
1. Periglomerular nephritis. This consists in a hyperplasia of the endothelium 
lining Bowman's capsule ; the cells accumulate and occupy the space between the 
glomerulus and capsule. They gradually become converted into fibroid tissue and 
compress and obliterate the glomeruli. 
2. Glomerular changes. In most cases the glomeruli appear enlarged, and their 
nuclei increased ; the capillary loops often contain fibrinous plugs (thrombi). It is 
difficult to satisfy one's self whether the nuclear increase takes place in the nuclei of the 
cells lining the capillaries (Friedländer), or in the nuclei which are outside the capil- 
laries. These glomerular changes lead to still further obstruction of the blood current, 
and, consequently, lessen the secretion of urine. The epithelium degenerates, becom- 
ing granular ; the tubules in places become enormously dilated, in consequence of 
being plugged by casts. 
These changes are usually found in cases dying during the fourth or fifth week, or 
later, after the nephritis has lasted ten or fourteen days or more. Such kidneys are 
enlarged, œdematous; the cortex pale and mottled, with injected vessels ; the Malpi- 
ghian bodies are enlarged, pale, and, with a lens, may be seen to be of irregular out- 
line. Death may be brought about either from uræmia or quite as often from cardiac 
dilatation and failure, pericarditis, pleuro-pneumonia or peritonitis. 
The following cases are illustrations of these lesions :- 
Case iv.-Scarlatinal Nephritis.-B. 72, Thomas R., aged five years ; father strong ; 
mother dead. Always good health till present illness ; April 28th, vomited and com- 
plained of his throat, and was feverish ; rash next day. Admitted April 30th. He is 
a well-nourished boy. Third day of illness pulse 120 ; temperature 101.2° ; remains 
of rash on thighs ; tonsils enlarged and red, with some yellow spots of secretion on 
them ; urine, no albumen. Sixth day pulse 120; temperature 101°; remains of rash. 
Eighth day, pulse 144 ; temperature 102° ; rash gone, throat improved. Eleventh 
day, pulse 120 ; temperature 102°; urine 770 cc., no albumen. Sixteenth day, 
temperature normal for first time since admission ; there has been some bronchial 
catarrh. Nineteenth day, temperature has touched normal for last two or three days ; 
discharge from right ear ; urine, yesterday, 550 cc., acid, clear, no albumen ; specific 
gravity 1010. Twenty-second day, urine contains blood and much albumen, acid, 
550 cc. Twenty-fifth day, urine still much blood, 300-500 cc. in last day or two ; sick 
and drowsy. Twenty-seventh day, is very sick ; temperature, intermittent for last 
two days; 400 cc. Twenty-ninth day, vomits everything, urine has passed 780 cc., hot 
packs, and potassium citrate and digitalis. Thirtieth day, still vomits; pulse 84 ; tem- 
perature keeps sub-normal ; passed a little urine into bed ; pilocarpine nitrate ; much 
perspiration ; is much wasted ; tongue dry and coated. Thirty-second day, drowsy ; 
temperature sub-normal; pilocarpine and hot packs; no urine for last forty-eight hours; 
some diarrhoea. Thirty-fifth day, only 25 cc. in last three days ; lies quite quiet ; 
pupils contracted ; much subsultus ; no oedema ; bleeds from nose ; unconscious ; some 
diarrhoea ; no convulsions ; death. 
Post-mortem.-Much emaciation ; slight rigor mortis in legs. Lungs : purulent 
mucus in bronchi ; lungs gorged ; some minute hemorrhages on surface and in section. 
Heart : pericardium adherent but separable ; muscle flabby; right ventricle dilated ; SECTION X DISEASES OF CHILDREN. 
589 
right ventricle wall thickened, cavity dilated. No valvular lesions. Liver 22 ounces, 
pale and fatty. Spleen 2 ounces. Kidneys 7 ounces, slightly enlarged ; surface pale 
and mottled ; cortex not increased ; Malpighian bodies are pale, enlarged, and stand 
out like grains of sand ; pyramids normal. 
Microscopical examination shows no normal glomeruli ; all are seen in different stages 
of periglomerular nephritis. The glomeruli are surrounded by a fibro-cellular growth, 
which compresses, and in some instances has destroyed the capillary loops ; the capsule 
is surrounded by a collection of leucocytes. The convoluted tubules are dilated and 
filled in many places with blood corpuscles. The straight tubes contain many blood 
casts. 
Case v.-Scarlatinal Nephritis.-B. 7, Richard R., aged six years. Has always been 
a healthy boy. Two weeks ago he vomited and was ill ; no definite history of a rash ; 
three days ago it was noted that he was desquamating, and two days ago his face 
swelled. Admitted January 15th. Face much swollen; eyes nearly closed ; discharge 
from left ear; cervical glands swollen; desquamating about feet, Pulse 80, tempera- 
ture 101.4°. Lung sounds normal; urine smoky; much brown deposit; about two- 
thirds albumen, blood cells and casts. January 16th, pulse 92, temperature 101°; has 
passed 60 cc. of urine, half albumen; is drowsy; "packs" and injected pilocarpine 
one-sixth gr. January 17th, pulse 116, temperature 101.6°; still drowsy; much sweat- 
ing; only passed 11 cc. of urine. 18th, pulse 88; drowsy; vomited three times; " packs " 
and jaborandi; much albumen. 19th, pulse 72, temperature sub-normal; vomited five 
times; tongue coated and dry; very drowsy; urine 26 cc. ; muscular twitchings about 
face; pupils sluggish. 20th, much vomiting; some diarrhoea; vapor baths. 21st, pulse 
80, temperature sub-normal; less drowsy; urine dark red, much deposit; half albumen, 
17 cc. passed. 23d, pulse 104, temperature 100.6°; tongue brown and dry; urine 77cc. ; 
diarrhoea. 24th, muscular twitching of face; grinding teeth; general convulsions; 
unconscious ; death four hours after onset of convulsions. Duration of illness about 
twenty-three days, but history not reliable. 
Post-mortem.-Nutrition poor, slight general oedema. Lungs : slight excess of fluid 
in pleurae; a few flakes on surface; lungs gorged and œdematous. Heart four ounces, 
all cavities, but especially right, distended with colorless clot; left ventricle, wall 
hypertrophied, cavity small; no endocarditis; excess of fluid in peritoneum, some 
flakes of lymph. Intestines distended, mucous membrane injected. Liver 22 ounces; 
pale, centres of lobules slightly injected. Kidneys eight ounces, large and œdematous, 
contain much serous-looking fluid ; surface pale pink color, consisting of red points on 
a cream-colored ground; cortex not relatively increased; pale cream-color with irregular 
mottling; Malpighian bodies appear enlarged and stand out like grains of sand; 
pyramids injected and of darker color than cortex. 
On Microscopical examination very few of the Malpighian bodies are normal, the 
majority having undergone marked changes. Many of the glomeruli are compressed 
and wasted by a fibro-cellular growth situated in the capsule space, apparently derived 
from the glomerular epithelium. In some cases there is an accumulation of leucocytes 
around the Malpighian body outside the capsule. Many of the glomeruli are gorged 
with blood, in others small thrombi of clear fibrin are present. The epithelium of the 
convoluted tubes is coarsely granulated and misshapen, the lumen of the tubes being 
blocked in some places by epithelial débris and coagulated albumen, in others by blood 
or fibrinous casts. Some of the tubes are dilated and their epithelium flattened as if 
they had been over-distended by urine. The interlobular plexus is gorged with blood. 
Case vi.-Scarlatinal Nephritis.-B. 175, James McG., aged four years. Always 
been a strong child. Three weeks ago began with vomiting and purging, sore throat, 
and rash. Admitted October 1st, 1884 (about twenty-second day). Is desquamating, face 
pale and puffy, cervical glands enlarged, tonsils irregular, ulcerations. Pulse 88; tem- 590 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
perature 100°. Heart's impulse in fifth space just within 1. n. 1. First sound murrnur- 
ish ; second accentuated. No general œdema, urine smoky, albumen about one-fifth. 
Twenty-fourth day, face more puffy; pulse 100; temperature 97°-100°; urine 270 cc. ; 
specific gravity 1014; some brownish deposit. Is drowsy and sometimes sick. Tr. 
digitalis ïq,5 and pot. citr. 4 hor. Twenty-sixth day, pulse 120; temperature 99° ; urine 
300 cc. ; blood, albumen and much brown deposit. Twenty-seventh day, pulse 84; 
intermittent; (?) systolic murmur at base, omit digitalis. Twenty-ninth day, pulse 
128; temperature 99°; pulse regular; vomited three times; urine 350 cc., dark; much 
brown deposit; specific gravity 1012; albumen about one-sixth; cardiac impulse 
diffused in 1. n. 1. In the evening became restless, and died very suddenly. 
Post-mortem.-Nutrition good; much purpuric staining. Lungs: some fluid in both 
pleuræ; œdematous old adhesions; both lungs œdematous. Heart: two ounces of serum 
in pericardium; some dark clot in right auricle; right ventricle empty; left auricle empty; 
some venous blood in left ventricle. All cavities dilated ; some hypertrophy of wall of 
left ventricle. No valvular lesions. Some ascites. Liver 26 ounces; normal. Spleen 
five ounces; normal. Kidneys six ounces; large capsule strips; surface cortex not 
increased; Malpighian bodies pale, stand out prominently ; papillæ normal. 
Microscopical examination shows the glomeruli enlarged, and their nuclei increased. 
In some there is a marked peri-glomerular nephritis. The epithelium is granular; the 
tubes contain many blood casts, including the convoluted, looped tubes and straight 
tubes. Some of the convoluted tubes have undergone dilatation. There seems to have 
been an exudation of leucocytes from some of the different arteries of the glomeruli, 
and also around the latter. 
Case VII.-Nephritis.-W. 557, Robert McC., was in C. H. P. two years ago, suffering 
from consumption (?). Been well since discharge. Was well up to July 16th, when 
mother noticed his face was swollen, and he noticed his trowsers tight; his urine was 
scanty and dark-colored ; nose bled yesterday, and he complained of shortness of breath. 
Boy died very suddenly soon after his admission to hospital, July 21st. No certain 
history of scarlet fever. 
Post-mortem.-Nutrition good; general oedema, though not excessive; purple stain- 
ing of dependent parts. Lungs: right, three ounces of serum in pleural cavity; left, 
adherent at base and side by old watery adhesions; right, upper lobe gorged and oedem- 
atous; lower lobe solid, on section dark purple, friable, sinks in water; left lung 
closely resembles right, but is less advanced. Heart: no clot in cavity, only some dark 
liquid blood. Right ventricle cavity much dilated; wall thin and flabby. Left ventricle 
cavity dilated; wall thickened and pale. Both auricles dilated; thin walls; no valvu- 
lar lesions; some fluid in the peritoneum. Liver large and gorged. Spleen very soft; 
pulp easily washes away. Kidneys: capsule strips readily, in places bringing away 
some of cortex; surface pale with injected stellate veins. On section, cortex pale and 
wide; Malpighian bodies stand out prominently like grains of sand; interlobular 
vessels; well-marked pyramids, dark purple. 
Microscopical Examination.-The Malpighian bodies are enlarged, the glomeruli 
being apparently swollen, occupying the whole of the capsule space, and not being sur- 
rounded by any fibro-cellular growth. The nuclei of the glomeruli are much increased 
in number; whether these are the nuclei of the epithelium lining the capillaries or 
belong to the extra-capillary connective tissue or epithelium, it is difficult to say; 
apparently they are extra-capillary. The epithelium of the contorted tubes is swollen 
and coarsely granular, and in some places completely choked with blood corpuscles; the 
straight tubes contain much blood, and the capillaries are gorged. 
These cases are fairly illustrative of the changes which take place in the kidneys, 
following on to the condition of acute inflammatory congestion. In Case VII it is un- SECTION X DISEASES OF CHILDREN. 
591 
certain whether the nephritis was of scarlatinal origin or not, but it is of interest in illus- 
trating a class of cases in which the changes are glomerular and not peri-glomerular. 
CONCLUSIONS. 
1. The "initial albuminuria" is of little importance in prognosis; it is mostly 
present where the fever is severe, but is also sometimes absent even in malignant cases. 
2. Cases in which the throat complications are severe and the fever continued into 
the second or third weeks, are often complicated by a form of nephritis of a septic 
character. There is usually albuminuria, but rarely oedema or uraemic phenomena. 
3. The post-scarlatinal form of nephritis belongs to croupous inflammations; second- 
ary changes are apt to follow, which mostly affect the glomeruli and lead to more or 
less stoppage of the circulation. In chronic cases degeneration of the epithelium and 
dilatation of the tubules take place. 
ON THE ANATOMICAL CHARACTERS OF SCARLATINAL NEPHRITIS. 
SUR LES CARACTÈRES ANATOMIQUES DE LA NEPHRITE SCARLATINE. 
ÜBER DIE ANATOMISCHEN KENNZEICHEN DER SCHARLACHNEPHRITIS. 
BY FRANK GRAUER, M. D., 
Instructor in the Carnegie Laboratory of Bellevue Hospital Medical College ; Pathologist to Harlem 
Hospital, New York City, and to the Workhouse and Almshouse Hospitals, Blackwell's Island. 
The different forms of nephritis that occur in scarlatina may be well classified from 
a pathological point of view, according to Friedländer, under one of the following three 
types 
1. The initial catarrhal nephritis. 
2. The large flabby hemorrhagic kidney. 
3. Acute glomerulo-nephritis, or nephritis post-scarlatina. The first two forms are not 
as frequently met with post-mortem as the latter, and as their pathological changes are 
well agreed upon, the writer will pass hurriedly over them and devote most of his time to 
the third form, upon which there still exists differences of opinion among pathologists 
as to the microscopical changes that occur in the same. The first form, namely, the 
initial catarrhal nephritis, is met with in the first week of the disease accompanying 
the exanthema, and is only recognized by a chemical and microscopical examination 
of the urine, in which you find albumen, mucus and hyaline casts, occasionally red and 
white blood corpuscles, renal epithelium and granular casts. It is of short duration 
and rarely leads to death. It is only in those cases in which children die from compli- 
cations that are associated with the disease, among which diphtheritis, bronchitis and 
broncho-pneumonia play an active part, that we are able to study or witness the follow- 
ing pathological changes. The kidneys are enlarged and hyperæmic, the capsule is 
readily stripped off, and on a cut surface there is seen thickening of the cortical sub- 
stance with more or less loss of striæ and the glomeruli appearing as red dots. 
Microscopical examination shows granular degeneration with desquamation of the 
epithelium lining especially the convoluted tubules. Hyaline and occasionally granular 
casts are found in the straight tubes, and where the process has been more severe the 
beginning of a round cell infiltration in the intestinal tissue. Friedländer noticed 
proliferation of the cells lining the convoluted tubules. From the above description 592 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
one would say the changes were those of a parenchymatous inflammation ; why not 
call it parenchymatous nephritis instead of initial catarrhal nephritis, so called by 
Friedländer ? According to Virchow's definition, parenchymatous inflammation leads 
to a fatty degeneration of a cell with disturbance of its function. In the above form 
of nephritis we have no fatty degeneration of the epithelial cells lining the urinary 
tubules. Again, in parenchymatous inflammation we do not, as a rule, have cellular 
proliferation. 
The second form of nephritis, namely, the large, flabby, hemorrhagic kidney, is not 
often met with. Friedländer found it present in only twelve cases of the two hun- 
dred and twenty-nine that he examined. It generally occurs after the first week of the 
scarlatina and runs a rapid course. CEdema is rarely present, and in some cases the 
urine is normal up to within twenty-four or forty-eight hours before death. This form 
of nephritis is found in those cases of scarlatina which are accompanied by extensive 
angina and diphtheritic inflammation. The microscopical appearances of the kidneys 
are as follows: They are enlarged and softened. The cortical substance is somewhat 
thickened and grayish-red in color. The striæ are lost, and the glomeruli, as a rule, are 
invisible. The cortex on its surface is studded with ecchymoses and large hemorrhagic 
infiltrations, and in some cases we often have small miliary abscesses. Microscopically, 
the tubules are found to contain red and white blood corpuscles, desquamated and 
degenerated epithelium and the various forms of casts. In a great many cases you have 
an acute interstitial nephritis that is situated in the cortical substance around the 
glomeruli and between the convoluted tubules, characterized by a round-cell infiltration. 
Occasionally small spots of coagulation necrosis are seen, in which, by means of one of 
the aniline dyes, you are often able to detect micrococci. Whether these micrococci have 
any distinct relation with the etiology of scarlatina, or whether they are merely one of 
the various forms of micrococci that are found in acute abscesses, such as the staphylo- 
coccus pyogenes aureus, I am unable to state, not having made cultivations from the 
same, but hope at some future day to be able to do so. This form of nephritis is 
probably to be looked upon as a septic inflammation of the kidney. 
The third form of nephritis, namely, acute glomerulo-nephritis, or nephritis post- 
scarlatinosa, rarely occurs in other diseases, and is almost characteristic of scarlatina. 
The writer met with it once in a case of heart trouble in which the diagnosis was veri- 
fied by a microscopical examination. Klebs found it present only in scarlet fever. To 
quote his own words, he states that the purest form of acute glomerulo-nephritis is found 
following scarlatina. This form of nephritis occurs in the third or fourth week of the 
disease. The patient is convalescing; there is no fever, and the urine is normal. 
Everything seems to go along nicely, when unexpectedly oedema is noticed about the 
eyes and lower extremities. Examination, then, of the urine shows evidences of albu- 
minuria. It is turbid, contains albumen, is diminished in amount and of a high spe- 
cific gravity. Microscopical examination of the urine shows renal epithelium, pus 
cells, red blood corpuscles, and hyaline casts, occasionally epithelial and blood casts. 
In favorable cases the oedema disappears within a few days, the urine approaches the 
normal type, and in a short time the patient fully recovers. In other cases the oedema 
increases, fluid accumulates in peritoneal, pleural and pericardiac cavities, the urine 
still diminishes, it becomes bloody, varying in color from a slight smokiness to a dark 
brown, and contains a large amount of albumen. If examined microscopically at this 
stage it is seen to contain a large number of red blood corpuscles, pus, and renal epi- 
thelial cells, hyaline, blood, granular and epithelial casts. If the process increases we 
have uræmic symptoms setting in, with anuria and death. 
As there still exist differences of opinion among histologists as to the microscopical 
anatomy of a glomerulus, and as the microscopical changes are limited to that part of SECTION X-DISEASES OF CHILDREN. 
593 
the kidney, it may probably be advisable, with the kind permission of the Section, to 
consider the structure of the same here, before proceeding to its pathological changes. 
The uriniferous tubules all arise within the labyrinth of the cortex by means of 
a globular enlargement, to T|? of an inch in diameter, called Bowman's capsule, 
which invests the tufts of capillary blood vessels called the glomerules. This capsule 
consists of a homogeneous membrane lined by a layer of flattened epithelial cells. The 
nuclei of these cells are generally arranged in groups, thus resembling in this point of 
structure the epithelium lining the air cells of the lung. The vasa afferentia which 
is derived from the interlobular artery enters the capsule at the side opposite the 
urinary tubule. Within the capsule it breaks up into a plexus of capillaries called the 
glomerulus. A vein, the vasa efferentia, which is smaller than the afferentia, pro- 
ceeds from the centre of the glomerulus and leaves the capsule at the point at which the 
afferent vessel enters it. Each glomerulus is covered by a layer of flattened, nucleated 
epithelial cells which dip down between the capillaries, thus separating them from 
each other. The epithelial cells that cover the capillary loops are readily distinguished 
from those that dip between them. The former appear as thin arched plates, being 
concave only on one side, which is attached to the convexity of the loop. The latter 
appear wedge-shaped. 
As regards the capillaries, their walls consist of two distinct coats: first, an external 
homogeneous membrane, called by Langhans basal membrane; second, an internal 
nuclear or endothelial layer, the protoplasm of which is so fine and delicate that it is 
hardly perceptible, but which, in certain pathological conditions, becomes thickened 
and is readily detected. In slight waxy degeneration of the kidney, these two layers 
are shown very nicely by staining with methyl-violet. The external homogeneous layer 
having undergone waxy degeneration, is stained violet, the internal layer being normal, 
is stained blue. With reference to the nuclei of the endothelial cells, they are few and 
far between, as first pointed out by Ribbert. Most authorities agree that there is no 
connective tissue situated between the capillary loops and the glomerulo-epithelium, as 
first described by Axel Key and still sustained by Klein and others. In an examina- 
tion of over one hundred teased and cut sections, the writer was unable to detect the 
slightest evidence of connective tissue between them. 
To Klebs is due the honor of first calling the attention of the profession to the fact 
that the glomeruli were affected in scarlatinal nephritis, and that the diminution and 
suppression of urine was produced by a compression of the capillaries, caused by a pro- 
liferation of the capsular epithelium and the connective tissue cells that are situated 
between the capillary loops. 
Klein, in an examination of twenty-five bodies of those dead of scarlet fever, 
observed the following microscopical changes in the kidney: first, increase of nuclei, 
probably epithelial, covering the glomeruli; second, hyaline degeneration of the elastic 
interna of the minuter arteries, especially the afferent arterioles. The interna of these 
vessels appear, from place to place, swollen up into cylindrical or spindle-shaped hya- 
line masses, which produce a distinct narrowing of the lumen of the vessel. This 
hyaline degeneration was also observed in some of the capillaries of the Malpighian cor- 
puscles, in the course of which greater or smaller parts become obliterated. The 
degenerated parts are at first hyaline, later on they assume a more fibrous aspect. A 
third change that he observed was multiplication of the nuclei of the muscular coats 
of minute arteries, and a corresponding increase in the walls of these vessels. Klein 
does not think that the anuria and uræmic poisoning are due to compression of the 
vessels of the glomerulus, but attributes them to the changed state of the arterioles. 
Langhans' results in the examination of twelve cases were as follows: The capillaries 
were dilated, cloudy and filled with a rich nucleated protoplasm. Long and cross 
cent,inns nf the eanillaries show in their lumen a reticulum with fine meshes, in which 
Vol. Ill-38 594 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
there were occasionally red and white blood corpuscles. In some capillaries thicken- 
ing of the endothelial layer was only noticed. There was also swelling of the glomerulo- 
and capsular epithelium, with slight desquamation of the former. 
Bibbert, in his examination, came to the following conclusion : That glomerulo- 
nephritis consists in a swelling and desquamation of the glomerulo- and capsular epithe- 
lium, with more or less accumulation of the same in a capsular space. The nucleated 
mass in the lumen of the capillaries he regards as thrombosed white blood corpuscles. 
The writer's observations are based upon nine cases of glomerulo-nephritis that occurred 
at the Allgemeines Städtisches Krankenhaus, in Berlin, and were conducted at the 
pathological laboratory of the late Prof. Carl Friedländer, to whom he was indebted for 
the above material. The results of the post-mortem examinations were briefly as follows: 
Case i.-A. K., aged ten years. Sudden death on the twelfth day after beginning 
of the first symptoms of scarlatina. No albumen or casts were found in the urine. 
Strong built child. Slight oedema of the lower extremities. No fluid in the abdom- 
inal or pleural cavities. Hypertrophy and slight dilation of left ventricle. No val- 
vular lesions. Weight of the heart 185 grammes. Bloody imbibition of the endocardium. 
Left lung showed hypostatic congestion. Extreme redness and swelling of the larynx. 
No diphtheritis; spleen swollen. The kidneys were slightly enlarged and the cortical 
substances were hyperæmic. The glomeruli were very pale. 
Case ii.-M. K., aged eight years and three months. General anasarca. Weight 
of body 25,840 grammes. Fluid was found in the abdominal, pleural and pericardial 
cavities. Weight of heart, 155 grammes. Extensive hypertrophy of the left and dila- 
tation of the right ventricles. No valvular lesions. The kidneys were enlarged and 
the glomeruli were pale and prominent. The cortical striae were somewhat obliterated. 
The brain showed evidence of a pachymeningitis. Suppuration. The ventricles were 
small, and contained an excess of clear fluid. 
Case hi.-J. I., aged eight years. Death in the sixth week of the disease. (Edema 
of the lower extremities noticed in the third week. No fluid in the abdominal, pleural, 
or pericardial cavities. Excessive hypertrophy of the left ventricle. No valvular 
lesions. Weight of heart, 180 grammes. Kidneys were slightly enlarged. The glo- 
meruli were prominent and pale. No other changes. 
Case iv.-M. B., aged three years and six months. Death in the third week of the 
disease. Albuminuria in the second week of disease. (Edema was present during the 
last three days of life. Slight oedema of lower extremities and face. Excessive hyper- 
trophy and dilatation of the left ventricle. Weight of heart, 110 grammes. The kid- 
neys were swollen, the cortical substance was hyperæmic, and the glomeruli were 
slightly enlarged and pale. 
Case v.-F. S., aged eight years. Death in the fourth week of the disease. Gen- 
eral anasarca. Fluid in abdominal and pleural cavities. (Edema of the lungs. Left 
lobe showed hypostatic pneumonia. Weight of heart, 163 grammes. Hypertrophy of 
both right and left ventricles. No valvular lesions. Kidneys were not enlarged. 
They were apparently normal, with the exception of the glomeruli, which were very 
pale. 
Case vi.-C. S., aged six years. No œdema. Fluid in the abdominal and pleural 
cavities. Both ventricles of the heart hypertrophied. Weight, 150 grammes. (Edema 
and congestion of both lungs. Swelling and congestion of the mucous membrane of the 
larynx and trachea. The kidneys were enlarged. Medullary and cortical substances 
were slightly congested. The glomeruli were enlarged and pale. 
Case vh.-R, aged twenty-nine years. (Edema fourteen days before death. 
There was fluid in the pleural and the abdominal cavities, with œdema of lungs. Left 
ventricle of the heart greatly dilated and hypertrophied. Weight of heart, 430 grammes. 
Kidneys were enlarged, the cortical substance was swollen and congestive, and the 
glomeruli were very pale. SECTION X-DISEASES OF CHILDREN. 
595 
Case viii.-D., aged fourteen years; death in the fourth week of the disease; 
oedema of the lower extremities and face; fluid in the pleural and abdominal cavities; 
left ventricle of the heart slightly enlarged ; extreme swelling and inflammation of the 
larynx and trachea; spleen enlarged; the kidneys were smooth and the cortical sub- 
stance was apparently normal ; the glomeruli were pale and prominent. 
The record of the ninth case was, unfortunately, lost. Then, to recapitulate, the 
following are the microscopical changes : The kidneys are enlarged and hypersemie; 
there is no loss of cortical striæ, and in some cases the cortices may be somewhat thick- 
ened. The glomeruli are more or less enlarged, pale and prominent. 
Microscopical appearance shows that the uriniferous tubules are apparently normal. 
Occasionally, now and then, one sees evidences of a slight parenchymatous inflamma- 
tion. When examined with a low power, the glomeruli are found larger than normal 
and covered with a mass of nuclei. With a higher power they are apparently bloodless. 
You very rarely see a red blood corpuscle in the lumen of a capillary, especially when 
stained deeply with eosin, which stains the red blood corpuscles a rose color. With an 
immersion lens the following is observed : In some capillaries the only change that is 
noticed is a thickening of the endothelial layer, which becomes more granular. In 
others the lumen of the capillaries are filled with a rich nuclear protoplasm. These 
nuclei are smaller and darker than the nuclei of white blood corpuscles. Some resemble 
somewhat one of the pictures of nuclear segmentation. The question that arises is, 
if they are not the nuclei of white blood corpuscles, what are they ? My answer to the 
same is that they are the nuclei of proliferated endothelial cells. Again, I have seen 
an endothelial cell, not a glomerulo-epithelial cell, swollen and projecting into the 
lumen of a capillary like a cubical epithelial cell and completely obliterating its caliber.* 
In certain loops you have the lumen filled with a reticulum, as described by Langhans, 
in the meshes of which you have red and white blood corpuscles. 
In reference to the glomerulo-epithelium, I have noticed swelling and prolifer- 
ation of the same. It is still considered by some authorities that it is a proliferation 
of the glomerulo-epithelium that produces a compression of the capillaries, thereby 
obstructing the circulation of the blood in the same. In all the specimens that I 
examined, although proliferation of the glomerulo-epithelium was present, the loops 
of the capillaries were larger, as a rule, than normal, showing that the pressure 
was from within and not from without. Although proliferation of the capsular 
epithelium occurs in glomerulo-nephritis, I can only say that I did not observe 
it in 182 sections that I examined. I think we can safely say that it is a prolifer- 
ation and thickening of the endothelial cells that is producing an obstruction of the 
blood through the capillaries. The vasa afferentiæ are occasionally found dilated to 
two and three times their normal diameter. This is due to the obstruction in the loops. 
You have noticed, in the records of the autopsies, that hypertrophy of the left ventricle 
of the heart existed in each case. This was first pointed out by Friedländer, and is 
probably due, I think, to two causes: First, changed state of the blood, due to the 
existence in it of some toxic element, whatever it may be being still questionable. 
Second, obstruction to the circulation of the blood in the Malpighian bodies, which com- 
pel the left side of the heart to do more work on account of the damming back of the 
blood. Before concluding, I would like to state that the term glomerulo-nephritis 
ought to be limited to those affections in which there is an obliteration of the loops of 
the capillaries in the Malpighian bodies, and not applied to those affections in which 
there is only a proliferation and desquamation of the glomerulo- and capsular epithelium, 
as this change has been noticed in all forms of chronic nephritis. 
* The microscopical sections were seen by Profs. Weigert, Ziegler, Von Recklinghausen, Fried- 
länder and Vanwerck, and all agreed to the writer's description of the same. 596 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ÜBER ACETONURIE BEI KINDERN. 
ON ACETONURIA IN CHILDREN. 
DE L'ACÉTONURIE CHEZ LES ENFANTS. 
VON DR. ADOLPH BAGINSKY, 
Privatdocent an der Universität Berlin. 
Nachdem von Jacksch das Auftreten von Aceton (CH3 CO CH3) und Diacetsäure 
(CH3 CO CIL, COOII) im Harn von Kindern, welche hochgradig fiebern und unter 
Convulsionen erkrankt sind, erwiesen hat, war es wichtig, die Frage der Acetonurie 
der Kinder einer eingehenden Untersuchung zu unterziehen. Bei den klinisch zu 
beobachtenden Beziehungen zwischen Rachitis, Laryngospasmus und Eclampsie war 
innerhalb dieser Untersuchung auf die Bedeutung der Acetonämie für die Entwickelung 
der Rachitis besonders zu achten. 
Zum Nachweis des Aceton im Ham dienten die jedesmal neben einander angewen- 
deten Reactionen von Lieben (Bildung von Iodoform bei Zusatz von Jodjodkalium zum 
alkalisch gemachten Harndestillat), von Legal (carmoisin-rothe, bald veränderliche 
Farbe auf Zusatz von Nitroprussidnatrium zum schwach alkalischen Harndestillat), 
von Reynolds (Lösungsvermögen des Harndestillats für frisch gefülltes Quecksilber- 
oxyd). Nur wo diese drei Reactionen sämmtlich eintreten, wurde die Anwesenheit 
von Aceton im Harn angenommen. 
Die Untersuchungsergebnisse waren folgende :- 
1. Bei ganz gesunden Kindern konnte in geringen Mengen Aceton im Harn nach- 
gewiesen werden ; indess ist die Anwesenheit des Körpers nicht constant, vielmehr 
kann derselbe im Harn auch fehlen. 
2. Im Ham von Kindern, welche hochgradig fiebern (bei verschiedensten Krank- 
heiten), findet sich reichlich Aceton ; auch geht der Acetongehalt analog der Fieber- 
höhe und verschwindet mit dem kritischen Temperaturabfall. 
3. Kinder, welche unter heftigen eclamptischen Anfällen erkrankt sind, lassen einen 
ausserordentlich reichen Gehalt von Aceton im Ham erkennen. 
Ueber die Quelle dieser Arten von Acetonurie wurden (zum Theil aus Thierversuchen) 
folgende Thatsachen ermittelt :- 
4. Wenn man Thiere mit stickstoffreichem Nahrungsmaterial füttert, so tritt bei 
denselben reichliche Acetonurie auf. Das Aceton verschwindet aber aus dem Harn 
vollständig bei möglichst stickstoffarmer Nahrung (Amylaceen und Fett). 
5. Künstliche Behinderung der Respiration und selbst bis zur Asphyxie getriebene 
Kohlenoxydvergiftung bewirkt bei stickstoffarmer Kost keine Acetonurie. (Versuch 
am Hunde.) 
6. Weder in den Fäces, noch im Mageninhalt dyspeptischer Kinder lässt sich Aceton 
nachweisen. 
7. Bei der Milchsäuregährang treten so geringe Mengen von Aceton auf, dass diese 
nicht als die Quelle der Acetonurie angesehen werden kann. 
Aus diesen Thatsachen ist zu schliessen, dass die Acetonurie ihre Quelle in einem 
eigenartigen Zerfall der Eiweisskörper hat. 
Ueber die Beziehungen der Acetonbildung zur Rachitis und den dieselbe beglei- 
tenden nervösen Symptomen, wurden im Wesentlichen nur negative Ergebnisse 
gefunden. Es stellte sich heraus :- 
8. Kinder, welche an Rachitis leiden und laryngospastischen Attaquen unterworfen SECTION' X DISEASES OF CHILDREN 
597 
sind, zeigen entweder keine Acetonurie, oder Aceton tritt nur in geringen Spuren im 
Harn auf. Auch bei Chorea wurde Aceton im Harn vermisst. 
9. Langdauernde reichliche Fütterung von Aceton und von Acetessigäther 
(CH3 CO CH2 COO C2 H5) erzeugt bei jungen Hunden weder eclamptische Krämpfe, 
noch Rachitis. Die Thiere bleiben durchaus gesund ; auch eine Erkrankung der 
Nieren tritt nicht ein. 
10. Die Stoffwechselanomalie, welche die Rachitis erzeugt, steht sonach mit dem 
die Acetonurie bedingenden Eiweisszerfall in keinem direkten Zusammenhänge. 
[Abstract.] 
ON ACETONURIA IN CHILDREN. 
DR. ADOLPH BAGINSKY, 
Of Berlin. 
After von Jacksch had detected the presence of acetone (CH3 CO CH3) and diacetic acid 
(CH3 CO CH2 COOH) in the urine of children affected with high fever and convulsions, 
it was important to submit the question of acetonuria of children to a more thorough 
examination. In the relationship of rachitis, laryngospasm and eclampsia, clinically 
to be observed within the scope of this examination, particular stress was to be laid on 
the importance of acetonuria for the development of rachitis. 
To prove the presence of acetone in the urine in each case, the reaction of Lieben 
(formation of iodoform on addition of iodized iodide of potassium to the distillate of 
alkalized urine), of Legal (crimson color readily changeable by the addition of nitro- 
cyanide of sodium to the slightly alkaline distillate), of Reynolds (capacity of the 
distilled urine to dissolve freshly precipitated oxide of mercury), were employed. 
Only when these three reactions took place, the presence of acetone in the urine 
was accepted. 
The results of the examination were as follows :- 
1. In perfectly healthy children very small quantities of acetone could be shown 
in the urine ; the presence of this body, however, is not constant, and it may be absent. 
2. In the urine of children with high fever (in the most different diseases) acetone 
is found abundantly ; the quantity of the acetone rises with the fever and disappears 
with the critical fall of the temperature. 
3. Children with violent eclamptic attacks show an extremely high amount of 
acetone in the urine. 
In regard to the source of these different forms of acetonuria, the following facts 
were ascertained (partly from experiments on animals) :- 
4. If animals are fed with nutriment rich in nitrogen, an abundant acetonuria is 
developed, but the acetone disappears completely by feeding with substances as free as 
possible from nitrogen. (Amylacea and fat. ) 
5. Artificial checking of respiration carried even to the point of asphyxia, by 
poisoning with carbonic oxide, does not produce acetonæmia when slightly nitrogenous 
food is given. (Experiment on dogs.) 
6. Neither in the fæces nor in the contents of the stomach of dyspeptic children 
can acetone be demonstrated. 598 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
7. By lactic acid fermentation so small quantities of acetone are produced that it 
is not to be regarded as the source of acetonuria. 
From these facts it may be concluded, that acetonuria has its source in a peculiar 
disintegration of albuminoid substances. 
Regarding the relationship of the development of acetone to rachitis and concomi- 
tant nervous symptoms, essentially negative results were obtained. It was found that- 
8. Children affected with rachitis and subject to laryngospastic attacks show either 
no acetonuria or acetone appears in slight traces only in the urine. 
9. Long-continued bountiful feeding with acetone or acetic ether (CH3 CO CH.? 
COO C2 H5) caused in young dogs neither eclamptic attacks nor rachitis. The animals 
remained perfectly healthy, and no affection of the kidneys followed. 
10. The abnormal nutritive metamorphosis producing rachitis is, therefore, in no 
direct connection with the disintegration of albumin causing acetonuria. 
A STUDY OF SOME OF THE BACTERIA FOUND IN THE DEJECTA 
OF INFANTS AFFLICTED WITH SUMMER DIARRHŒA. 
UNE ÉTUDE DES BACTERIES TROUVÉES DANS LES DÉJECTIONS D'ENFANTS 
AFFLIGÉS DE LA DIARRHÉE D'ÉTÉ. 
UNTERSUCHUNG EINIGER DER BAKTERIEN IN DEN ENTLEERUNGEN VON KINDERN, 
WELCHE AM BRECHDURCHFALL LEIDEN. 
WILLIAM D. BOOKER, M. D., 
Baltimore, Md. 
The term summer diarrhoea is used in this article to include conditions usually 
classified as functional or non-inflammatory diarrhoea, gastro-enteric catarrh, dysentery 
and cholera infantum. The transition from one of these conditions to the other is often 
so gradual and their symptoms are so often blended that it is not permissible, or even 
possible, to draw sharp lines of distinction between them. 
The great increase of diarrhoeal affections in children with the increased heat of 
summer was observed first by American physicians, and a thorough report upon the 
subject was made by Benjamin Rush in 1789.* For a long time this disease was sup- 
posed to be confined to America, but since the middle of the present century it has 
been recognized in England, Germany, France and other countries. During the last 
twenty-five years the European contributions to the literature of cholera infantum are 
not less than those from American sources, f 
Of the causes which lead to the greater frequency and severity of these affections in 
summer, the effect of heat has been naturally considered to be the most important, but 
in what manner this influence is exerted is still a subject of discussion. 
That microorganisms are in some way concerned in the causation of the group of 
affections embraced under the name summer complaint or summer diarrhoea of chil- 
dren, is a view which has often been suggested and which, of late years, has gained 
favor. The increasing popularity of this mycotic theory is based more upon the advance 
*B. Rush. "Medical Inquiries and Observations," Philadelphia, 1789. The article "Cholera 
Infantum " bears the date 1773. 
f A full bibliography of cholera infantum, up to the year 1882, is to be found in the Index 
Catalogue of the Library of the Surgeon-general's Office, United States Army, Vol. in, p. 148, 
et seq. SECTION X-DISEASES OF CHILDREN. 
599 
in our knowledge in general concerning the relation between bacteria and infectious dis- 
eases, than upon any actual discoveries of specific pathogenic organisms in the diseases 
now under consideration. 
In the absence of any such actual discoveries the following facts have been urged, 
with more or less plausibility, in favor of the mycotic theory. Under favoring external 
conditions the summer diarrhoea of children occurs as an epidemic. It is not possible 
to explain at least a large number of the cases by the anatomical lesions found after 
death, which are often entirely disproportionate to the severity of the symptoms during 
life, and when present may often be regarded as secondary. It is generally admitted 
that abnormal processes of fermentation and of decomposition in the gastric and intesti- 
nal contents play an important rôle in the etiology and symptomatology of these affec- 
tions, and these processes outside of the body have been proven to depend upon the 
presence of various low vegetable organisms. The influence of heat is no less apparent 
in favoring the development of these processes than in favoring the development of the 
summer diarrhoea of children. 
In view of these circumstances, and others of a similar purport might be adduced, 
it is not unnatural that many investigators have directed their attention to the micro- 
scopic study of the dejecta, in the hope of finding there microorganisms which might 
be regarded as the cause of the disease. Although these researches brought to light 
the fact that the diarrhoeal stools are swarming with a large number of various forms of 
bacteria and of fungi, no positive conclusions could be drawn from this fact, inasmuch 
as the normal stools also contain countless bacteria. Indeed, many observers went further 
than this, and drew the unwarrantable inference that bacteria cannot be concerned in 
the causation of diarrhoeal affections, because the normal stools as well as the diar- 
rhoeal stools contain an enormous number of various bacteria. This inference is 
unwarrantable, inasmuch as the mere microscopical examination of the stools affords 
only imperfect information as to the morphological characters, and no information at all 
as to the biological characters of the organisms present, and it may well be that in 
diarrhoeal stools organisms with specific pathogenic properties are present which do not 
exist in healthy stools. 
Evidently the only way in which to attack with any hope of success the problem as 
to the significance of the microorganisms in the diarrhoeal stools of children is to isolate 
so far as possible the various species according to the modern bacteriological methods, 
which we owe to Koch. The organism thus isolated must be studied morphologically 
and biologically, more especially with reference to their fermentative and pathogenic 
properties. Furthermore, such organisms must be compared with those found in 
healthy stools, and the frequency of their presence in diarrhoeal stools and their relation 
to different varieties of summer diarrhoea of children must, if possible, be established. 
Before the work thus outlined can be satisfactorily prosecuted, it is necessary to 
become familiar with the bacteria found normally in the stools. It is from this point 
of view that Bienstock, Stahl, and especially Escherich, have made their valuable 
investigations of the bacteria in normal faeces.* Previous observers confined their 
* Bienstock. Fortschritte d. Medicin, 1883, p. 609 (preliminary communication), and Zeits- 
chrift f. klin. Med., Bd. vm, p. 1. Stahl. Verhandl. d. Congresses f. Innere Medicin 3d Con- 
gress, p. 193, 1884. Escherich. Fortschritte d. Medicin, 1885, Nos. 16 and 17, and " Die Darm- 
bacterien des Säuglings," Stuttgart, 1886. 
Bienstock was the first systematically to isolate and study by the bacteriological methods the 
bacteria of the faeces. Stahl isolated twenty varieties, concerning which only a brief notice was 
published. His work, which was undertaken under Koch's direction and which promised much, 
was cut short by his death. 
Individual species of bacteria have been isolated from the faeces by Brieger, Koch, Finkler 
and Prior, Miller, Kuisl, Weisser, and others. 600 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
examinations to the microscopical study of the stools. This method of examination is 
indispensable, but for reasons which have already been mentioned it has hitherto shed 
little or no light upon the problem before us. Hence it is that we pass over without 
further comment the painstaking microscopical examinations of the stools made by 
Hausmann, Szydlowski, Woodward, Nothnagel, Uffelmann, Baginsky and others. 
As the bacteria in the fæces of adults living upon a mixed diet differ greatly in 
number and in kind from those in the healthy fæces of milk-fed infants, and as our 
interest is solely with the latter, we pass at once to the consideration of the bacteria pres- 
ent in the stools of healthy sucklings. We owe to Escherich the fundamental investiga- 
tion of this subject. His researches are of great value and have been made according to 
the most approved bacteriological methods. These researches have laid the foundation 
for a fruitful study of the bacteria in the pathological stools of infants. 
Escherich found, as had also previous observers, that our present bacteriological 
methods do not enable us to isolate in the form of pure cultures all of the bacteria 
existing in the fæces. There is therefore a discrepancy between the results of micro- 
scopical and those of bacteriological examination of the fæces, the latter method showing 
a smaller variety of organisms than the former. For this reason, if for no other, it is 
plain that the bacteriological cannot displace the microscopical examination. The two 
methods must be used in combination with each other. Efforts to obtain culture media 
more suitable than those in common use for the cultivation of a larger number of fecal 
bacteria have not hitherto been successful. 
Escherich proved the correctness of the common belief that the meconium of the 
newborn infant is entirely free from microorganisms. After a variable period bacteria 
make their appearance in the meconium, and usually by the second day after birth 
they are present in large number. The chief mode of ingress of bacteria to the intes- 
tine is through the air, saliva and food which are swallowed, but inasmuch as bacteria 
are sometimes found in the meconium taken from the rectum three to seven hours 
after birth, Escherich believes that they may enter per anum. The bacteria found 
in meconium stools are fewer in number but greater in variety than those in the subse- 
quent milk fæces. 
While bacteria are present in enormous number in the fæces of healthy milk-fed 
infants, it was found that two species of bacteria are constantly present, and that of 
these one species so greatly preponderates that it is sometimes found almost as a pure 
culture. The bacteria constantly present are the bacterium lactis aerogenes and the 
bacterium coli commune. These are designated obligatory milk-fæces bacteria, in dis- 
tinction from the inconstant bacteria, which are called facultative or potential milk- 
fæces bacteria. The bacterium lactis aerogenes is present greatly in excess of the colon 
bacterium in the upper part of the small intestine, but in the lower part of the small 
intestine and throughout the colon it diminishes in number, and in the healthy stools 
only comparatively few individuals of this species are found. On the other hand, the 
bacteria coli commune* becomes more and more numerous toward the end of the intes- 
tine and vastly exceeds in number all other varieties of bacteria in the stools. 
The obligatory milk-fæces bacteria are capable of growing . with the production of 
fermentation, without oxygen. The bacterium lactis aerogenes causes lactic acid fer- 
mentation of milk sugar, with the development of CO2 and H, and there is every 
reason to believe that it is this organism which causes this species of fermentation, which 
has been proven to occur normally in the infant's intestine. The colon bacterium, 
which is found also in the meconium and in fæces from a mixed diet, probably causes 
* Escherich thinks it possible that under this name several closely allied species are included, 
as he found some differences in the appearances of the colonies on gelatine plates. SECTION X-DISEASES OF CHILDREN. 
601 
some species of fermentation or of decomposition in the secretions of the large intes- 
tine, perhaps in the mucus. 
The potential or inconstant milk-fæces bacteria are for the most part aerobic, and so 
far as they develop at all in the intestinal canal, probably grow in the peripheral layer, 
which contains a small amount of oxygen. The inconstant bacteria are, as a rule, 
somewhat more numerous in the faeces of infants fed with cow's milk than in the stools 
of sucklings. 
Two facts of the greatest importance are brought to light by Escherich's investiga- 
tions, viz. : the remarkable and unexpected simplicity and uniformity of the bacterial 
vegetation in the healthy fæces of milk-fed infants, and the variation in this vegetation 
which occurs with a change in the quality of the diet. 
At first glance it is not easy to understand why, of the manifold varieties of bacteria 
which gain access to the infant's intestine, only two should develop there constantly and 
in large number, but this difficulty is less considerable when we consider that an organ- 
ism in order to supply itself with the necessary oxygen and food in the intestine must 
be capable of causing anaerobic fermentation of the intestinal contents. In harmony 
with the simple and uniform food of the milk-fed infant, we find a corresponding uni- 
formity in their intestinal bacteria. 
It is not possible to foresee to what clinical and therapeutic uses may be put the 
knowledge of the constant characters of the bacterial vegetation in the normal milk 
fæces. It seems a justifiable inference that any marked variation in the quality of this 
bacterial vegetation is an expression of some disturbance in the alimentary tract. 
So long as the normal fæces were believed to contain a chaotic mass of all sorts of 
bacteria, it seemed a useless and unpromising task to make any especial study of the 
likewise chaotic mass of bacteria in diarrhoeal stools. This point of view, however, is 
now changed. With definite information concerning the more important and constant 
bacterial species in the normal stools, it has become a matter of the utmost interest to 
learn what new species of bacteria appear in diarrhoeal stools, and what changes occur 
in the normal bacterial vegetation. 
Such knowledge may prove of value in many ways. Hitherto the study of the fecal 
bacteria in pathological cases has had especially for its object the hope of discovering 
some specific forms which might be regarded as the essential cause of the disease. This 
is, of course, a most important object of research, and one which I have kept in view in 
my investigations. There is, however, another point of view hardly less important and 
which is based upon the fact that the kind of bacteria found in the fæces vary with the 
intestinal contents which serve as food for the bacteria. Thus, we find sharply defined 
differences in the bacterial vegetations characterizing milk fæces, meconium, meat fæces, 
fæces from a mixed diet, etc. In cases of summer diarrhoea there are abnormal changes 
in the contents of the stomach and of the intestine, in consequence of morbid secre- 
tions, peristalsis and fermentations, and corresponding to these abnormal intestinal con- 
tents we may expect to find abnormal vegetations of bacteria, and it is reasonable to 
suppose that some definite relations may be discovered between certain forms of bacteria 
and certain definite changes in the intestinal contents. Such a discovery might be of 
diagnostic and, perhaps, of therapeutic value. 
It is evident that we must be very cautious in assuming that any causative relation 
exists between strange forms of bacteria in the fæces and the existing disease. Various 
interpretations of such a coincidence are possible. First : it may be that the new forms 
of bacteria are to be regarded simply as the necessary accompaniment of the altered intesti- 
nal contents, and do not influence in any way the disease. Even upon this supposition 
of their harmless saprophytic nature the study of these bacteria may prove of diagnostic 
and therapeutic value, for reasons which have already been mentioned. In the second 
place, the new forms of bacteria, while not the primary cause of the disease, may, by NINTH INTERNATIONAL MEDICAL CONGRESS. 
602 
their presence and growth in the intestine, cause a continuance and aggravation of the 
disease. For instance, we can readily suppose that a gastric or intestinal catarrh, or 
some abnormality in peristalsis or secretion, induced primarily by error in diet, or by 
heat, or by some constitutional cause, or by unhygienic surroundings, may be kept up 
and aggravated by the presence of microorganisms whose continued existence in the 
intestine is first rendered possible by some abnormality which would otherwise be transi- 
tory. In the third place, the bacteria may begin their work outside of the body, by 
developing in the milk or other food taken by the infant and causing abnormal pro- 
ducts of fermentation or decomposition, possibly poisonous ptomaines. In the fourth 
place, one or more of the species of bacteria found in the stools of infants affected with 
summer diarrhoea and not found in the normal stools may be the essential and specific 
cause of the disease in the same sense that the typhoid bacillus is of typhoid fever, or 
the anthrax bacillus of anthrax. It must be admitted that without further proof of 
any given case the presumption is against this last supposition. 
In view of the very peculiar qualities which bacteria must possess in order to adapt 
themselves to the conditions of growth in the healthy infant's intestine, and in view of 
the preoccupation of the field by other bacteria, it is not likely that bacteria which 
enter the normal intestine will be able to displace those normally existing there. That 
preparation of the soil which we vaguely call predisposition doubtless plays a most 
important rôle in the class of diseases now under consideration. Given a favorable soil, 
such as that resulting from gastric or intestinal catarrh, or from abnormalities in peri- 
stalsis or secretion, then bacteria which would fail to gain lodgment in the healthy intes- 
tine may grow, and by their presence become the most serious factor in the disease. 
The foregoing considerations have led me to undertake the biological investigation 
of the bacteria found in the dejecta of infants affected with summer diarrhoea. 
METHODS PURSUED IN THIS INVESTIGATION. 
(a) For collecting material : A small, slightly pointed glass tube, sterilized in the 
flame of a spirit lamp, was introduced into the rectum, and immediately after with- 
drawing it the contents were emptied into a sterilized test tube plugged with sterilized 
cotton wadding. As only the contents of the tube were put in the test tube, and the 
room in which the work was carried on was comparatively free from germs (as shown by 
the small number of colonies, often none, growing upon agar plates exposed for a con- 
siderable time), the purity of the cultures maybe reasonably assured. Agar plates 
were made at once, and all colonies showing the slightest difference were planted in 
agar tubes. The cultures were then transferred to the pathological laboratory of the 
Johns Hopkins University, where the further isolation and study of the bacteria were 
carried on under the general supervison of Prof. Welch and Dr. Meade Bolton, the 
assistant in the Bacteriological Department. 
(&) For the study of the morphological and biological characters of the bacteria the 
modern methods introduced by Koch were employed. The usual solid and fluid nutri- 
tive media, such as nutrient gelatine, nutrieqt agar, steamed potatoes and bouillon were 
used. As a rule, in place of the old plate method, Esmarch tubes were employed to 
isolate different species of bacteria, to test the purity of cultures and to observe the 
characters of the colonies. The investigation of the fermentative properties of the 
organisms was carried on chiefly with milk, as will be described hereafter. 
(c) For testing pathogenic properties : The animals used were guinea pigs, young 
kittens, rabbits, white mice and rats. The experiments consisted in : (1) feeding pure 
cultures in milk which had been previously sterilized one hour for three successive days 
in the steam sterilizer. It was fed to mice in small sterilized glass dishes, and small 
pieces of bread were crumbled in it when the mice would not take the milk culture by 
itself ; 3-8 cc. of the milk was given daily until death occurred, or for five to eight days, SECTION X-DISEASES OF CHILDREN. 
603 
when no effect was produced. A similar quantity was fed to the guinea pigs and kittens, 
through a sterilized pipette. The animals otherwise were fed as usual during the 
experiments. (2) Hypodermatic and intra-venous injections : The injections were made 
with a sterilized Koch's syringe. The fluid used for injection was sterilized water or 
bouillon impregnated with the bacteria and injected at once. (3) In other cases bouillon 
was inoculated and allowed to stand for several weeks, and then sterilized according to 
Tyndal's method of fractional sterilization. Hypodermatic injections were made in rats 
and mice, at the root of the tail ; in guinea pigs and kittens about the middle of the 
abdomen. The intra-venous injections were made in rats in the jugular vein, and in 
rabbits in the outer vein of the ear. 
(d) To test if the bacteria were pathogenic in very small quantities, a pocket was 
made in the skin with sterilized scissors, after trimming off the hair, and by means of 
a straight platinum needle dipped into a fresh culture a very minute quantity of the 
culture was taken up and introduced into the pocket under the skin. 
Autopsies were made as soon after death as possible, and cultures and cover slip 
preparations made from different cavities and organs of the body. Before opening the 
abdomen the hair was singed or cut off, and the skin washed with sublimate. In 
making cultures from the organs of the body, the needle was introduced through an 
opening made with heated scissors, so that it could only come in contact with the inte- 
rior of the organ. 
Condition of the children from whom the cultures were obtained.-From 1500 to 2000 
children affected with summer diarrhoea are sent every summer from Baltimore city to 
the Thomas Wilson Sanitarium, ten miles out in the country. Since the opening of the 
Sanitarium, in 1884, only one case of cholera infantum, according to the classical 
description, has been brought to it, though a modified form of the disease is not uncom- 
mon.* The great majority of the children have acute or chronic gastro-enteric catarrh, 
and simple diarrhoea, and about one per cent, have dysentery. 
The children from whom the faeces were taken for examination were chosen with 
special reference to the severer forms of these affections, with one perfectly healthy child 
for control, and one just beginning with a mild diarrhoea, in all, seventeen children. 
DESCRIPTION OF THE INDIVIDUAL CASES. 
Case I.-Three months old; fed exclusively on breast milk; has decided stupor, and 
is extremely emaciated; evacuations frequent, watery, and yellow or greenish in color. 
Case it.-Eleven months old; chiefly cow's milk diet; has high fever, stupor, and 
very frequent vomiting and purging; evacuations watery. 
Case hi.-Nine months old; chiefly cow's milk diet; is emaciated, has slight fever, 
drowsiness, frequent vomiting and purging; •evacuations watery. 
Case iv.-Eight months old; chiefly breast milk diet; sick only a few days; has 
stupor, vomiting and purging; evacuations rice colored, watery, and mixed with con- 
siderable fecal matter. 
Case v.-Eight months old; cow's milk diet; has stupor and persistent vomiting 
immediately after anything is taken into the stomach; evacuations are not frequent, 
and are semi-fluid and of yellow color. 
Case VI.-Eleven months old; chiefly cow's milk diet; has frequent vomiting and 
purging and decided stupor. 
Case vii.-Six months old; condensed milk diet; is emaciated; has drowsiness, 
frequent vomiting and purging; evacuations green and watery. 
Case viii.-Five months old; breast milk diet; frequent vomiting and purging. 
* True cholera infantum and the modified form of the disease will he classed together in this 
article as cholera infantum. 604 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case IX.-Ten months old; chiefly breast milk diet; slightly emaciated; has vomit- 
ing and purging; evacuations watery. 
Case X.-Eight months old; cow's milk diet; extremely emaciated; evacuations 
white and watery, with small quantity of fecal matter. 
CASE XI.-Six months old; cow's milk diet; extremely emaciated; evacuations 
greenish fluid with mucus and white lumps mixed through it. 
CASE XII.-Six months old; cow's milk diet; extremely emaciated; has sallow com- 
plexion; evacuations greenish and watery. 
Case xiii.-Eight months old; milk diet; is emaciated, restless and has frequent 
vomiting and purging. Evacuations watery. 
Case xiv.-Eight months old; breast milk diet; the rectum is covered with a 
croupous deposit; evacuations very frequent and containing a large quantity of pus, 
sometimes mixed with blood. 
Case xv.-Eight months old; cow's milk diet; emaciated; evacuations frequent 
and composed of bloody mucus or pus, with a small quantity of fecal matter. The 
dysentery is secondary to catarrhal enteritis. 
Case xvi.-Seven months old; breast and cow's milk diet; evacuations semi-fluid 
and have a whitish-yellow color; commencing with a mild diarrhoea; no previous 
digestive disturbance. 
Case xvii.-Four months old; breast milk diet; has one evacuation daily; the 
fæces are formed and have a light brown color; has never had any digestive disturb- 
ance. 
Summary.-The children were from three to eleven months old. Twelve were fed 
exclusively upon milk and the others chiefly upon milk. Case II had been sick for 
four or five days with a mild diarrhoea, and true cholera infantum only 24 hours. 
Cases I to VII inclusive, excepting Case II, had been affected with a modified form of 
cholera infantum from three days to two or three weeks. In these the nervous symp- 
toms were especially prominent. Cases Vlll to XIII inclusive were cases of chronic 
gastro-enteric catarrh. Case xiv had primary dysentery (croupous), which was con- 
fined chiefly to the rectum. Case XV had secondary dysentery. Case XVI, previously 
healthy, was just beginning with a mild diarrhoea. Case XVII was perfectly healthy. 
BACTERIA SEPARATED. 
Eighteen different varieties of bacteria have been isolated. The differentiation was 
made by the morphology of the organisms, by the characters of the growth upon various 
nutritive media, particularly gelatine, agar and potato, by the action on milk and by 
the effects of inoculating animals. All the varieties belong to the bacilli except one, 
which is a coccus. Three varieties of bacilli liquefy gelatine, the others do not liquefy it. 
The greatest number of varieties were found in the cases of cholera infantum; a larger 
number in gastro-enteric catarrh than in dysentery; and the smallest number in the 
healthy child; only one variety being found in it. Eight different varieties, the 
largest number isolated in any single case, were found in each of two cases. Table I * 
shows the distribution of the bacteria. , 
The difference in the number of varieties found in the fæces does not necessarily 
indicate a similar difference in the intestinal cavity. In the diarrhoeal fæces, which 
come from the upper as well as the lower intestine, and are discharged at such short 
intervals that no considerable delay can occur in any part of the canal, the condi- 
tions are more favorable for obtaining representations from all portions of the canal, 
* The table is not yet complete, as not all the cultures from Cases iv, vi, vn, xi have been 
completely investigated, and, owing to the present imperfect means for differentiating bacteria 
the identity of some varieties is not positive ; this is especially the case with bacillus C. SECTION X-DISEASES OF CHILDREN. 
605 
than is the case in the dysenteric discharges, which come chiefly from the lower intes- 
tine, and in the healthy fæces which are voided once in 24 hours, and are probably 
retained in the colon sufficiently long to cause the death of many bacteria which cannot 
exist for a long time in the large intestine. Nor is it claimed that the cultures obtained 
represent absolutely all the varieties of bacteria contained in the fæces, as the bac- 
teria may not be equally distributed through the fæces, and their colony growth, 
especially upon agar, to which we are limited in this climate during the greater portion 
of the summer for plate cultures, is not always distinctive enough to be recognized. 
Moreover, not all the bacteria present in the fæces will grow in our ordinary culture 
media. 
TABLE I. 
SHOWING THE DISTRIBUTION OF THE BACTERIA. 
Cholera Infantum. 
Catarrhal Enteritis. 
Dysentery. 
Beginning 
Diarrhcea. 
Healthy. 
I 
II 
III 
IV 
V 
VI 
VII 
VIII 
IX 
X 
XI 
XII 
XIII 
XIV 
XV 
XVI 
XVII 
Bacillus 
A 
4- 
4- 
ll 
B 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
ll 
C 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
+ 
T 
+ 
+ 
II 
D 
+ 
+ 
+ 
ll 
E 
4- 
4_ 
ll 
F 
+ 
+ 
ll 
H . 
+ 
+ 
II 
K 
+ 
+ 
ll 
L 
+ 
ll 
M 
+ 
+ 
+ 
+ 
+ 
ll 
N 
4- 
ll 
0 
4. 
ll 
P 
+ 
ll 
Q 
+ 
ll 
R 
4- 
ll 
S 
+ 
+ 
+ 
ll 
T 
+ 
Micrococcus V... 
+ 
+ 
+ 
+ 
+ 
+ 
CONSTANCY OF THE BACTERIA. 
The bacterium coli commune, or varieties of bacteria so closely resembling Escher- 
ich's description of it that positive separation has not yet been successful, was found 
in all the cases except the two of dysentery. It was present in smaller numbers in the 
more serious cases, especially in cholera infantum, but was found apparently as a pure 
culture in the faeces of the perfectly healthy child. 
One variety was found nearly constantly, and in large quantities in cholera infantum, 
and not in the dysenteric or healthy faeces. It resembles the description of the b. 
lactis aerogenes, but the resemblance is not sufficient to be regarded as an identity. A 
liquefying bacillus, possessing marked pathogenic properties, was found in four cases of 
cholera infantum, and not in other cases. The variety of micrococcus was found in 
three cases of cholera infantum and three cases of catarrhal enteritis, and was not found 
in the dysenteric or healthy fæces. The bacteria found in dysentery were also found in 
cholera infantum and catarrhal enteritis, but many varieties appeared in the latter 
which were not found in dysentery. 
A rough comparison was made between the healthy and pathological fæces, by 
studying cover-slip preparations and making cultures from the smallest quantity that 
could be taken up from the fæces by a straight platinum needle, and then estimating 
the difference in the number of the colonies. This estimate can only be approximative, 
as the solid fæces are more adhesive than the liquid fæces, and a larger quantity is 
taken up by the needle when introduced the same depth. Cover-slip preparations from 606 
NINTH INTERNATIONAL MEDICAL CONGRESb. 
the fæces of the perfectly healthy child showed almost a pure culture of a bacillus iden- 
tical with Escherich's drawing and description of theb. coli commune (Die Darmbak- 
terien des Säuglings). Table II, Fig. 1. The bacilli were in immense numbers and the 
fæces appeared to be composed almost entirely of them. There were, besides these, a 
few short bacilli joined in twos and resembling Escherich's drawing of the b. lactis aero- 
genes. No other forms were seen. From the cultures made from the fæces only the form 
resembling the b. coli commune was obtained. Cover-slip preparations from a child 
just beginning with a mild diarrhœa showed the b. coli commune and two or three 
other forms, but the number of bacilli in this case were not so great as in the per- 
fectly healthy child. The cover-slip preparations from the diarrhœal fæces varied in 
different cases; in some the bacteria were in immense quantity, in others they were 
not so numerous, but in all the preparations more than two different forms could be 
recognized. In the plate cultures made it was difficult to distinguish any difference in 
the number of colonies growing from the healthy and pathological fæces; but always a 
greater variety of colonies could be seen in the cultures from the diarrhœal fæces. 
DESCRIPTION OF THE INDIVIDUAL SPECIES OF BACTERIA. 
Bacillus A.-Found in cholera infantum. 
Morphology.-Varies somewhat in different stages of growth. In fresh cultures the 
bacilli are narrow, with rounded ends and varying in length, sometimes growing into 
long rods or dividing into twos. Fig. 1, Table II. The average size in agar culture 
twenty-four hours old is about three to four p long and seven p wide. In older cultures 
the bacilli are shorter and smaller. The bacilli show active motion in hanging-drop 
preparations. 
Gelatine Growth.-They liquefy gelatine rapidly at ordinary temperatures; the colo- 
nies grow in twenty-four hours to a size large enough to be seen by the naked eye; under 
the microscope they appear nearly colorless; after reaching a certain size liquefaction 
begins. The gelatine in stick culture is completely liquefied in three or four days. 
Agar Growth.-In stick cultures the surface is covered in a few days with a nearly 
colorless skim ; in the depth is a luxuriant and delicate stalk corresponding to the line 
of insertion of the platinum needle. The colony growth is characteristic; the colonies 
are bluish to the naked eye, and have an indistinct halo around them which shades off 
imperceptibly into the surrounding agar; slightly magnified, the colonies are light 
brown and the borders indistinct. The surface of the colony has a delicate, wavy 
appearance. 
Potato Culture.-The growth is luxuriant, a dirty brown color, raised slightly above 
the surface and has well-defined borders. 
Blood Serum.-In twenty-four hours a small, white patch is noticed; this gives 
place, in a few days, to a white semi-fluid sediment around the edge of the tube; in six 
weeks about one-third of the stick culture is liquefied. 
Action on Milk.-Milk is coagulated into a gelatinous mass with alkaline reaction. 
In a few days the milk is separated into a clear fluid upper stratum and a lower thick 
gelatinous stratum; as the culture grows older the fluid stratum increases at thé expense 
of the lower thick stratum. In some cultures in which milk was acid when inoculated 
the reaction afterward beca me alkaline, but a sufficient number of experiments have not 
yet been made to be conclusive upon this point. 
Pathogenic properties tested by experiments upon lower animals:- 
(a) Feeding with milk cultures which were from one to six weeks old :- 
Experiment 1.-Three mice and three young guinea pigs. 
Results.-All died; death occurring in from one to eight days. Autopsies were 
made in each case as soon after death as possible. No abnormal changes were 
noticed in any case, except a certain degree of emaciation. TABLE IT. 
Explanation.-The drawings were all made with Zeiss' homogeneous immersion ocular 3. Magni- 
fying about 650 times. 
Fig. 1, Bacillus A, from an agar plate culture 24 hours old. Fig. 2, Bacillus B, from a gelatine plate 
culture 8 days old. Fig. 3, Bacillus B, from a potato culture 4 days old. Fig. 4, Bacillus C, from a 
potato culture 4 days old. Fig. 5, Bacillus M, from a potato culture 4 days old. Fig. 6, Bacillus D, 
from an agar culture 24 hours old. Fig. 7, Bacillus F, from a potato culture 24 hours old. Fig. 8, 
Bacillus H, from a potato culture 24 hours old. Fig. 9, Bacillus E, from a potato culture 24 hours 
old. Fig. 10, Bacillus L, from a potato culture 4 days old. Fig. 11, Bacillus K, from a gelatine plate 
culture 4 days old. SECTION X- DISEASES OF CHILDREN. 
607 
Cover-slip preparations showed, in the stomach and intestines, among other 
bacteria, a bacillus identical in microscopic appearance with the original, and usually 
in large numbers. From the blood of the heart, spleen, liver, kidneys and perito- 
neal fluid the bacilli were sometimes found, but not always. 
Esmarch tubes from the stomach, intestines and kidneys gave chiefly liquefying 
colonies. Cover-slip preparations and potato cultures from the colonies were iden- 
tical with the original. As a rule they were in greater numbers in the small than 
the large intestines. In the kidneys they were generally pure and in large numbers. 
From the heart, spleen and liver negative results, except in one case from the heart 
and one from the liver pure liquefying colonies were obtained. 
Only one of the animals, a mouse, lived longer than three days. On the fourth 
day it was noticed to have frequent discharges, which were soft, of a whitish* yellow 
color and contained some mucus. Esmarch tubes, made from the discharges, had 
the appearance of being almost pure of the original, and cover-slip preparations 
from the liquefying colonies showed the same. The diarrhoea continued four days, 
when the animal died, being very much emaciated. There was no diarrhoea in the 
other animals. 
Control.-Two guinea pigs of the same age as those used were fed, one upon 
the customary food alone, and the other upon this and sterilized milk. There was 
no difference between these two, and both continued healthy. Mice were fed with 
sterilized milk without being affected. 
Experiment 2.-A young kitten was fed with milk cultures in the same manner 
as the guinea pigs, without results; it was then given croton oil until diarrhoea was 
produced, and fed with the culture without results. 
Experiment 3.-Mouse. Milk culture, fourteen days old, sterilized by the inter- 
rupted method, was given six days without results. The animal was then fed on 
the infected unsterilized milk without being affected, except a slight diarrhoea which 
lasted two days. In this experiment the milk was slightly acid when it was inocu- 
lated, and the casein was not liquefied to the same extent as happened when it was 
alkaline at the time of inoculation. 
(&) Intra-venous injections. 
Experiment 1.-Three rats. Bouillon culture, 18 days old and sterilized by the 
interrupted method. Sterilization was proved by the failure to obtain cultures from 
it. .5 cc. was injected into a jugular vein of each rat. Results : all died. Death 
occurring in two and a half to five hours. Autopsies show no changes, except that 
the blood vessels on the posterior part of the brain appeared congested. 
Control.-A rat was injected in a similar manner, with the same quantity of 
pure sterilized bouillon, without being affected. 
Experiment 2.-Rat. A small quantity of an eight-days' agar culture was put 
into one cc. of distilled water, and .5 cc. of this injected at once into a jugular vein ; 
no results. 
Experiment 3.-Rabbit. Milk, treated in the same manner as in Experiment 1, 
was filtered in a sterilized filter, and two cc. of it injected into the ear vein without 
results. 
(c) Hypodermatic injections. 
Experiment 1.-Three kittens. One cc. of freshly inoculated bouillon was 
injected into each kitten. 
Results.-Two recovered after being somewhat dull and stupid for several days. 
The third died on the fifth day. 
Autopsy.-The organs of the body appeared healthy. There was suppuration 
for a space of two centimetres around the point of inoculation. Cover-slip prepara- 
tions from this point showed a large number of bacilli identical with the original, 608 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and Esmarch tubes from it and the peritoneal cavity gave pure cultures of the 
original. 
Experiment 2.-Mouse. .3 cc. of liquefied gelatine culture injected. 
Result.-Death in twenty-four hours. 
Autopsy.-On the back, just above the point of inoculation, the skin was puffed 
up with air about the size of a hazel nut. The skin around the point of inocula- 
tion was red and appeared to be inflamed. Nothing else abnormal noticed. Cover- 
slip preparation and Esmarch tubes from the point of inoculation, liver, spleen 
kidney, peritoneal fluid and heart appeared to be pure cultures of the original. 
Experiment 3.-Two rats. .5 cc. of liquefied gelatine culture injected into each 
rat. 
Results.-In one the skin on the posterior half of the back was gradually separated 
by a process of necrosis. Complete separation, leaving the under surface bare, was 
effected in two weeks. The edges were clean cut and there was no suppuration. 
In the other rat a similar but much smaller separation of the skin took place on 
the side of the thigh and about one inch from the point of inoculation. 
Experiment 4--Mouse. A straight platinum needle dipped into a fresh potato 
culture was inserted under the skin. 
Result.-Death on the sixth day. 
Autopsy, immediately after death.-The organs of the body appeared healthy. 
Cover-slip preparations and cultures from the spleen, heart, liver and peritoneal 
fluid gave negative results. 
SUMMARY. 
RaciHus A was found in four cases, one of which was in the stage of stupor of acute 
cholera infantum, and the others were more chronic cases of a modified form of cholera 
infantum in which the nervous symptoms largely predominated. It was not among 
the most numerous bacteria found in the discharge in either case, and owing to this 
fact it may have been overlooked in other cases. It produces a gelatinous coagulation 
in the milk, which is afterward more or less completely liquefied, and changed into a 
light brown color. It leaves the oil globules unaffected. Its pathogenic properties 
appear to reside in the power of producing injurious products in albuminous compounds, 
and its action seems to vary according to the manner it is introduced into the blood. 
Milk cultures fed to mice and guinea pigs proved fatal, while the sterilized milk cul- 
tures had no effect when fed. When introduced directly into the blood a small quan- 
tity of sterilized bouillon cultures proved rapidly fatal, while the unsterilized fresh 
cultures injected into the veins of rats had no effect. In all the animals to which it 
was given more or less drowsiness or stupor was produced. Only one had pronounced 
diarrhoea, and one a mild diarrhoea. Besides being found in the elementary canal of all 
the animals that died after being fed upon the culture, it was also found in some cases 
in other organs, especially the kidneys. 
Bacillus B.-Found nearly constantly in cholera infantum and gastro-enteric 
catarrh. 
Morphology.-Short, thick bacilli, with slightly rounded ends, often joined in pairs. 
The average size is 2-3 u long and 1 p wide. Thick, long filaments were often seen. 
Some of the bacilli and nearly all the long filaments contained a clear, glistening spot, 
which had every appearance of a spore, but cultures containing these apparent spores 
were not more resistant to heat than were others. In cultures.eight days old the bacilli 
are longer than they are in fresh cultures, and many of them show when stained with 
gentian violet a deep violet centre with purple or clear poles. The bacilli often show 
capsules. The bacilli show no motion of their own in hanging-drop preparations. 
Gelatine cultures.-The colonies develop rapidly; the superficial ones are raised SECTION X-DISEASES OF CHILDREN. 
609 
and spread out; they are generally round with even borders, though often irregular in 
shape and white to the naked eye. When seen under the microscope they are loose 
and granular, and have a yellowish-brown centre with a white border; by the third 
day this becomes a nearly uniform light brown color, and a few days later a dark cen- 
tral zone displays itself with a light brown peripheral zone. Older cultures show a 
number of concentric rings of different shades of brown. The deep colonies remain 
small and have a yellow or brown color. In stick cultures the surface growth is raised, 
white, and extends about half over the surface; in the depth it has a solid and uniform 
stalk without any marked end swelling. 
Agar cultures.-The colonies develop rapidly, and in forty-eight hours reach a con- 
siderable size. They are white to the naked eye, and are round and dome-shaped. 
Under the microscope they have a light-brown color and are not compact. Neighboring 
colonies run together without any mark of separation at the point of junction. The 
deep colonies are small and dark, and have a granular appearance. 
Potato cultures.-Cream or pale yellow color, with a raised and nodulated surface, 
well defined and notched borders and sloping edge. Gas bubbles appear over the sur- 
face in two or three days. There is but slight moisture about the growth at first. But 
slight, if any, difference can be noticed between the cultures on old and new potatoes. 
Action on milk.-Milk is coagulated with acid reaction, and sometimes with evolu- 
tion of gas. 
On blood serum a small whitish patch appears in a short time, but instead of con- 
tinuing to grow as a solid growth, it gives place to a whitish semi-fluid substance seen 
around the sides of the tube. 
Pathogenic properties tested by experiments upon lower animals :- 
(a) Hypodermatic injections. 
Experiment 1.-Mouse. .5 cc. of a fresh bouillon culture injected. 
Result.-Death in forty-eight hours. 
Autopsy, at once.-Skin around the point of inoculation was red and appeared 
to be inflamed. Organs of the chest and abdominal cavities appeared healthy. Cover- 
slip preparations from the point of inoculation, peritoneal cavity, spleen and right 
auricle, showed a short, thick bacillus identical with the original. Cultures were 
obtained from the point of inoculation and from the peritoneal fluid. 
Experiment 3.-Guinea pig, injected with two cc. of fresh bouillon culture. 
Result.-Death in twenty-four hours. 
Autopsy.-Slight oedema and redness of the skin around the point of inoculation. 
The peritoneal cavity contained about ten cc. of a grayish-white viscid fluid which 
began to escape as soon as the cavity was opened. There was general peritonitis and 
the stomach and intestines were congested. The other organs of the abdominal cavity 
and those of the thoracic cavity appeared healthy. Cover-slip preparations from the 
peritoneal fluid showed an enormous quantity of pus cells and a pure culture of the 
bacillus; some of the bacilli were around the pus cells and some appeared to be in 
the cells. Cover-slip preparations from the right auricle also showed a pure culture 
of the original. Cultures from the peritoneal fluid, spleen and right auricle gave 
pure cultures of the original. 
Experiment 3.-Rat and mouse. Five-tenths to one cc. of bouillon culture, 
obtained from the right auricle of the guinea pig, was injected into each. 
Results.-The rat died in forty-eight hours and the mouse on the fourth day. 
Autopsy of the rat showed a small inflamed spot at the seat of inoculation, and 
the body somewhat emaciated. The organs of the body appeared healthy. Cover- 
slip preparations and cultures made from the heart, spleen, kidney, peritoneal fluid 
and point of inoculation only succeeded from the spleen, peritoneal fluid and point of 
inoculation ; in these the original bacillus was obtained pure. 
Vol III-39 610 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Autopsy of the mouse.-The body was very much emaciated and the skin was 
separated, by sloughing, from the abdomen and right thigh. The lymphatics of the 
mesentery were white and distended and the receptaculum chyli was very large 
and filled with a white fluid. The organs of the body appeared healthy. Cover- 
slip preparations from the abscess and receptaculum showed a large number of 
bacilli identical with the original. 
Experiment 4--Rat injected with .5 cc. and a kitten with one cc. of fresh buillon 
culture, with negative results. 
Experiment 5.-Two mice. A straight platinum needle was dipped into a fresh 
potato culture and inserted under the skin. 
Results.-One mouse was unaffected; the other died on the sixth day. 
Autopsy showed nothing abnormal, and cover-slip preparations and cultures were 
negative. 
(&) Feeding with milk cultures. 
Experiment 1.-Three mice. 
Results.-Death in two to four days. 
Autopsies.-No pathological lesions were noticed in any case. Cover-slip prepa- 
rations from the stomach and duodenum showed a larger proportion of short, thick 
bacilli, resembling the original, than the lower part of the ileum. In some preparar- 
tions the cover-slip preparations from the stomach and duodenum looked like almost 
pure cultures of the original. A bacillus identical with the original was also found 
in the cover-slip preparations from the heart, spleen, liver and kidney; in these it 
was generally the only bacillus found, and pure cultures were obtained from these 
organs. Esmarch tubes made from the contents of the stomach and intestine gave 
a large proportion of the colonies in every way resembling the original, and this 
proportion appeared to be greater in the upper than in the lower intestine. 
Experiment 2.-Mouse, young guinea pig and kitten. Negative results. Artifi- 
cial diarrhoea was produced in the kitten, with croton oil, and the milk culture 
again fed to it with negative results. 
Summary of Bacillus B.-Found nearly constantly in cholera infantum and catarrhal 
enteritis, and generally the predominating form. It appeared in larger quantities in 
the more serious cases. It was not found in the dysenteric or healthy fæces. It resembles 
the description of the b. lactis aerogenes, but the resemblance does not appear suffi- 
cient to constitute an identity and, in the absence of a culture of the latter for compari- 
son, it is considered a distinct variety, for the following reasons : Bacillus B is uni- 
formly larger, its ends are not so sharply rounded, and in all culture media long, thick 
filaments are seen, and many of the bacilli have the protoplasm gathered in the centre, 
leaving the poles clear. There is some difference in their colony growth on gelatine, 
and in gelatine stick cultures bacillus B does not show the nail-form growth with 
marked end swelling in the depth. In potato cultures the b. lactis aerogenes shows 
a difference between old and new potatoes, while bacillus B does not show any 
difference. 
Bacillus B possesses decided pathogenic properties, which was shown both by hypo- 
dermatic injections and feeding with milk cultures. 
Bacillus C.-Found nearly constantly in the stools of cholera infantum, catarrhal* 
enteritis and the healthy suckling. It appeared in diminishing quantity the more 
serious the case of diarrhoea. It answers so fully to the description of the b. coli 
commune that the two are regarded as identical. The difficulty which Escherich met 
with in being always able to consider his culture of the b. coli commune as pure, 
and yet unable to separate it into more than one variety, was experienced by myself 
with the cultures of this variety obtained from different children. Cultures of bacillus 
C taken from different children would sometimes, on the same medium, appear identi- SECTION X-DISEASES OF CHILDREN. 
611 
cal, and at other times, with all the conditions for the two cultures as nearly alike as it 
was possible to have them, each would appear sufficiently different to constitute distinct 
varieties if the difference had remained constant. It is highly probable, as Escherich 
suggested, that instead of this being one variety it may prove to be a group of varieties, 
or a family of closely allied organisms. 
Bacillus D.-Found in cholera infantum and chronic gastro-enteric catarrh. 
Morphology.-Small, narrow bacilli, varying in length and thickness at different 
stages of growth. In the faeces, and in fresh blood serum cultures they are narrow and 
have very small, round, clear spaces throughout the body of the cells, which give a gran- 
ular appearance when seen with Zeiss homogeneous immersion objective one-twelfth 
and eye piece I. In fresh gelatine cultures the cover-slip preparation has the appear- 
ance of being mixed ; large rods with vacuoles and staining deeply, and small, narrow 
rods which do not stain so deeply being seen ; but repeated plating failed to separate 
them into two varieties. The bacilli show no motion of their own in hanging-drop 
preparations. 
Agar stick growth.-A small, round, white patch on the surface, with a thick stalk 
in the depth. 
Gelatine stick growth.-A colorless, slightly raised patch, with irregular borders on 
the surface, and a delicate stalk in the depth. 
Gelatine colony growth.-The surface colonies on the second day, small, white and 
beginning to spread ; on the third day they have nearly reached their full growth, and 
are white or bluish white to the naked eye. Microscopically, at first they have a dead 
white appearance, and as they grow older the central part changes to a light yellow 
color, and is slightly raised ; the borders are irregular and notched and remain white. 
The old colonies have a uniform light yellow color. The deep colonies remain small 
and have a uniform light yellow color and granular appearance. 
Agar colony growth.-Small, pale yellow colonies, not characteristic. 
Potato growth.-Characteristic. A bright golden yellow color, raised and dry sur- 
face, and well-defined border. There is no difference in the growth on old and new 
potatoes. 
Action on milk.-No change is produced for three or four days ; after this time it 
becomes more decidedly alkaline, but never coagulates. In six to eight weeks the milk 
has a brown, transparent appearance. 
Pathogenic properties :- 
(aj Hypodermatic injections. 
Experiment 1.-Five mice, two rats and two guinea pigs. Buillon cultures used ; 
.5 cc. injected into the mice, one cc. into the rats, and two cc. into the guinea pigs. 
Results.-The rats and three mice were unaffected, and two mice and the guinea pigs 
died, death occurring in 24 hours to four days. Autopsies.-Nothing abnormal was 
noticed beyond a limited inflammation at the point of inoculation, which was sup- 
purative in the guinea pigs. Cover-slip preparations and cultures from the point of 
inoculation, peritoneal fluid, spleen and heart in the mice gave a pure culture of 
a bacillus identical with the original, and the same from the peritoneal fluid and 
point of inoculation in the guinea pigs. 
Experiment 2.-Two mice. A straight platinum needle was dipped into the pure 
cultures obtained from the mice that died, and inserted under the skin, with nega- 
tive results. 
(&) Feeding with milk cultures. Four mice and two kittens. 
Results.-Three mice and the kittens were unaffected, and one mouse died on 
the seventh day. 
Autopsy.-Body emaciated ; nothing else abnormal was noticed. Cover-slip 
preparations from the peritoneal cavity, stomach, intestine, heart and liver were 612 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
mostly negative. Esmarch tubes from the stomach, duodenum and ileum gave in 
the second tubes about 100 colonies from each. The great majority of the colonies 
were identical with the original. Potato cultures made from the colonies were also 
identical with the original. 
Summary.-Bacillus D was found in only three cases of cholera infantum, and was 
not found in large numbers in any case. 
Its pathogenic properties are not strong, as more than half the animals in which it 
was tested were unaffected by it. 
Bacillus E.-Found in cholera infantum, gastro-enteric catarrh and dysentery; it was 
not found in many cases. 
Morphology.-In fresh gelatine cultures they are short, small bacilli, with rounded 
ends, many joined in twos and some in long filaments. In potato and milk cultures 
they are longer and some have small, clear spaces in the ends. 
Potato cultures have straw or yellow color, raised surface and the borders sometimes 
defined and sometimes not well defined. 
Gelatine plate culture.-The surface colonies are white and not much spread out; 
under the microscope they have a uniform lemon color. The deep colonies remain small 
and have a light yellow border with a brown centre. Gelatine stick culture has a 
slightly raised, smooth and nearly colorless patch on the surface, and a luxuriant stalk 
with fringed border in the depth. 
In agar the colonies are bluish to the naked eye and uniform grayish-white under 
the microscope. The stick culture has a smooth, white, raised patch on the surface, 
and a thick stalk in the depth. 
Only negative results were obtained in the experiments made upon lower animals 
with this variety, and milk is apparently unaffected by it. 
Bacillus F.-Found in only one case of cholera infantum. 
Morphology.-In fresh cultures they are small, short bacilli, which do not stain 
deeply with a few longer and thicker forms which take a deeper staining; in old cul- 
tures small, clear spaces are seen throughout the body of the cell. In some cultures, 
especially milk, very long filaments are seen. 
Potato growth.-A moist, dirty brown and sometimes glossy surface, but slightly 
raised, with borders generally defined. 
Gelatine growth in stick culture.-A dry, light brown patch on the surface, with a 
very delicate growth in the depth. The growth is very slow and never very extensive 
on the surface. The colonies also grow very slowly and seldom reach a large size. 
Microscopically, the surface colonies are white, glistening and coarsely granular; as 
they grow older they show a light yellow centre surrounded by darker concentric rings ; 
the deeper colonies remain small and are yellow aud granular. 
Agar growth in stick culture.-Small, moist, glass-colored patch, slightly raised and 
lobulated surface, with well-developed stalk in the depth. 
Colony.-The surface colonies are large and round, and have a ropy consistency. 
Microscopically, they are yellow and have a wavy surface. 
It renders milk more alkaline without coagulation. Old milk cultures have a brown, 
transparent appearance. 
Pathogenic Properties :- 
(a) Hypodermatic injections. 
Experiment 1.-Two mice. .5 cc. of melted gelatine culture injected. 
Results.-Death in 24 and 48 hours. 
Autopsies showed nothing abnormal in either case. Cover-slip preparations and 
cultures from the point of inoculation gave an enormous quantity of bacilli identical 
with the original. SECTION X DISEASES OF CHILDREN. 
613 
Experiment 2.-Two mice injected with .5 cc. of bouillon culture, with negative 
results. 
(ö) Intra-venous injection. 
Experiment 1.-Rabbit. One cc. of bouillon culture injected into the outer vein 
of the ear, with negative results. 
(c) Feeding with milk culture.-Four mice and one kitten. Negative results. Two 
of the mice were then given croton oil and again fed on the milk culture. 
Results.-'Death in 24 and 36 hours. 
Autopsies.-No abnormal changes noticed. Cover-slip preparations and cultures 
from the intestines gave a large number of bacilli and colonies which closely 
resembled the original. Potato cultures made from the colonies were identical with 
the original. 
Bacillus H.-Found in one case of cholera infantum and one case of dysentery. 
Morphology.-In fresh agar cultures they are small bacilli with rounded ends. In 
fresh potato cultures they are larger and longer, and the ends are more pointed. 
Potato growth.-Bright yellow-colored growth, but slightly raised, with dry surface 
and defined borders. 
Gelatine growth.-The stick cultures have a small, colorless patch, but slightly 
raised above the surface, and a well-developed growth in the depth. In plate cultures 
the surface colonies are bluish and spread out. Microscopically, they show a white, 
irregular and notched border, with a yellow, slightly raised centre. 
Agar growth.-The stick cultures have a smooth, nearly colorless and but slightly 
raised patch on the surface, and a thick stalk in the depth. In plate cultures the 
colonies are round and white, with flat surface. Microscopically, they have a uniform 
brown color and are not compact. 
Action on milk.-Coagulates milk with reaction. 
In the few experiments with this variety upon lower animals only negative results 
were obtained. 
Bacillus K.-Found in one case of cholera infantum and one case of dysentery. 
Morphology.-Short, small bacilli, varying in size. The growth on potato is not uni- 
form. Sometimes several days elapse before anything is noticed; at other times the 
culture develops more rapidly and is yellow, defined, raised and dry. 
In gelatine plate cultures the colonies are whitish, or nearly colorless, and but 
slightly spread out. Under the microscope they are uniform, smooth and have a straw 
color. The stick culture has a small colorless patch on the surface, with a delicate 
stalk in the depth. 
In agar plate cultures the colonies are round and white. Under the microscope they 
have a uniform light yellow or straw color. In agar stick culture the surface is moist 
and glassy, with a delicate stalk in the depth. 
It renders milk acid, and coagulates it only after standing in the thermostat for five 
or six days. Pathogenic properties not tested. 
Bacillus L.-Found in one case of mild diarrhoea. 
Morphology.-Short, thick bacilli; many in the form of the figure eight; a few long 
filaments sometimes seen. It resembles somewhat the b. lactis aerogenes, but differs 
from it in important particulars. 
In gelatine plate cultures the colonies are usually not spread out, but are thick, with 
a flat surface, and white to the naked eye. Microscopically they have a uniform light 
yellow color, or a flat, straw colored, central zone, which is raised above a white border. 
On potato the culture is lemon colored, dry and not well defined. It renders milk 
acid, and coagulates it only when kept in the thermostat at 38° C. for five or six days. 
Pathogenic properties not tested. 614 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
BaciHus M.-Found in cholera infantum and gastro-enteric catarrh. 
Morphology.-Solid, thick bacilli, about two /z long and one /z wide. Some are 
joined in twos and some are in long filaments. The colony growth in gelatineris 
changeable. The surface colonies at times are spread out, white or bluish white, and 
often showing a concentric arrangement to the naked eye. Microscopically they have 
the appearance of a large yellow colony placed in a larger white colony with only the 
irregular border of the latter showing, or they show a concentric arrangement, some of 
the rings being lobulated and some fringe-like or homogeneous. At other times the 
colonies are nearly colorless and show under the microscope, at first, a uniform green- 
ish-yellow color with fine concentric markings. As the colonies grow older they show 
a yellow central zone with fine bar-like markings, and an outer white zone. The deep 
colonies are small and yellow. 
Ou potato, the growth has a golden-yellow color with a moist, glistening surface, 
and well-defined borders. 
Milk is rendered acid, but is not coagulated. As far as tested it showed no patho- 
genic properties. 
Bacillus M resembles the b. coli commune in many respects, but differs sufficiently 
to be considered a separate variety. It is larger, and never shows the protoplasm 
gathered into the centre of the cell with the poles clear. On potato, it has a brighter 
yellow color, and the colony growth in gelatine, though often resembling, is never 
identical with the b. coli commune. 
Bacillus N.-Found in one case of cholera infantum. 
Morphology.-Exceedingly small and short bacilli. 
Potato growth.-A faint straw or light yellow-colored growth, with a dry and 
slightly raised surface and defined border; in some cultures nothing is seen upon the 
potato. 
Gelatine plate cultures.-The colonies are small and glassy or colorless, and are 
taken up entire with the needle. 
Agar growth.-In stick cultures the surface has a small raised patch with a rough 
surface, and a well developed growth in the depth. The surface growth is drawn in 
ropes with the needle. In plate cultures the colonies are small. The superficial colo- 
nies are bluish to the naked eye; microscopically, a lemon-colored centre which gradu- 
ally tapers to a white border; the deep colonies are uniform light yellow and remain 
very small. As far as tested it showed no pathogenic properties. 
Bacillus 0.-Found in one case of catarrhal enteritis. 
Morphology.-Small, short bacilli, many joined in pairs. The potato cultures are 
dry, yellow, raised and defined, sometimes having a bright yellow color, at others a 
dark yellow. In gelatine plate cultures the colonies are spread out and have a grayish- 
white centre with a bluish outer zone. Microscopically they have a yellow centre 
with a white border. In gelatine stick culture the surface has a small, colorless, 
slightly raised patch with smooth surface. In the depth is a luxuriant stalk with fringe 
border. In agar plate culture the colonies are large, round and white. Microscopically 
they have a light yellow color, and gradually taper from the centre to the border. 
It coagulates milk rapidly into a solid, firm clot with acid reaction. Pathogenic 
properties not tested. 
Bacillus P.-Found in one case of dysentery. 
Morphology.-Small bacilli with rounded ends, some in long filaments. Potato cul- 
tures are yellow, with dry raised surface and well defined borders. 
Gelatine plate cultures.-The superficial colonies are spread out and bluish-white. 
Under the microscope they have a light yellow centre with a white border. As the 
colonies grow older they have a uniform light yellow color. In agar plate cultures the 
colonies are large, round and white. Under the microscope they have a light brown SECTION X DISEASES OF CHILDREN. 
615 
centre with a white rim. It coagulates milk more slowly than bacillus 0„ and the 
coagulation is not as solid or as firm. It renders milk strongly acid. Pathogenic 
properties not tested. 
RaciZZws Q.-Found in one case of catarrhal enteritis. 
It resembles bacillus B in many respects, but is not identical with it. It is a short, 
thick bacillus, having a similar form to bacillus B, but does not stain clean like the 
latter; its borders show fine, fuzzy processes, and the intermediate spaces between the 
bacilli are stained, showing a peculiar network. 
The colony growth in gelatine resembles that of bacillus B, only it is darker and 
more of a grayish-brown color under the microscope. The potato culture resembles 
bacillus B, but is more luxuriant and juicy. The most marked difference is in its action 
on milk. Bacillus Q renders milk acid, and coagulates it only when kept in the thermo- 
stat, at 38° C., for five or six days. 
Bacillus B.-Found in one case of catarrhal enteritis. 
It resembles bacillus Q in its action on milk but resembles bacillus B more closely 
in other respects. In morphology bacillus R is shorter, smaller, and more rounded 
ends, often having the appearance of diplococci. 
In its growth upon potato and gelatine it resembles bacillus B very closely ; the only 
difference observable is that the colonies are more compact in bacillus R. 
The pathogenic properties of bacilli Q and R were not tested. 
Bacillus S.-Found in one case of cholera infantum and one case of catarrhal 
enteritis. 
Morphology.-Small bacilli, varying in length, some joined at the ends, forming long 
chains. On potato the culture is dirty yellow, slightly raised and has well-defined 
borders. 
It liquefies gelatine more slowly than bacillus A, and coagulates milk with an acid 
reaction. 
In agar plate cultures the colonies are blue to the naked eye; under the microscope 
the colonies are indistinct and whitish. 
Pathogenic properties were not tested. 
Bacillus T.-Found in one case of cholera infantum. 
Morphology.-Plump, oval bacilli. 
On potato it has a pretty pink growth with well-defined borders, and the surface is 
raised, in places, into large gas bubbles. On old potato culture the growth eats into the 
potato and is lower than the surrounding border. It liquefies gelatine rapidly and 
coagulates milk with acid reaction. Pathogenic properties were not tested. 
Micrococcus V.-Found in cholera infantum and catarrhal enteritis. 
Morphology.-Small round cocci, some joined together, forming diplococci. 
Nothing is seen, in potato cultures, on the surface of the potato 
Gelatine cultures.-Both the plate and stick cultures develop very slowly. In stick 
cultures a small dry patch is seen on the surface, and limited to the point of inocula- 
tion after a considerable time; the growth in the depth is more flourishing. In plate 
cultures the colonies cannot be seen with the unaided eye before the seventh or eighth 
day. They are round and have a bluish appearance; under the microscope a uniform 
lemon or light brown color. The colonies never reach a large size. In agar the growth 
is also slow. In stick culture the surface growth is limited to a small patch at the 
point of inoculation. The growth in the depth is not extensive. In plate cultures the 
colonies remain small and have a bluish appearance. Microscopically, they have a 
light yellow, granular appearance. It produces no apparent change in milk, and, as far 
as tested, has shown no pathogenic properties. 616 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
GENERAL CONSIDERATIONS. 
Regarding the work in its present condition as too incomplete to admit of positive 
conclusions, the following considerations are given as showing the tendency of the 
results thus far obtained :- 
The bacterium coli commune does not disappear in the diarrhoeal faeces of infants, 
but appears to diminish in number, according to the severity of the disease. It, or a 
variety or varieties closely resembling it, appears to be constantly present, but not as a 
pure culture or in the same largely predominating form as in the healthy milk faeces. * 
It was not found in the dysenteric discharges. 
No variety of bacteria has been found which bears the relation of constant or obliga- 
tory bacterium to the diarrhoeal and dysenteric discharges that the colon bacterium 
bears to the healthy milk faeces. 
One variety was found nearly constantly and generally in the predominating form 
in cholera infantum and catarrhal enteritis, but was not found in the dysenteric or 
healthy faeces. This variety resembles the description of the b. lactis aerogenes, but 
differs from it in certain particulars, and in the absence of a positive culture for 
comparison, has been regarded as distinct. The identity of the two, however, is ren- 
dered more probable by the fact that the b. lactis aerogenes is a constant or obliga- 
tory bacterium, and the predominating form in the healthy upper intestine of suck- 
lings, while it gradually diminishes in number or altogether disappears in the lower 
intestine and fæces; and it is easy to conceive that with the frequent and rapid passage 
of the diarrhoeal discharges through the intestine, a large number of the b. lactis 
aerogenes might be contained in them and in a suitable condition for obtaining cul- 
tures. Should the separation into a distinct variety be confirmed by proper compari- 
sons, then we have a new form possessing many of the characteristics of the b. lactis 
aerogenes, with marked pathogenic properties, nearly constant in cholera infantum and 
catarrhal enteritis, which has not been found in the contents of the intestine of the 
healthy suckling, or their fæces. Should the two forms prove identical, then we have 
the b. lactis aerogenes occurring more frequently and in much larger quantity in the 
diarrhoeal than in the healthy stools. 
The number of varieties of bacteria in the diarrhoeal fæces exceeds that of the 
dysenteric and healthy fæces. 
The actual number of individual bacteria in the healthy fæces is as great as in that 
of the diarrhoeal fæces. 
The number of varieties of bacteria as well as the number of individual bacteria is 
less in the dysenteric than in the diarrhoeal fæces. 
The bacteria found in the dysenteric fæces were also found in the diarrhoeal, but a 
number of varieties were found in the diarrhoeal fæces which were not found in the 
dysenteric. 
The bacteria differ from the inconstant varieties found by Escherich in the contents 
of the healthy intestine of sucklings and their fæces. 
The number of varieties of micrococci, liquefying and chromoginic bacteria was less 
than that found by Escherich in the healthy suckling. 
Considerable difference was manifest in the effects produced upon lower animals by 
the different varieties of bacteria with which experiments were made. 
Two varieties appeared to possess marked pathogenic properties; in others the patho- 
genic properties were less marked and some appeared entirely uon-pathogenic. 
A liquefying bacillus which was found frequently but not constantly in cholera 
* It is probable that some of the cultures which have been considered as identical with the 
b. coli com. would prove, with better means for the differentiation of bacteria than we have at 
present, to be different varieties. SECTION X-DISEASES OF CHILDREN. 
617 
infantum, and not in other forms of summer diarrhoea or healthy faeces, effected changes 
in albuminous compounds which proved rapidly fatal when injected in small quantity 
into the veins of rats, and milk cultures of the same bacillus generally resulted in death 
when fed to mice and guinea pigs. 
Diarrhoea was not a prominent symptom in the animals in which the experiments 
were made. A pronounced diarrhoea was noticed in only one case. 
It was shown by experiment that none of the bacteria were capable of multiplying 
in ordinary hydrant water, and cultures could not be obtained from the water in any 
case forty-eight hours after it had been inoculated, and in the great majority twenty, 
four hours afterward. 
All the varieties of bacteria found are capable of thriving in milk. Some varieties 
produce coagulation of the milk with acid reaction, some render milk acid without 
coagulation, some render milk alkaline without coagulation, some have no apparent 
effect upon milk, and one variety coagulates milk with alkaline reaction. 
INFANTILE MARASMUS. 
MARASME DES ENFANTS. 
BY I. N. LOVE, M. D., 
St. Louis, Mo. 
KINDERMARASMUS. 
In presenting a paper for your consideration, with many misgivings I select the sub- 
ject of infantile marasmus. I am aware that the subjects of abdominal and other forms 
of surgery are more alluring, and such as this are, as a rule, unattractive, yet we must 
remember that nothing in the form of disease is trivial, for a human life is always 
involved, and all that influences and affects life for good or ill is of the greatest import. 
A series of interesting cases met with in private practice during the past few years, 
compared with other cases occurring in hospital and dispensary practice, have impressed 
upon my mind the importance of this condition, and the means of antagonizing it. 
The term marasmus, like malaria, is a misnomer, and expresses but little as regards 
the pathology of the disease ; it declares simply that our patient is wasting away, 
repair on the part of the tissues having surrendered partially or completely to decay. 
A condition of " marasmus, " wasting or consumption occurs in all forms of exhaust- 
ing diseases, but the name is only applied in cases of wasting accompanied with fever or 
symptoms pointing to any well-defined disease. 
It is more frequently met with among the young and the aged, but whether infant- 
ile or senile, it is usually dependent upon similar causes and conditions. Among infants 
we meet cases which can clearly be referred to congenital syphilis, which at once 
takes them off the list of marasmus cases and places them under the specific classifica- 
tion. Others, again, have been so classified when they would probably have been 
more correctly diagnosticated as tuberculosis, tabes mesenterica, etc. Care in eliciting 
the family history and examining the cases will generally avoid these errors of diagnosis. 
Many cases of so-called marasmus, if closely investigated, will present a history 
and general indications of intestinal catarrh. 618 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Niemeyer, in writing upon the subject of chronic intestinal catarrh of children, 
refers to the fact that the imperfect diagnosis of 1 ' marasmus ' ' is frequently assigned to 
such cases, and he is undoubtedly correct. 
Eliminating all cases clearly belonging to other classifications, there remains those 
cases of wasting or general atrophy in which no fever or local lesion can be discovered. 
Pronounced pictures they are, too, after a prolonged period of progression ; muscles 
shrunken and flabby, osseous prominences everywhere visible, with the pale, shriveled, 
dry skin hanging in broad folds and wrinkles about them, like a pair of loose and 
baggy trowsers upon calfless legs ; face withered, wrinkled and worn, suggesting the 
miniature daguerreotype of some emaciated, toothless hag. The most pronounced 
features in the case being loss of flesh, loss of strength, loss of color, the complexion 
being of a dull leaden color. 
Having excluded all cases of wasting dependent upon tangible conditions, such as 
tuberculosis, congenital syphilis, intestinal or gastric catarrh, etc., I shall devote my 
attention to the consideration of the cases which can properly be called marasmus. 
They present all the symptoms above referred to, and in marked degree we have 
inactivity of the secretory glands. 
In life there is dryness of everything-skin, alimentary canal and the emunctory 
organs in general, and after death, upon examination, we find further evidences of lack 
of fluidity or proper moisture of the tissues, confirming the thought that there has 
been a lack of secretion and excretion, exosmosis and endosmosis. 
Primarily, then, I take the position that inactivity of the glandular system is at 
fault. In the very outstart of every infantile career we have more or less inactivity of 
the glands; the liver, with other glands, is larger (being more engorged) at birth rela- 
tively than at any later period in life. Attention to the proper establishment of the 
equilibrium of the circulatory, secretory and excretory system of the infant is of vital 
importance. 
Given this torpid, glandular condition, coupled with improper or insufficient food, 
and other hygeinic errors, we have the factors favorable to the furnishing of a full-fledged 
case of typical marasmus. The five digestive juices upon which depends the proper 
preparation of pabulum for prompt appropriation on the part of the absorbents, are 
the products of parts of the secretory glands and the proper elimination of effete matter ; 
the ashes of combustion, if you please, depends upon the zealous work of the excretory 
glands. 
To illustrate my position, I herewith report, in a concentrated form, the notes of one 
of a series of cases under my care during the past year. 
A. D., born August 1st, 1886, of healthy, wealthy parents, who have been under my 
observation constantly for over ten years (three other strong, hearty, robust children 
having been previously born), no hereditary taint whatsoever. At birth well formed, 
fairly well developed; the labor was, in common parlance, a dry one, but there were no 
complications, and nothing to indicate but what the child would be as healthy as his 
predecessors. 
After a few days, bowels being slow in moving, olive oil was ordered, and nothing more 
was heard from the child until it was two months old. At this time aid was sought, 
for the reason that the child was constipated, uncomfortable and evidently not thriving. 
Inquiry developed the fact that from birth there had been habitual constipation, but 
little urination and continual restlessness and discomfort. The mouth and tongue were 
dry, the skin inactive, dirty, and yellow looking, the child smaller than at birth, with 
shrunken and flabby limbs, distended, overfilled and protruding abdomen, with the 
blue and close crowded veins standing out like whip cords over its surface. 
There was evidently lack of proper secretion, excretion and assimilation; the baby 
was starving, though apparently furnished with sufficient and proper nourishment by SECTION X DISEASES OF CHILDREN. 
619 
the mother. I at once ordered one grain of calomel and twenty grains of sugar of milk 
triturated thoroughly for a full half hour, and divided into twenty powders, one powder 
to be given every two hours, dry on the tongue, and followed at frequent intervals with 
liberal quantities of water. After twenty-four hours had passed, the bowels began to 
move freely, the aid of several warm water injections being given, and enormous quan- 
tities of hard, undigested, cheesy masses were passed, followed for several days by 
numerous large, loose, offensive dejections. More than likely, on account of this great 
accumulation, an acute intestinal catarrh would have soon been developed. During 
this time, when the activity of the glandular system was becoming aroused and the 
outlook better, the mother was taken very seriously ill with malarial fever, and it was 
soon apparent that a substitute was demanded. A strong, full-habited wet nurse (with 
a baby of the same age as our little starving patient, about three times as large and 
almost hoggishly fat) was secured, and to her credit, she refused to serve unless permit- 
ted to bring her child with her, promising to artificially' feed him, and reserve her 
breasts for our patient. At this juncture the family removed some distance from the 
city and beyond my observation, until about six months had elapsed, when I was sum- 
moned and found my little patient in a condition every way aggravated. Investigation 
developed the fact that the motherly instinct of the wet nurse had prompted her to per- 
mit her own lusty boy to empty her breasts before giving them to the little starveling 
under her care. Not to go too much into detail, suffice it to say, that inability to secure 
a proper wet nurse soon necessitated artificial feeding. Various foods in the market 
were tried, without avail; a fermentative dyspepsia and gastro-intestinal catarrh pre- 
sented, and the beginning of the end seemed near. All milk and malty foods were now 
relinquished by the stomach, and a raw meat liquid food, ten drops in a teaspoonful of 
water and two drops of brandy, were given every hour, and the child ordered to be 
given a bath every two hours, in either warm, fully-digested milk, warm cod-liver oil 
or warm water, with a teaspoonful of alcohol to the pint. 
The internal medication was the infinitesimal dose of calomel triturate (previously 
referred to) every two hours, given for the purpose of stimulating secretion and excre- 
tion, antagonizing fermentation, antisepsis in the rendering inert of the ptomaines and 
other poisonous products of decomposition in the alimentary canal. This course was 
followed uninterruptedly, except by the gradual increase of the food, with gradual 
improvement for one week. Artificially digested milk was then cautiously added to 
the diet list and the amount of the liquid raw meat food doubled. From this time on, the 
progress toward perfect nutrition, growth and development was more and more rapid, 
and within one month he was becoming a well-nourished baby and possessed of a 
ravenous appetite, taking goodly quantities of water, and his excretory organs doing 
good service. 
The one-twentieth grain of calomel was continued three times daily for two months, 
and after that resumed whenever indicated. The nutritious baths, with gentle mas- 
sage and friction, were diminished in frequency, but not' thoroughness, to three times 
daily, and later were given only morning and night. 
From the observation and study of a series of twelve cases (the case which I have 
presented being typical of the twelve), where well defined causes of innutrition, such as 
syphilis, tuberculosis, etc., did not enter, I feel that I am justified in deducing the 
following 
1. Infantile marasmus, so called, is dependent primarily upon torpidity and inac- 
tivity of the glandular system, and aggravated by unsuitable, over-abundant, insufficient 
food and unsanitary surroundings. 
2. That which is of first importance in the treatment is the arousement of secretion 
and excretion, and the most valuable remedy we have for this purpose is minute doses 
of calomel, given in conjunction with as much water as can conveniently be adminis- 620 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tered, the two agents, calomel and water, both being ardent accelerators of glandular 
action, stimulators of the secretion of the digestive juices, true aiders and abettors of 
digestion, and decided openers of the dammed up organs of diuresis, and awakeners of 
the dormant organs of defecation, cleansers of the vital sewerage system. 
3. In the matter of diet, the mother's milk is best, and some other mother's milk 
next best. 
Whether mother's milk or artificial food be given, the quantity and quality should 
be most carefully guarded. 
In many instances the liquid raw meat foods in small quantities, well diluted and 
frequently given, will be of great service. All artificial food should be pre-digested. 
4. In extreme cases the administration of soluble foods in the form of baths and by 
gentle friction will be of value, and in all cases gentle massage and frequent bathing 
(sometimes adding diffusible stimulants to the water) are of great service, much of the 
water being directly absorbed by the hungry and thirsty tissues. 
TREATMENT OF SCROFULA, BY SEA BATHS, IN WINTER, AT 
CANNES, ALPES MARITIMES, FRANCE. 
TRAITEMENT DU SCROFULE PAR LES BAINS DE MER, EN HIVER, À CANNES, 
ALPES MARITIMES, FRANCE. 
BEHANDLUNG DER SCROPHULOSE DURCH SEEBÄDER IM WINTER, IN CANNES, SEEALPEN, 
FRANKREICH. 
DOCTOR DE VALCOURT, 
In Charge of the Civil Hospital and of the Maritime Hospital for Children at Cannes. 
Sea baths have power in giving health and strength to children in general, and are 
of particular efficacy in overcoming and curing scrofulous manifestations in those pre- 
disposed thereto. This fact has been recognized by physicians, and during the last few 
years special establishments, hospitals for children thus afflicted, have been founded in 
European countries along the sea coast. The sea baths in the north offer many advan- 
tages, but present serious obstacles. The tide in many places prevents a fixed hour for 
baths. Often the surf is too strong for puny and delicate children, particularly on a 
pebbly beach ; many shores have a sand so fine that the least wind blows it in clouds, 
and causes, or aggravates, those ophthalmic troubles to which scrofulous children are 
predisposed. Finally, the temperature of the sea, also that of the air, the fogs and the 
absence of sun, are so many obstacles which render sea bathing in the north of Europe 
uncomfortable, if not impossible, to these unfortunates. These unfavorable conditions 
do not exist on the shores of Riviera, and notably at Cannes. There, no tide or current, 
rarely any surf, a beach gently inclining, porphyric sand too heavy to be lifted by the 
wind and on which the children can walk so easily as to dispense, for the most part, 
with attendants in the bath. The temperature of the water is never so low as to hinder 
the short baths, hydrotheric marine, which constitute the tonic treatment of scrofula. 
Finally, the light and the heat of the solar rays, even in winter, produce a healthy re- 
action after the immersion. 
Because of the presence of these hygienic conditions, Cannes has received every 
winter, from the different northern countries, children afflicted with coxalgia, Pott's 
disease, scoliosis or other bone diseases; children puny or delicate, young girls with SECTION X-DISEASES OF CHILDREN. 
621 
whom menstruation is delayed or difficult, and even rheumatic sufferers. Then, when 
these acute manifestations may have disappeared, and their feeble constitutions are to 
be strengthened, we prescribe for them, not only the sea baths, but also exercise on the 
beach and in the boats on the water. Those who are not able to take the baths by 
immersion, take warm sea baths or bathe in cold sea water at their houses. 
As to the sea bath given warm, we desire, but as yet without entire success, that the 
baths should be heated instantaneously by a current of steam, as is done at the mineral 
baths at Schlangenbad, so as to avoid the partial decomposition of the salt water by the 
prolonged heating. 
Until 1882, the northern children frequenting the beach at Cannes belonged princi- 
pally to families in easy financial circumstances, these only being able to pay the 
expense of dwelling on the sea coast. At this time Monsieur Jean Dollfus generously 
founded a marine hospital for scrofulous children, to the end that those of the poorer 
classes might participate in the benefits. 
Children were sent us from Mulhausen, Paris or Geneva. Those who were subjects of 
pulmonary tuberculosis were not admitted, for the sea baths are not satisfactory to 
them, and we would not risk the connection of children simply scrofulous with those 
affected with phthisis. The children arrive about the first of October and remain until 
the first of June. 
The baths are administered to them on their arrival and are continued as long as 
possible. In 1886-7, for example, the autumnal season lasted until December 23d. The 
children like the baths so that they would voluntarily continue them all the winter. 
The temperature of the sea was 65° in October and gradually descended to 52°, the 
minimum at Cannes. 
It is, therefore, not because of the low temperature of the sea water, but rather that 
of the atmosphere, that we ceased the bathing in the open sea during the winter. Yet 
we know many persons who continue bathing during the entire winter, and it is quite 
possible that we will arrive at this point with some of our children. 
We have never yet found a case of bronchitis, or like affection, which could be attri- 
buted to cold baths; on the contrary, the amelioration of the health of those who were 
specially sick was manifest and prompt. The baths were renewed on the 17th of Feb- 
ruary, when the temperature of the sea was 58°, and were rarely interrupted by atmos- 
pheric perturbations until the close of the season at the end of May. Some of our child- 
ren had running abscesses, but that did not hinder them following the bath treatment. 
The suppuration increased slightly under the influence of the first baths, the edges of 
the sores reddened slightly, but that once passed and a rapid improvement was the rule. 
In some exceptional cases we covered the sores with a protective during the bath, and 
on coming out bathed the parts with soft water. Some of our sick were attacked by 
Pott's disease or scoliose. We put on these Sayre's corsets, which were taken off dur- 
ing the bath. 
We think that the sea baths must be rejected during the period of painful muscular 
contraction of coxalgia. It is necessary, then, that we content ourselves with the 
treatment of immobility, of continued extension and rest at the sea shore. But the 
acute symptoms of contraction once passed, we return to the use of the baths, cease the 
immobility, whether there be suppuration or not, this symptom having only a secondary 
signification and not retarding the final cure. I say even more: in those cases where 
there is suppuration, the treatment is easier, more certain; this prognostication is favor- 
able at least among the children sent to us. The hospital Dollfus commenced in a 
' small villa, much restricted for the number of children under treatment. To avoid the 
evil effects of bad air and odors, the matron had the idea to keep the windows open dur- 
ing the entire day. We were at first opposed to this, but experience proved that the 
children improved so much under this exposition to the fresh air, even during the most 622 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
rigorous days of our winter, that now, instead of combating, we are in favor of the 
system, and it forms part of our treatment. We have not had a single case of bronchitis 
among our children. The only case of acute sickness which we had to treat was our 
cook, who contracted a pleurisy from imprudently sleeping in a damp room. 
We would not prescribe open windows to a new comer unused thereto ; to do this 
would incur a needless responsibility ; but if the children arrive at Cannes in October 
or November, while the season is yet warm, they will soon be prepared by their sea 
baths against any atmospheric changes, and this will be an advantage in securing a gen- 
eral good result to their health. 
One can easily compare the benefits of this hygienic régime with that of the poor 
children penned up in the vicious air of a hospital and in the immediate neighborhood 
of, if not in contact with, other children affected with contagious diseases. 
The results obtained are extremely remarkable. I could give a long list of observa- 
tions, but it will suffice to refer to the many of our foreign confrères who have visited 
the hospital Dollfus and seen for themselves. 
The establishment has just been transferred and enlarged. M. Dollfus has purchased 
a hotel on the Square Brougham, admirably situated on the beach. It is arranged to 
receive forty-five children. Fifteen beds have been reserved for children coming from 
Geneva, through an arrangement made by the charitable committee of that city. 
We can but wish that these establishments should be multiplied, for they will never 
be enough to receive and care for all the children thus unfortunately and sadly afflicted, 
but who, we will hope, can thus be saved to life and restored to health. SECTION X-ORTHOPÆDIC SURGERY. 
623 
ORTHOPÆDIC SURGERY. 
THE TREATMENT OF CONGENITAL CLUB FOOT. 
TRAITEMENT DU PIED BOT CONGENITAL. 
DIE BEHANDLUNG DES ANGEBORENEN KLUMPFUSSES. 
BY MR. WILLIAM E. BALKWILL, 
London, Eng. 
In the few remarks I have the pleasure of addressing to you there is a twofold 
object. As you know, my subject is that of the cure of club foot. The text is aq old 
one, but still worth consideration: to this end I wish to sketch our method in England, 
and so free the way for any discussion that may to our President and yourselves seem 
valuable. It is said that to make an old tree again bear fruit, you must dig about and 
dress the ground; that, I feel, is our position with regard to Orthopaedic Surgery, a 
subject which is but too often relegated to the waste-paper basket. In spite of slight 
differences, our mutual ideas are the same, simply and only the surest and most perfect 
way to alleviate deformity of the feet. To this end I ask you to kindly follow me 
closely, as the subject involves more than superficial thought. In stating the practice 
I have been in the habit of using-and, I am proud to say, never without success-I 
ask your opinion, so that I may take across the water a message from our American, 
Canadian and other brethren. This may well come from the home of specialties. 
To describe club foot is not necessary, so I confine myself to treatment alone. We 
will take, if you please, a case of simple primary congenital talipes equino-varus. 
The child is brought to you at some two or three weeks old, and you have to decide 
w hen to operate, for operate you must ; no extension apparatus is of permanent good. 
Well, the time to be fixed is to be judged by the health, strength and size of the child. 
I have operated at fourteen days and postponed until three or four months older. 
My invariable practice has been-first, to be sure of a really good assistant; secondly, 
to know that my tenotomes are perfect; and, thirdly, to be careful that a flexible splint 
or two, some lint, bandages, and strapping are at hand. Then, with the little patient 
perfectly prostrate on the side, I take a sharp-pointed knife with a large belly, and, 
feeling for the internal malleolus, insert the tenotome in the mesial line until I feel 
the bone ; slightly withdrawing it, I slope the knife until it enters the tendon sheath. 
Then altogether withdrawing the tenotome, its place is taken by a blunt-pointed instru- 
ment, which is inserted with its cutting edge toward the malleolus. The assistant, 
meanwhile, has been careful not to move the foot at all. With-and I wish you to note 
this, gentlemen-careful ease you will find the knife slip into the opened sheath, and 
then your assistant stretches, not too quickly. A snap of the posterior tibial tendon ; 
take your knife away partly, get the assistant to again turn the foot back, again stretch 
it, and the flexor longus digitorum follows. At once place a pledget of lint and strap- 
ping. Get your assistant to hold it, feel carefully for the tibialis anticus, which is, in 
varus, as a rule, just to the inner side of a pucker of skin ; divide, and place the foot in 624 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the same position as prior to the operation. By this you avoid any possible trouble, 
and the quiet stretching afterward gives, in my opinion, a stronger foot, with less chance 
of relapse. After the anterior tibial tendon has been divided, feel for the plantar fascia. 
In a primary congenital case it is very seldom division is necessary. If there be tension, 
divide at once, but leave the Achilles tendon until, by means of the flexible splint and 
bandaging two or three times weekly for three weeks, you are able to proceed further 
to the second stage. This means division of tendo-Achillis. My best results have 
arisen when, instead of extending fully at once and keeping the foot in that position, 
I have taken time over it, and, in fact, used the foot as Isaac Walton did his frog-no 
force, no undue pressure, but a careful guidance. With this, gentlemen-though the 
treatment may occupy longer time, and not so much either-with this and good nursing 
you may always prognosticate a good end. 
Subsequent treatment depends a great deal on the necessities of the case. Some 
require instruments such as I have to show you. Others require well-made boots, with 
stiffening to go even as high as the calf. Given the chance of treatment at an early 
age, little is requisite. In London we have the character of always using so-called 
irons. Our cases are gathered from all over the world, have been mostly neglected by 
their parents after the doctor has said good-bye, and in these relapsing ones all of us 
must apply and devise various supports of divers kinds. Do not be terrified when a 
conscience-stricken mother says: "I will not let my child wear irons." I cannot 
counsel irons for all ; that must be a clinical point. 
These various supports that I have here for valgus, varus, etc., I shall be happy to 
show any of you, or, with our President's permission, hand them round. They are but 
models. As I said before, my object in speaking to you was more to bring forward a 
greater esteem for orthopædism, grasping, as it does, the extremes of all surgery. 
I thank the members of this Section most heartily for their patient hearing. 
SECTION OF CONTRACTURED TISSUES ESSENTIAL BEFORE 
MECHANICAL TREATMENT CAN BE EFFECTUAL. 
SECTION ESSENTIELLE DES TISSUS CONTRACTURÉS AVANT D'EFFECTUER LE 
TRAITEMENT MECANIQUE. 
DURCHSCHNEIDUNG DER VERKÜRZTEN GEWEBE WESENTLICH, EHE MECHANISCHE 
BEHANDLUNG WIRKSAM SEIN KANN. 
BY LEWIS A. SAYRE, M.D., 
Of New York. 
Distortions or deformities which are the result of contractured tissue can only be 
removed by forcible rupture of the same, or by cutting before traction is applied ; but 
similar deformities resulting from simply contracted tissue may frequently be rectified 
by manipulation and constant traction properly applied, without section of the tissue. 
A contracted tissue is one that is simply shortened, but which can be elongated by 
careful, continuous and judiciously applied traction and manipulation, and, therefore, 
does not require to be divided. 
A contractured tissue is one which has undergone some change of structure in the 
fibrillæ of the muscles, and which cannot be elongated or stretched unless the tissues 
are severed or torn, and, therefore, section in such cases is absolutely necessary. Mr. SECTION X ORTHOPÆDIC SURGERY. 
625 
Little, of London, describes this condition as one of "structural shortening;" but I 
prefer to call it contracture, to designate it from the simply contracted muscle. Upon the 
recognition of which class of shortened tissue we are dealing with, will depend the 
selection of the means most proper for the treatment and consequent removal of the 
resulting deformity. And as the two classes demand somewhat different treatment, it 
is well to have some positive rule to aid us in our diagnosis. 
How are we to know whether the tissue is contracted or contractured ? The following 
simple rule, which I have very carefully observed in many hundreds of cases for the 
past twenty years, without a failure in a single instance of its proving to be correct, 
leads me to feel almost justified in laying it down as a law of universal application in 
all cases of contractured tissues. 
If, in any case of club-foot or other deformity from muscular contraction, we stretch 
the shortened parts to their utmost tension by manual force or mechanical aids, and 
when the parts are thus stretched, we suddenly add to the tension by pressing with the 
thumb or finger on the part thus stretched, or by pinching the stretched tissue between 
the thumb and finger, and if, by either of these acts, we produce a reflex spasm or sud- 
den shivering of the whole body, that muscle tendon or tissue thus yielding this reflex 
spasm is contractured and cannot be elongated without severing of its fibres. 
If, on the contrary, when the test is applied, as above described, and no reflex irrita- 
tion or muscular spasm is produced, it is evident that the parts are simply contracted and 
can be further elongated by persistent constant traction and proper manipulation, and, 
therefore, do not require division. 
This is a very important rule to observe in practice, as it will save the surgeon a 
great deal of valuable time, the patient months of useless and unnecessary torture, and 
will always yield the most satisfactory results. 
To attempt to stretch a contractured tissue is to subject the patient to a great amount 
of unnecessary pain, and at the same time run the chance of producing serious disturb- 
ance of the nervous system, as the involuntary contraction or " reflex spasm " of the 
muscular system is produced in a less degree, may be, every time the contractured tissue 
is stretched, and we are all aware of the disastrous results which sometimes follow long- 
continued irritation of the nervous system, both from " reflex " and other causes. 
If a ship is fastened to the dock by a cable stronger than the engine can possibly 
break, she cannot leave her moorings until some one has severed the hawser or else 
loosened it from its attachment. 
The same with any deformity, the result of contracture of any tissue. The deform- 
ity cannot be removed until the contractured tissue is divided. 
In all such cases it is infinitely safer to make such- division by subcutaneous section 
than by manual or mechanical force, as a force sufficient to tear these dense tissues 
could not readily be released before damage to other and more yielding tissues might 
be done. 
By dividing subcutaneously all the shortened or contractured tissues, and hermeti- 
cally closing the wound made by the tenotome, and immediately placing the parts in their 
normal positions, and retaining them there, the space between the severed ends of the 
tendon, muscle or fascia becomes filled with bloody serum or lymph, which being pro- 
tected from atmospheric influences, becomes organized, and makes the tissue thus 
divided as much longer than it was before, as the distance between the severed ends. 
Should the skin be contractured, as is frequently the case, it must also be divided 
freely and the wound stretched until the parts are brought into their normal position, 
allowing the gap to become filled with a clot of blood, which is to be left in situ, and 
being dressed antiseptically, it soon becomes organized and fills the space, without the 
formation of any pus, as has been frequently proved by Dr. Schede, of Hamburg. 
Of course the parts must be kept in their normal position, and at absolute rest until 
Vol. in-40 626 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the new tissue has become thoroughly organized, which generally takes about twelve to 
fourteen days. 
After this has taken place, massage, frictions, active and passive motions, with the 
use of electricity to develop the weakened muscles, together with such mechanical 
appliances as may be required in each particular case, will be demanded and must be 
thoroughly practiced in some cases for many months before the cure will be complete. 
The following cases are very good illustrations of the principles here expressed:- 
Case I.-Congenital double varo-equinus. Eversion shoes with strong traction 
applied when child was eight weeks old, and continued for 14 months. No improve- 
ment. Subcutaneous section of contractured tissues and immediate replacement, fol- 
lowed by rapid recovery. 
Helen A. G., aged sixteen months, daughter of George H. G., of Bergen Point, 
N. J., was brought to me on January 14th, 1887, with congenital double varo-equinus, 
as seen in Fig. 1, from drawing by R. H. Sayre. The mother states that the feet were 
in the same position they are at present when the child was born. When two months 
old was taken to a prominent orthopaedist of the city, who had made for her the exten- 
sion shoes she now has on, and who has had charge of the case for the past 14 months. 
Finding no improvement, they brought the child to me on January 14th, 1887, but I 
Fiy.l. 
refused to take charge of it without consultation with the former attendant. On the 
following day I received a very kind note from the Doctor, stating his inability to be 
present, but requesting me to take charge of the case. 
The condition at the time was as seen in Fig. 1. Both heel cords were very strongly 
contractured, also the tissues in the sole of the feet, especially on the left side ; both 
tibiæ curved out and knees bent in. Child walked with feet at right angles to front 
axis of body. Reflex spasm very marked on point pressure of both tendo-Achillis and 
plantar fascia of each foot, thus showing contracture of these tissues, which had not 
yielded in any perceptible degree to fourteen months of faithful stretching. 
January 17th. Tendo-Achillis and plantar fascia of both feet subcutaneously divided 
by Dr. R. H. Sayre. Feet put in right-angle position and retained by footboard and 
adhesive plaster. 
February 1st. Removed dressings for first time; wounds healed ; outside of foot 
still lower than inside border. The feet were easily forced by the hands into their nor- 
mal position, and retained there by plaster-of-Paris bandage. The feet being held in 
nearly natural position until the plaster "set." 
February 10th. Removed plaster-of-Paris boots; feet improving. Massaged feet SECTION X-ORTHOPÆDIC SURGERY. 
627 
and legs and reapplied the plaster boots, inserting a hook in the plaster bandage on the 
outside of each leg, about the middle of the calf. When the plaster was " set " a strong 
India-rubber band, such as are slipped over letters, was attached to each of the hooks, 
and passing behind the legs, tended by its contraction to evert the feet. These bands 
can easily be increased in number, or made of thicker and stronger rubber, as the case 
requires. When the plaster was " set " and the India-rubber attached, she could walk 
quite well with the toes everted. 
March 1st, 1887. New plaster-of-Paris boots applied. Position of feet improving. 
May 1st, 1887. Various plaster boots have been applied from time to time, as it is 
necessary to change them frequently in a rapidly growing child. 
Is now quite well, as seen in Fig. 2. 
JFicf 3. 
Fiy.2. 
The feet can now be retained in a very good position when the boots are removed. The 
boots, which had been made on the feet, over a very nicely fitting stocking, were cut 
through stocking and plaster in front, from top to bottom, and opened wide enough to 
slip off the feet. The feet and legs were then well rubbed-massaged, electricity 
applied for five minutes, and then the plaster boots were reapplied and secured by a 
roller bandage, and the India-rubber bands attached as before. 
The mother was instructed to remove the boots daily, and after giving similar treat- 
ment to reapply them. July 1st, 1887, very greatly improved, as seen in Fig. 2, from 
photo; can walk well in bare feet, with both feet flat on ground. Ordered ordinary 
laced boots, with high counters to sustain the ankles, in which she walks very well. 
Case II.-Equino-varus, from post-diphtheritic paralysis, tibials of left foot, fol- 
lowed by contracture of tendo-Achillis and plantar fascia. 
Strong traction applied daily for fourteen months without improvement. Section of 
contractured tissues and immediate replacement to normal form resulted in perfect resto- 
ration of natural position and limited voluntary motion inside of four weeks. 
Julius G., aged eight years, son of Sigmund G., of E. 116th street, was brought to me 
May 28th, 1887, with equino-varus of left foot, as seen in Fig. 3, photo, from Dr. E. H. 628 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Sayre. He had had scarlet fever and diphtheria when three years old, which left him 
with more or less deafness of both ears and paralysis of posterior and anterior tibial 
muscles of left foot. 
His father says that he brought the boy to me in the fall of 1885, and that I advised 
an operation at the time ; but that I was sick at the time, and unable to perform the 
operation personally ; he sought other advice. 
The surgeon consulted did not think an operation necessary, but advised massage, 
electricity and the application of " Shaffer's Extension Club-foot Shoe" (see Fig. 4) for 
a few minutes at a time, twice a day. 
This treatment was carried out very faithfully for more than a year, without, as the 
father states, any improvement. His present condition is seen in Fig. 3. Severe pain 
accompanied with strong reflex spasm was produced by point pressure on the plantar 
fascia when stretched, and the same result followed point pressure on pinching of the 
tendo-Achillis when stretched, thus proving both to be in a state of contracture, and 
requiring section before they could be relieved. As the most faithful efforts to stretch the 
parts with Shaffer's extension shoe had been made for more than a year without any 
apparent improvement, the father readily assented to the operation. I at once adminis- 
tered the chloroform and my son, Dr. L. H. Sayre, divided subcutaneously the plantar- 
fascia and tendo-Achillis of the left foot. Immediately closing the wound, and restor- 
Fig. 4. 
ing the foot to its normal position, he retained it there by my usual form of dressing, 
with footboard, adhesive plaster and bandage. A few hours after the operation he had 
to go to Harlem (116th street) to remove the bandage, on account of the pain under the 
great toe. On removing the bandage a small blister was discovered under the great toe, 
from the pressure of a splinter in the wadding. This was removed and the foot 
redressed as at first.* 
This dressing remained undisturbed for 14 days, without the slightest inconvenience 
to the patient, and without any change in the position of the foot or bandage. 
On removing the bandages on the fourteenth day the wounds were found entirely 
healed, without any pus, and the effused material between the severed ends of the 
tendon was so firmly organized that the patient could voluntarily extend the foot 
against a quite firm resisting pressure. 
* After an operation for club-foot and dressing it in the manner I have described, if the patient 
complains of any pain after a few hours, do not give him an anodyne to allay it, but immediately 
remove all the dressing and ascertain the cause of the pain ; by removing it before you replace 
the bandages, you will save your patient from all pain, and avoid any danger of sloughing from 
undue pressure at any point, or of abscess from injury by foreign body, as in this instance. 
This is a very important rule which I wish to enforce strongly. 629 
SECTION X-ORTHOPÆDIC SURGERY. 
A nicely fitting stocking was put on, and the foot being held at a right angle with 
the leg, and perfectly straight, was encased in a plaster-of-Paris bandage from the toes 
to near the knee. The leg being slightly shorter than the other, an oval pad of the 
plaster-of-Paris was placed under the foot to elongate the limb, and when the plaster 
was set the patient was able to walk remarkably well, the oval sole under the foot 
almost compensating for the stiffened ankle joint. He walked upon this plaster sup- 
port for one month, when he was fitted with a nice pair of laced boots with a very high 
counter and elongated heel and sole, in which he walks very well, and no deformity, as 
shown in Fig. 5 (from photo.). 
Case hi.-Talipes equino-valgus paralytica; subsequent contracture of tendo- 
Achillis, and plantar fascia. 
Treated daily for two years and a half by a strong screw extension apparatus with- 
out any improvement, but producing great disturbance of the nervous system. Sub- 
cutaneous section of the contractured tissues and immediate replacement of parts to 
Fia 5. 
normal position resulted in perfect recovery of form and partial voluntary motion, in 
two months. The only deformity remaining being the shortness of the limb. 
G., aged six years, 743 Broadway; always healthy until three years of age, when 
she was confined to bed for a week with severe indigestion and a very high fever 
(probably spinal meningitis). When she attempted to get up it was discovered that 
she hßd lost the power of moving either lower extremity. She recovered partial 
power of the left leg in about two months, and could flex the right thigh slightly, but 
could not extend the leg upon the thigh. The right heel began to draw up and the 
foot to evert ; was treated for six months by electricity and massage, but made no 
improvement. A brace was applied, which she wore for two months, but it caused so 
much pain that it was abandoned. She was then placed under the charge of a special- 
ist, an orthopaedic surgeon, who applied his peculiar club-foot shoe, with a powerful 
screw worked by ratchet and key, for the purpose of stretching the tendo-Achillis and 
plantar fascia. 630 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The child was taken to the surgeon's office daily during the winter, and every 
other day during the summer (when they were at their country seat, out of town) for 
two years and a half, for the purpose of having his personal adjustment of the appa- 
ratus. Another special shoe was worn during the night. As there was no improve- 
ment in her condition, her uncle, Dr. Purron sent her to me on the 27th of June, 1887. I 
sent her back with a request to bring her former attending surgeon, if they wished me 
to examine the child. Dr. Purron came with the child himself, on the 29th, and 
requested me to take charge of the child, as her former surgeon was absent from the 
city. 
On removing the apparatus I found the limb two and three-quarter inches shorter 
than the other, with extreme equino-valgus, with contracture of tendo-Achillis and 
plantar fascia, both giving reflex spasm on point pressure when stretched. 
As the most faithful efforts had been made to stretch the parts for two years and a 
half, without, as the Doctor stated, the slightest improvement, he readily assented to 
my operating. 
Assisted by Dr. Purron and my son, Dr. L. H. Sayre, I subcutaneously divided the 
tendo-Achillis and plantar fascia, and dressed in my usual way, on June 29th, 1887. 
The tendon was unusually hard and very difficult to cut. I have noticed this fact 
in many cases where they have been subjected for a long time to extreme traction. 
lïq 6. 
Does this severe traction produce inflammation and condensation of the tissues ? 
June 30th. Perfectly comfortable; slept well all night; foot in good position; went 
to the country. 
July 30th. To-day dressed the foot for the first time since operation. Bandages 
and footboard exactly as when applied fourteen days ago. Aunt says the child is very 
much less nervous, and sleeps well. 
Wounds perfectly healed. Tendo-Achillis firmly united, and can extend the foot 
voluntarily. 
Put on stocking, placed foot at right angles and applied plaster-of-Paris bandages, 
with extra roll of plaster under foot, to equalize the length of legs, as shown in 
Fig. 6. 
July 13th. Walks well on plaster boot, the rounded and elongated sole almost 
compensating for the stiffened ankle joint. 
Aug. 12th, 1887. Has been running with the other children for the past month, 
and is in perfect health, as seen in Fig. 7. 
Removed the plaster boot, and had her measured for a pair of laced boots. The one 
on the left foot to be elongated and rounded, similar to the plaster-of-Paris-boot. SECTION X ORTHOPÆDIC SURGERY. 
631 
A photograph of her in her shoes was taken at this time by Dr. R. H. Sayre (see 
Fig. 8). 
The two following cases have already been published in the New England Medical 
Monthly of November 1886, but as they very strongly illustrate the principles I have 
endeavored to inculcate in this paper I have concluded to add them to my report. 
Case I.-Some three years since, Dr. T. Gaillard Thomas brought a gentleman to 
my office with his little son, about six years old, who was suffering from congenital 
equino-varus of both feet in a very marked degree. 
He had been subjected to various treatment since early infancy, and for the past 
twelve months had been visited daily at his house by a prominent orthopaedic surgeon 
of this city, who had applied for a few minutes to each foot daily, during all this time, 
7. 
Fig 8. 
a shoe of his own construction, which was capable of making very powerful traction upon 
the contractured parts; but as the father and Dr. Thomas both stated, without having 
produced the slightest change in the deformity. 
But the effect of the torture had made such an impression on the child's nervous 
system that he was almost ungovernable and would submit to the treatment no longer. 
Upon stretching his foot with one hand, and pressing with the fore-finger of the other 
on the tense plantar fascia, an instantaneous spasm of almost all the muscles of the body 
was produced, and the child screamed in agony. The same result was produced when 
the same test was applied to the plantar fascia of the other foot, and also when applied 
to the tendo-Achillis of either side. 632 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Thomas was convinced, after this examination, of the folly of attempting to 
stretch such tissues, and advised the father to place the child under my care. 
The same afternoon I went to his house in the upper part of the city, and assisted 
by my son and Dr. Develin, who administered the chloroform, and in the presence of 
Dr. Walker, Dr. Thomas' assistant, I divided subcutaneously the plantar fascia, tibialis 
anticus, and tendo-Achillis of either side, and immediately restored the feet to their 
normal position, and dressed them in my usual way while he was still under the anaes- 
thetic; but this plan of dressing is so fully described in my " Manual of Club-Foot," 
and in my lectures on ' ' Orthopaedic Surgery, ' ' that there is no occasion to repeat it here. 
I visited him on the following day, and to my surprise he put out his hand and greeted 
me with a cordial welcome, instead of screaming, as the mother said he had always done 
before when any doctor came to see him. The father said that he behaved so differ- 
ently from what he had ever done before, and seemed so happy, that he acted like a 
" reconstructed ' ' boy. 
The dressings were removed for the first time on the fourteenth day, when all the 
wounds were perfectly healed, without a drop of pus, and the Achillis tendon of either 
side was so firmly united that he could voluntarily extend either foot even when quite firm 
resistance was made against the bottom of the same. He was measured for a new pair 
of shoes, as his feet were so much longer that he could not wear his old ones, and the foot- 
board and adhesive plaster re-applied for another week, as a means of protection until 
the organization should become more firm. Three weeks from the time of the opera- 
tion he walked very well, with both heels upon the floor, in an ordinary shoe, simply 
requiring Hudson's elastic attachment to aid in flexing the feet. 
These he wore for nearly a year, when, by the daily use of electricity, massage and 
manipulation, his cold and atrophied legs had become so well developed that he could 
run and play with the other children, without any artificial support whatever, and has 
remained well until the present time, with constant improvement in the development 
of his lower extremities. 
Case II.-John S., of Brooklyn, aged nine, was brought to me on the 15th of July, 
1886, with a very marked equino-varus of the right foot, with severe contraction of the 
plantar fascia, standing on the ball of the great toe, as seen in Figure 9. 
The mother says that the child was perfectly natural at birth, but that when eleven 
weeks old it rolled over on its face in the bed and was nearly suffocated. Two days 
later it had convulsions, which were repeated at intervals for two days, during which 
time the bowels were obstinately constipated. After forty-eight hours a passage from 
the bowels was effected and the convulsions ceased. Some weeks afterward it was 
noticed that the child had lost full control of the muscles of the eyes, being unable to 
move the eyes in all directions as it formerly had done. This gradually disappeared, 
and when he began to sit up the mother noticed that the feet were strongly drawn 
backward, and the knees widely separated. When he began to stand he did so on his 
toes, the heels of both feet being strongly drawn upward. Wore braces of different 
kinds, without benefit, and when he was twenty-four months old was taken to a public 
institution in this city, where the surgeon divided the tendo-Achillis of either side, and 
succeeded in obtaining an excellent result on the left side, but the right one was very 
unsatisfactory. 
He remained under treatment for two years after the operation, without any improve- 
ment in the right foot, and in February, 1885, he went to another institution in the 
city, where the surgeon applied an "extension shoe," similar to the one described in 
the previous case. 
This shoe was personally applied by the surgeon once every day from February until 
the 1st of May, and from May until July it was applied twice a day by the parents, but, 
as they state, without producing the slightest change in the position of the foot, although SECTION X-ORTHOPÆDTC SURGERY. 
633 
the traction power of the instrument was so great as to cause the child to suffer intense 
pain, which frequently lasted for some time after the "extension shoe" had been 
removed. 
The parents therefore decided to try some different treatment, and brought him to 
me on the 15th of July, 1886. On extending the foot and making pressure with the 
finger on the plantar fascia an instantaneous shivering of all the muscles in the body was 
produced. The same result followed point pressure on the tendo-Achillis when stretched, 
only in a much more marked degree. This shivering or tremor of the whole body is 
what I mean by the reflex spasm produced by point pressure on stretched tissues, and 
Fig. 9. 
proves that those tissues are contractured and must necessarily be divided before any 
elongation can be produced. 
As the case was one in which traction had been thoroughly tested by a perfectly 
competent surgeon, and without any improvement, according to the parents' account, I 
decided to cut him. I sent a request for the surgeon who had attended him to be 
present at the operation, and sent the boy to the photographer's, and Fig. 9, from the 
Moss Engraving Company, gives an exact representation of his deformity. At 3 P.M. 
of the same day, July 15th, assisted by my son, Dr. L. H. Sayre, Dr. J. Woodbury 
and Dr. E. Develin, who administered the chloroform, I divided subcutaneously the 
plantar fascia and the tendo-Achillis, and immediately brought the foot into its normal 634 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
position by considerable force, and dressed it in my usual way, as above described. Only 
a few drops of blood were lost in the operation, but the space between the severed ends 
of the divided tendo-Achillis was much greater than in any of my previous operations. 
Unfortunately the gentleman whom I had invited to see the operation was out of the 
city, and therefore could not be present. 
No local or constitutional irritation of any kind followed the operation. The child 
slept soundly every night without opiates, and ate his meals with perfect regularity. 
The bandages were never changed in the slightest degree until the 31st of July, just 
sixteen days after the operation, when they were removed for the first time, in the pres- 
Fig. 10. 
ence of my son, Dr. Develin and Dr. John F. Ridlon. The wounds were all healed, 
without the formation of a drop of pus; could flex and extend the foot, showing that 
the tendo-Achillis had united, and could stand erect with heel upon the floor. Left for 
his home in Brooklyn that afternoon. 
August 6th. Boy at office; foot in perfect condition, but from too much exercise and 
the pressure of a tight-laced shoe there was a slight abrasion of the skin near the wound 
in the tendo-Achillis. 
The mother stated that he was so happy in being able to walk that he got a number 
of boys in the back yard with some goats, and as some of the boys had seen the lassoing 
by " Buffalo Bill" in the ''Wild West," then performing on Staten Island, they SECTION X-ORTHOPÆDIC SURGERY. 
635 
attempted the same performance on the goats, and in this way he had hurt his heel, 
and finding a little moisture on his stocking she had brought him to see me. Fearing 
that too much motion might extend the irritation to the deeper and j ust newly-organ- 
ized tissues, I put on his stocking and applied over it a plaster-of-Paris bandage, thus 
immobilizing the ankle joint. When the plaster was hard I cut a fenestra through the 
plaster and stocking on the abraded part and dusted it with iodoform. 
He was able to walk without any trouble, but with no motion at the ankle. 
He wore the plaster cast until the 16th of August, when I removed it and found the 
abrasion entirely healed, the foot in good position, and he was capable of flexing and 
extending it quite freely, and walked with his heel firmly on the floor. 
Figure 10 was taken on that day, August 16th, just one month and a day after the 
operation, and illustrates practically the result of the treatment. 
August 28th, walked across the Brooklyn bridge without assistance, a distance of 
half a mile or more, and can run up or down stairs without limping. 
Foot in natural position; requires merely time, massage, electricity and exercise, to 
develop his atrophied muscles, to make the cure complete. 
DISCUSSION. 
Dr. A. B. Judson, New York.-The treatment of congenital club-foot should 
be divided into two stages by the arrival of the time when the child begins to try to 
stand. Before that time, in the period during which the child's weight does not 
interfere with corrective procedures, the varus should be reduced by whatever means 
may be at hand-a succession of carved-wood splints, tractable metal splints, adhe- 
sive plaster, plaster-of-Paris splints, the artificial muscles, or a combination of these 
methods, one with another, or with tenotomy, as the case may require. Whatever 
the plan adopted, by the time the child begins to put his weight on the foot, the 
varus should be so far reduced that the sole is presented squarely to the ground. Of 
course, if nothing further be done, the varus would return when walking begins, and 
would soon be as bad as ever, and what is now required in this, the second stage of 
Fig. 11. 
treatment, is a slight splint extending up the inner side of the foot and leg, and so 
furnished with buckles and webbing that pressure may be applied from within out- 
ward along the inner border of the foot and at the inner and upper part of the leg, 
and from without inward in the neighborhood of the ankle. This club-foot shoe or 
splint is more efficient if made without a movable joint at the ankle. It should be 
made of tractable steel, so that it may be bent from time to time, and thus take the 
lead as the foot improves in shape, and requires patient attention on the part of the 
surgeon to secure at all times an efficient and comfortable fit. Its efficiency may be 
greatly increased by the untwisting force of a strip of adhesive plaster and webbing 
wound around the foot and buckled to the upright portion of the foot piece, as 
shown in Fig. 11, which represents schematically a transverse vertical section of 
the foot and foot piece, the broken line representing the plaster, the dotted line the 636 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
webbing, and A the place for the buckle. The object of the splint is to give the 
foot a push toward the position of valgus, so that when the child steps the sole will 
present squarely to the ground or a little more than squarely. Every footfall will 
then be an impulse in the right direction, applied with the force of the rapidly 
increasing weight of the child. 
Mr. Edmund Owen, London.-Mr. Balkwill has come forward as the repre- 
sentative of the old-fashioned treatment of club-foot, and as such he narrows the 
issue to the difference between that and the modern or American method. This 
being so, I am glad to say that I am, and have been for some years, as heartily devoted 
to the American plan. The old plan consisted in dividing first the tendon of the 
tibialis posticus, and, perhaps, also that of the flexor longus digitorum, and then in 
putting the foot up in only a slightly improved position ; then, when it was supposed 
that plastic effusion had connected the divided ends of the tendon, to begin with 
Scarpa's shoe to correct the inversion. Later on, perhaps weeks afterward, when 
the inversion had been fairly dealt with, the tendon of Achilles was divided, and in 
a few days flexion of the foot was started with. This plan is now, even in England, 
giving place to the method of dividing all the tendons at one and the same time ; and 
not only that, but bands of fascia and ligaments were also divided. I wish to call 
particular attention to the need of dividing the anterior part of the internal lateral 
ligament of the ankle joint, which was much concerned in keeping the front part of 
the tarsus flexed and inverted on the head of the astragalus, Scarpa's shoe, together 
with mechanical spinal supports, should be relegated to the limbo of extinct surgical 
instruments ; the introduction of the plaster-of-Paris method of treatment had 
rendered them superfluous. There need be no fear of failure of union occurring in 
the divided tendon after putting the foot at once in the correct position ; plastic effu- 
sion and blood in the sheath of the tendon quickly prepared the way for an efficient 
splicing of the tendon. 
I cannot accept entirely all that Dr. Sayre has said as to the difference between 
contractured and contracted tendons. I do not deny its existence, in fact, but am not 
prepared to accept it, but commend in the highest terms Dr. Sayre's teaching and 
practice. 
Dr. Lewis A. Sayre, New York.-The treatment of congenital talipes should 
be begun immediately after birth. If prompt treatment were the rule, section of 
tendons would rarely be called for. 
Dr. E. R. Lewis, Kansas City, Missouri.-The distinction made by Dr. Sayre 
between contracted and contractured tendons, if it proves to be a reliable guide, is 
an important diagnostic sign in considering the question of operative interference. If 
I mistake not, the late Prof. S. D. Gross taught, years ago that the administration of 
chloroform would lead to a correct decision of the question. I have used this method 
in torticollis and talipes with good results, but I shall resort to the method of Dr. 
Sayre, and feel amply repaid for my trip to Washington if it proves as certain as I 
think it will. 
Dr. W. N. Hingston, Montreal.-I would like to ask Mr. Balkwill if, in stating 
he had operated on no child under fourteen months of age, he intended it to be 
understood that he discountenanced operations on children at an earlier period. My 
views on the question of the time of operating have undergone great modifications. 
Formerly, it was usual to delay operating till after the period of teething, at least, 
but the terse words of Dr. Sayre, written some years ago, that one is warranted 
in delaying an operation only till the tenotome can be procured, is an advice SECTION X-ORTHOPÆDIC SURGERY. 
637 
which I have followed from the time they were uttered, with ahnost invariable 
satisfaction. 
A very marked distinction is made by Dr. Sayre between contracted and con- 
tractured tendinous tissue. Does he apply the latter term to a tendon which he has 
already divided, and which, having united in a faulty manner, the question of 
re-division or stretching presents itself? How soon after division was the foot put 
into restraining apparatus ? 
Mr. Balkwill.-I am in favor of early operations for dub-foot. I have never 
operated earlier than fourteen days, and do not think anything is to be gained by 
operating earlier than that. I have also postponed the operation for three or four 
months, for what appeared to be sufficient reasons, and have secured as good results 
as could have been obtained by an earlier interference. 
Dr. Lewis A. Sayre.-I place the foot, forcibly stretched to its position, in plaster 
immediately after section. If I see the case as an original one, I never have to 
re-divide ; but frequently cases come to me from other practitioners who have failed, 
and then I do not hesitate to re-divide the tendon. 
Dr. D. A. K. Steele, Chicago.-I came to the Section a strong partisan of 
American surgery, but if Mr. Owen's views and methods prevail in England, I am 
as firm an adherent of English surgery. The results of our experience in Chicago 
have suggested the following rules : (1) Operate as early as the child is brought, 
provided the tendon is shortened. (2) Divide all tissues that prevent perfect resto- 
ration of the foot. (3) Retain the foot in a correct position by plaster-of-Paris 
dressing applied over cotton batting and carried above the flexed knee, to prevent 
rotation. (4) Leave the toes uncovered, in order to watch the circulation. (5) Let 
the entire procedure be clean, aseptic and antiseptic. 
PRINCIPLES OF PROGRESS IN ORTHOPÆDIC SURGERY. 
PRINCIPES DE PROGRES DANS LA CHIRURGIE ORTHOPÉDIQUE. 
GRUNDSÄTZE DES FORTSCHRITTES IN DER ORTHOPÄDISCHEN CHIRURGIE. 
BY MR. NOBLE SMITH, 
London. 
Progress in any science can take place only when correct principles are followed out, 
and I would urge that orthopædic surgery should be studied and practiced upon some 
such basis as that which I here suggest. I advance the following propositions:- 
I. THAT IT IS ABSOLUTELY NECESSARY FOR THE SURGEON TO POSSESS MECHANICAL 
APTITUDE BEFORE HE CAN DEAL SUCCESSFULLY WITH THE CASES INCLUDED IN 
ORTHOPÆDIC SURGERY. 
In the first place, the surgeon ought not to leave to the instrument maker the devis- 
ing of new or the modification of existing instruments. This fact is much more appre- 
ciated in the United States of America than it is in England. 
In the second place, even where no instrument is required, the appreciation of 
mechanical principles and the solving of mechanical difficulties form a very important 
part of the orthopædic surgeon's work. 
The advantage of dealing with orthopædic surgery as a special branch is based upon 638 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the mechanical nature of the treatment, and this "mechanical nature" not only 
includes the use of instruments, but the adaptation of mechanical principles to every 
plan of correcting deformities: First, in mechanically applying antagonistic forces to 
counteract the abnormalities, whether (a) by operation, (ft) by mechanical appliances, 
(c) by muscular exercises, (d) postures, or (e) by the combination of two or more of 
these forces. 
To enlarge somewhat upon these points:- 
(а) In counteracting abnormalities by operation, a very familiar instance may be given 
in the appreciation of the necessity of reserving operation upon the tendo-Achillis in cases 
of talipes varus until the inversion of the foot has been overcome, i. e., the appreciation 
of the mechanical value of the fixation of the heel in the treatment of the inversion of 
the foot. 
(б) In the application of mechanical appliances. It is very desirable that the surgeon 
should possess the ability himself to adjust all instruments to the patients and make 
alterations in them as the case proceeds, and this obviously requires mechanical apti- 
tude. 
(c) By muscular exercises. These should also be applied upon mechanical principles. 
An instance of fault in this respect is the manner in which exercises have been devised 
for the treatment of lateral curvature. It has been suggested, and is a not uncommon 
practice (at least in England), to recommend that the patient should exercise upon a 
trapeze or horizontal double bar, with the arm upon the side of the dorsal concavity 
raised higher than the other arm, with the view of drawing out the concave part of the 
spine. The surgeon who applies mechanical principles to this subject will see that as 
the muscles connecting the arm with the back are attached to the apices of the spinous 
processes of the vertebræ, the chief effect of acting with increased force upon these 
muscles will be to increase the rotation of the bones by the leverage exerted upon their 
spinous processes, whereas, bringing the arm into action upon the convex side from before 
backward, will tend to draw the vertebræ, by the same muscles upon this side, out of 
their rotated position toward a normal one. This is only a very general description 
of the theory involved, many particulars of detail having to be observed to carry out this 
system with effect. 
(d) By posture. Here, again, it is obvious that mechanical principles are generally 
involved. To give an instance, I may refer to the fact that although it has for long been 
recognized that flexion of the spine increases the rotation, yet it has not been usually 
taught that enforced extension (not longitudinal extension, but the reverse of flexion) 
may be made a valuable method of removing this condition. 
II. THAT THE SURGEON SHOULD AIM AT SIMPLIFYING MECHANICAL APPLIANCES. 
This principle, it might be thought, "goes without saying;" but if we study the 
figures of machines to correct deformity as portrayed in mechanician's catalogues of 
the present day, another opinion must be arrived at, namely, that a large field is open 
in this direction. 
A simple metal splint, adaptable by the surgeon, might often take the place of many- 
jointed Scarpa's shoes and elaborately made apparatus for straightening fingers. 
A gutta-percha mould or plaster bandage will often prove a more effectual method 
of retention or support than the more expensive appliances. 
III. THAT JUDGMENT AS TO COMPARATIVE ADVANTAGES OF OPERATION AND MECHAN- 
ICAL PRESSURE SHOULD BE CAREFULLY AND FAIRLY GAUGED. 
Upon this point I will take as an example the subject of osteotomy for knock-knees. 
The brilliancy of the operation, the value of which in some cases I fully appreciate and 
observe, seems to have unhinged the discretion of some surgeons of the day. They SECTION X-ORTHOPÆDIC SURGERY. 
639 
have adopted this means as a sure and certain plan of straightening the limbs, and 
have dismissed as useless an older method which they have not the skill or patience 
to conduct. 
It is not a matter of opinion, but of fact, that the former treatment is not so abso- 
lutely certain in its ultimate effects, while the latter, when judiciously applied, will 
lead to excellent results in many cases. 
IV. THAT NATURAL FORCES SHOULD BE USED AS MUCH AS POSSIBLE TO ACT 
remedially, both by (a) exercises, and also (&) by directing the natural move- 
ments of the body when applying instruments. 
With regard to the first (a) nothing need be added, but in explanation of the latter 
(&) it may be stated that when instrumental treatment is required (apart from the 
immediate treatment after operation and the fixation of inflamed joints), the apparatus 
should be so constructed and applied that the actions of the body are utilized as much 
as possible to perform the necessary correction, and as little dependence as possible 
placed upon statical force. 
As an example, the support of weak joints may be referred to where, instead of 
fixing or firmly encompassing such joints by firm bandages, a not too tightly fitting 
apparatus, which prevents irregular movements, while permitting freedom to those 
which are normal, will tend to cause the natural movements to bring about a cure 
without perpetuating the existing weakness. 
An elastic bandage or lacing knee cap is often thought to be a simpler contrivance 
for these cases than a steel support. Whereas, the former conduces rather to a perpet- 
uation of the evil, while the latter, if skillfully constructed, should act in the manner 
described above (of course, there are some cases in which the elastic bandage or knee- 
cap is necessary). 
V. THAT THE SURGEON SHOULD CONSIDER THE PECULIARITIES OF EACH INDIVIDUAL 
CASE, AND NOT DEPEND UPON CONVENTIONAL MECHANICAL MACHINES. 
VI. THAT IN DEVISING MECHANICAL APPARATUS, WE SHOULD TAKE INTO CON- 
SIDERATION THE VARIOUS MOVEMENTS OF THE BODY, AND NOT ATTEMPT TO 
ADAPT A MACHINE AS IF IT WERE BEING APPLIED TO AN IMMOVABLE 
STRUCTURE. 
Probably the cases in which it is most important that this principle should guide 
us, is in the use of apparatus for the spine. Even in cases of diseased bones, where 
fixation is our chief object, consideration for the usual movements of the trunk is 
necessary in first arranging such supports, and it is only by degrees that carious spines 
can be comfortably brought into a posture of complete repose. In lateral curvature 
spinal instruments are only justifiable when they permit the action of spinal muscles 
and allow movement to the trunk. 
The progress of orthopaedic surgery must, I think, be based upon some such prin- 
ciples as those which I have sketched. 
In conclusion, I would add a few salient points which, I think, we should bear in 
mind when determining as to the use of mechanical appliances :- 
1. Necessity. 
2. Efficiency. 
3. Lightness, in compliance with the necessary strength. 
4. Simplicity. 
5. Construction admitting of alteration by the surgeon himself. 
6. Construction being such that while fulfilling the above requirements, instruments 
should be as inexpensive as possible, both as regards first cost and small liability to 
require repair and alteration. 640 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE TREATMENT OF LATERAL CURVATURE OF THE SPINE. 
TRAITEMENT DE LA COURBATURE LATÉRALE DE L'ÉPINE. 
DIE BEHANDLUNG DER SEITLICHEN VERKRÜMMUNG DER WIRBELSÄULE. 
BY DR. JAMES KNIGHT, 
New York. 
Viewing the human form in the erect position, we observe that the entire weight of 
the body is borne upon a very limited base, the outline of which is an ovate circle, 
formed by the two feet placed together. The inner border of the outline of each foot 
presents a concavity directed inward, which is the lateral counterpart of the vertical 
curve called the arch of the foot. The only other plantigrade animal walking erect is 
the bear, whose foot is lacking in the elastic arch and the curvilinear inner border. 
Man, therefore, has much the advantage of the bear, inasmuch as the elastic arch of 
the human foot and coordinated muscular action render possible a great variety of atti- 
tudes and motions, with the maintenance of equilibrium. But this extraordinary and 
unequally distributed demand on muscular power may be attended by an impairment 
of force on the part of a muscle or group of muscles, thus producing an impairment of 
equilibrium. 
This view leads to an appreciation of the readiness with which a loss of equilibrium 
of the spinal column is induced in predisposed persons, who habitually adopt strained 
positions of the body, and especially in females who sit for a long time using the right 
hand and arm in knitting, crocheting and doing fine needlework, or who rest a 
burden on the left hip while using the right arm, as is the habit of young girls 
who carry a babe while dusting the room. This leads me to the observation 
that liability to lateral curvature depends in a large degree on the station in lite 
occupied by the individual. We have the independent élite who perform no manual 
labor. We also have families of the middle class, in which the greater part of 
the labor is done by hired help, while the daughters of the family are often found 
performing hand-sewing and at times sweeping with a heavy broom, which requires 
the shoulder to be advanced, and sometimes pressing ruffled dresses, fine laces, etc., 
with a heavy iron, which requires severe muscular exercise of the right arm and 
shoulder. It is this female labor that presents a most important factor in tendency to 
lateral curvature of the spine, and that curvature to the right side. The wealthy do 
not labor thus, and the indigent laboring female invigorates her muscles by more gen- 
eral exercise in the ordinary pursuits of her life. Hence it is that the largest number 
of cases of lateral curvature of the spine is to be found in the middle class of society, in 
girls from twelve to fourteen years of age. 
In considering the subject of treatment it is necessary to restore that uniformity 
of development which is found in the normal child, and the earlier this is attempted 
the better. The tendency of the body is to be depressed by the force of gravitation, 
which is imperfectly opposed by the muscular power of the trunk. It is, therefore, 
harmful, rather than beneficial, to place weights on the head, as is often done in the 
management of these cases. The immediate object of treatment should be to 
encourage the extension of the muscles, and this is best done, not by limiting our atten- 
tion to the muscles which are believed to be affected, but rather by placing the whole 
body in such an attitude that the muscles will be stretched and the deformity reduced. 
Such attitudes should be assumed in frequent exercises, and the improvement thus 
gained should be maintained by a brace worn in the intervals of exercise. It has been 
observed that patients who apply for treatment are often in a poor general condition, 
with loss of appetite and a haggard appearance. Their condition forces them to come 641 
SECTION X-ORTHOPÆDIC SURGERY. 
for advice, and as they attend punctually to the treatment they are relieved. The 
health of the patient must be carefully attended to during the progress of treatment. 
The parallel bars furnish the best form of exercise, and these should be used twice a 
day for five minutes, having the brace loosened or taken oif during the exercise, and 
afterward laced tightly. The patient being relieved of all clothing that would in the 
least restrict muscular exercise or freedom, the bars should be elevated so as to only, at 
first, permit the person to sustain the upright position upon the extreme ends of the 
toes, the body and lower limbs being, as nearly as possible, suspended by the vertical 
support of the arms upon the bars. This position having been attained, the patient 
should then be directed to flex the leg to a right angle with the body, and to keep up 
an alternate extension and flexion of the body and legs until fatigue gives notice of the 
necessity of rest, when a suitable support of equal elevating force should be applied to 
the body while in a suspended position. 
The brace (figured below) consists of upright bars, but the sides and back consist of 
extending bars from below the hips to the axillæ, and shaped to conform to the body 
in a normal state. They are conjoined by riveting them to a belt bar, more than half 
encircling the body for the upper circle and the same for the hips. In a line from the 
hips upward (for an ordinary person) a four-inch plate, about four inches square, for the 
right shoulder, and two cross strips of steel about two inches lower down, thus form- 
ing a waist, and you have the steel frame ready for a brace. The steel is three-eighths 
of an inch in width and not one-eighth of an inch in thickness, which is heavy enough 
if the metal is fine. It is covered with twilled muslin, the steel having a padding of 
blanket, which is increased in thickness under the arms. There are straps to pass over 
the shoulders, and all the bars have an outer covering of leather. The lacing in front 
is attached to the two bars which extend from below the hips to the armpits, and made 
to fit the body properly immediately in front of the lacing. 
The braces are intended to maintain what has been gained by extension upon the 
bars; hence, the necessity of lacing up carefully after exercising, in order not to lose 
what has been gained by the practice on this valuable means of relief. Tight lacing 
in other circumstances has proved a serious matter, but lacing as here directed is difier- 
Vol. Ill-41 642 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ent, because the upright bars prevent any injury which lacing under ordinary condi- 
tions might inflict. The bars press outward over the irregular surface so as to protect 
the rest of the body. 
During a period of twenty-three years 2072 cases of lateral curvature have been 
treated in the Hospital of the New York Society for the Relief of the Ruptured and 
Crippled. Of these, 1667, or 80.5 per cent., were females and -405, or 19.5 per cent, 
were males. 187, or 9 per cent, were over twenty-one years of age, 976, or 47 per 
cent., were between fourteen and twenty-one years, and 909, or 44 per cent., were under 
fourteen years. Many of the latter class were obscure in their origin, some being con- 
genital and others the result of pulmonary disease. Of the whole number, 1723, or 
83 per cent., were of the projecting right shoulder, and 349, or 17 per cent., were to 
the left. 
THE AMERICAN HIP-SPLINT. 
ÉCLISSE AMÉRICAINE DU FEMUR, 
DIE AMERIKANISCHE HÜFTSCHIENE. 
BY DR. A. B. JUDSON, 
New York. 
In the present Congress, the first held in America, it will not be thought inappro- 
priate to devote a short paper, chiefly historical in its character, to the American splint 
for the treatment of hip disease. 
This apparatus was first described by Dr. Henry G. Davis and Dr. Lewis A. Sayre, 
in the April number of the American Medical Monthly, published in 1860. These two 
surgeons wrote independently, but by a curious coincidence they both described a new 
splint which was recognized as an important invention, not only in this country, but 
especially in England and France, where it was known as the American splint. Under 
this name it has been described and discussed by Edwards', Barwell2, Holmes3, Marsh4, 
Adams5, Thomas6, Bouvier7, Le Fort7, Velpeau7, Verneuil7 Giraldes7, Armand8, E. 
Boeckel9, Hennequiu10, Monod" and Philipeaux12, and doubtless by other eminent 
European surgeons. 
It will be interesting to inquire whether the name American has been rightly given 
to this apparatus? As first described, in 1860, it has two important features: (1) A 
perineal strap or ischiatic crutch-head, for the purpose of keeping the weight of the 
body from resting on the affected limb, the patient being thus enabled to engage 
actively in ordinary pursuits while wearing the splint and (2) adhesive plaster applied 
with the view of making traction on the limb. 
1 Edinburgh Medical Journal, June, 1861, p. 1118. 
2 Lancet, Nov. 7th, 1863, p. 530. " Diseases of the Joints," 2d Edition, London, 1881, p. 467. 
3 " Diseases of Infancy and Childhood," 2d Edition, London, 1869, p. 432. 
4 British Medical Journal, July 28th, 1877, p. 98. 
6 British Medical Journal, Jan. 5th, 1878, p. 10. 
6 " Review of the Treatment of Hip Disease," Liverpool, 1878. Preface. 
T Bull. de la Soc. de chir. 1866, pp. 122, 126, 147, 154. 
8 Thèse de Paris, 1878, p. 37. 9 Bull. gén de Thérapeutique, 1875, p. 451. 
10 Arch, gin., Jan., 1869, p. 62. n Arch, gin., June, 1878, pp. 704-712. 
12 "De la Coxalgie," Paris, 1867, pp. 261, 262, 284. SECTION X-ORTHOPÆDIC SURGERY. 
643 
In regard to these two features, ischiatic support and traction by the use of adhesive 
plaster, the first was not an American invention, nor was it a novelty. Support of 
this kind had been used for a long time in the construction of artificial limbs, and even 
in the treatment of hip disease the possibility of so supporting the body had occurred 
to M. Ferdinand Martin, a wood-cut of whose splint is found in Bonnet's "Treatise on 
Diseases of the Joints," published in 1853. 
But when we come to consider the other remarkable feature of this splint, we 
recognize a real advance in mechanical surgery, and one which may rightly be called 
American. The use of adhesive plaster for prehension of the limb, in the treat- 
ment of fracture of the long bqnes, was an American invention, and the transfer of this 
device from the treatment of fractures to that of hip disease was first effected in the 
new splint. For many years it had been a common practice in the treatment of hip 
disease to make traction with the long splint for fracture of the femur, prehension of 
the limb being made by a gaiter, or fillet or handkerchief placed around the ankle. 
These instruments of torture were supplanted in the new hip splint by the abso- 
lutely comfortable and convenient adhesive plasters. Thus we see that the new splint 
was a combination of an old device, ischiatic support, with an American invention, 
traction by adhesive plaster, and as the happy combination was made in America, it is 
not strange that the courteous attitude of European surgeons toward the surgery of a 
comparatively new country, led them to call the new method the American method, 
and the new splint the American splint. 
Following the history of the hip splint in this country for the past twenty-seven 
years, one is amazed at the great number of the so-called improvements that have been 
made upon it. The most important has been a perfecting of that part of the apparatus 
which provides for ischiatic support of the body in standing and walking. The first 
splint did not extend to the ground, but depended on the integrity of the plaster adhe- 
sion for keeping the weight of the body from resting on the inflamed joint. Dr. 
Edmund Andrews,1 of Chicago, and Dr. C. Fayette Taylor,2 of New York, proposed 
and perfected an extension of the splint to the ground, pnd thus left but little to be 
desired as an ischiatic crutch. Aside from this great improvement no essential changes 
have been made. Experience and increasing light have shown that certain things 
which it was thought that the splint accomplished are mechanically beyond its reach, 
and that some things supposed to be desirable and even necessary to proper mechanical 
treatment are of no importance whatever. The two things which the splint does to- 
day, and which it has done ever since the improvement above mentioned, the two func- 
tions of the splint, so to speak, are (1) to make the affected limb a pendent member, 
resembling in this respect the arm, when the patient is erect,3 which it does as an ischi- 
atic crutch, and (2) to apply traction to the distal member of the joint, which it does by 
its rack and pinion and adhesive plaster. Traction protects the joint from the frau- 
matism of motion, muscular or otherwise, and the ischiatic support protects it from the 
traumatisms of standing and walking, while the patient runs about and follows the 
ordinary pursuits of life for the months and years necessary to bring about a recovery 
with restoration of ability and symmetry, so far as may be. 
I will close by briefly referring to two points of practical utility. The first is in 
regard to an early diagnosis, which is especially of great importance, inasmuch as there 
is reason to believe that if treatment can be begun sufficiently early the focus of osteitis 
1 Chicago Med. Examiner, Dee. 1860, pp. 753, 754. 
2 Medical Record, Sept. 1st, 1867, pp. 289-291. 
3 It is interesting in this connection to recall the words of M. Hennequin : " Mais le corps 
humain peut-il conserver pendant des mois entiers l'attitude verticale, touchant le sol par un pied 
seulement? Evidemment non; c'est au-dessus de ses forces."-Arch, gén., Jan., 1869, p. 64. 644 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in the cancellous tissue may be resolved before the other structures of the joint are 
involved. Reason for this belief is found in the fact that disease of the joints is com- 
paratively rare in the upper extremity, where a focus, being in a pendent member, may 
undergo resolution, protected, as it is by the nature of the case, from the traumatisms 
which assail the lower extremity in standing and walking. 
Now, if the lower extremity can be made pendent, as can easily be done by the 
use of the hip splint, in the very incipiency of articular osteitis of the hip, before the 
articular contours are changed and before the circumarticular muscles are seriously 
involved, we may look for resolution of the osteitic focus and recovery without lameness 
or impairment of motion. 
To assist in making an early diagnosis in a doubtful case a careful study should be 
made of those limitations in the motions of the joints which become apparent only when 
the extremes of normal motion are approached. This may be done in various ways. I 
have found two methods easy in practice and certain in their revelations. The first 
method applies to rotation, which is a direction in which limitation of motion first 
takes place. Let the patient lie supine with the feet slightly apart. With the hand 
placed lightly on the knee of the unsuspected limb a rocking or oscillating motion is 
given to the whole limb, outward and inward rotation following each other, while the 
toe sweeps through an arc of nearly 180°, the inner border of the foot striking the 
table, and the outer border nearly reaching that level. This occurs in the well limb. 
A similar manipulation of the suspected limb may reveal a slight limitation of rotation, 
the result of hip disease. The other simple procedure relates to flexion. Let the patient, 
still on the table, sit up and kiss the knee. By flexing the neck and back and drawing 
the limb up with the hands this can easily be done with the unaffected limb, while the 
attempt to do it with the suspected limb may reveal a slight limitation of flexion indica- 
tive of hip disease. 
Another diagnostic sign, too little thought of perhaps, but of importance in the very 
early stage, has recently been referred to by Dr. A. J. Steele,1 of St. Louis, Missouri, as 
" a brawny thickening about the joint in front of the capsule or behind the trochanter." 
There will in some cases be found a condensation of the soft tissues, due apparently to 
the vicinity of osteitis, not visible, perhaps, but recognized by palpation or pinching 
with the thumb and finger, and then often not detected, excepting by comparing the 
two sides. It will be found that a smaller pinch of the skin and underlying tissue can 
be made on the well than on the affected side. These tests are to be used, of course, in 
connection with other diagnostic helps and with due regard to other conditions which 
have the power to produce similar phenomena. Properly used they may betray the 
presence of hip disease in a patient as yet entirely free from pain and lameness. 
The other practical point which I would emphasize relates to the position of the 
limb. Adduction is most to be dreaded. It causes tilting of the pelvis and apparent 
shortening, which, although technically apparent, produces more disability and deform- 
ity than the shortening which is called real. It is due, as a general thing, to the fact 
that the patient uses the well limb more than the affected one in walking, putting the 
former forward in less time than the latter, and unconsciously keeping the affected 
limb off the ground more than half of the time, and drawing up and adducting it in 
order to make it less of an impediment. To remedy and prevent this, the patient, dur- 
ing and after treatment, should be drilled in rhythmical walking, which compels the 
affected limb (protected by the splint during treatment) to do its full share of the work 
of locomotion, and leads the patient unconsciously to thrust the affected limb down and 
to abduct it so that it may be in the best position to receive the weight of the body, and 
do its half of the work of progression. It is gratifying to witness a recovery in which 
1 Transactions Missouri State Medical Association, 1887, p. 102. SECTION X-ORTHOPÆDIC SURGERY. 
645 
real shortening is more than counterbalanced by apparent lengthening. Although this 
may be the case when the patient is discharged, the abduction, which is so favorable a 
feature, is likely to disappear and give place to adduction, with its disability and 
deformity, if the gait is allowed to become habitually irregular. 
Figures 1, 21 and 32 will give an idea of modifications made in the hip splint by 
the writer. 
Fig. 3. 
Fig. 1. 
Fig. 2. 
Front view. 
Side view. 
In closing, I would deprecate a tendency to complicate the mechanics of the hip 
splint. If its true functions, which are few in number and simple, and the limitations 
of its usefulness, are duly recognized, it will be found a most useful and convenient 
appliance. 
1 New York Medical Journal, January 24th, 1885, pp. Ill, 112. 
2 Medical Record, June 25th, 1887, pp. 721, 722. 646 
ON CONTRACTED KNEE JOINT AND AN APPLIANCE FOR RAPID 
REDUCTION OF SUBLUXATED TIBIA. 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SUR LA CONTRACTION DE L'ARTICULATION DU GENOU ET UN REMÈDE POUR 
RÉDUIRE RAPIDEMENT LA SUBLUXATION DU TIBIA. 
ÜBER DAS CONTRAHIRTE KNIEGELENK UND EINEN APPARAT ZUR SCHNELLEN REDUC- 
TION DER SUBLUXATION DER TIBIA. 
DR. E. H. BRADFORD, 
Boston, Mass. 
Contracted knee joints can be straightened in several ways. 
1. By gradual mechanical means. 
2. By osteotomy or wedge-shaped excision. 
3. By force suddenly applied (brisement forcé). 
These methods have their respective merits, each suited to a certain class of cases. 
The latter is a well-recognized procedure with comparatively little risks in proper 
cases. 
The chief dangers in forcible straightening are- 
1. Danger of exciting a severe arthritis. 
2. Fracture of the bones forming the joint. 
3. Rupture of the popliteal artery. 
The first of these can be avoided by the exercise of judgment in selecting proper 
cases; the other two by care in the application of force and in the amount used. 
It is advisable that the greatest amount of force should be applied in such a way that 
if an excess is used damage to the bone and artery will not take place. The first rup- 
ture of the adhesions glueing the joint together is the part of the procedure which 
demands most force, and it is safer that this be done by forcible flexion rather than 
forcible extension. 
Forcible flexion is best done in the following way :- 
The patient, anaesthetized, is placed on the floor, or low table ; the surgeon, stooping 
over the patient, holds the affected limb with both hands placed under the popliteal 
space, the thumb pressing on the patella. The patient's ankle is firmly held between 
the surgeon's knees. It will be found that by bending the knees the surgeon's whole 
weight can be thrown upon the end of the patient's limb (/. e., the long arm of the 
lever). The surgeon is able to adjust carefully the amount of force that he will use, by 
regulating the amount of pressure he exerts. He can be guided, in a measure, by the 
sensation felt in his hands grasping the patient's knee. After adhesions have been thor- 
oughly broken down in this direction, the patient is to be turned on his face and a 
cushion or hard pillow placed under the patella; forcible extension is then to be used, 
with careful and gradually increasing force, the surgeon holding the patient's ankle in 
his hands and an assistant holding the knee. 
Tenotomy of the ham-string tendons is advised, but it will not be found to be of 
great assistance as a rule, as the chief obstacle to correction is in the ligaments and 
fasciæ. After the limb is straight, it is desirable that it be kept straight, as a tendency 
for recontraction remains. The most ready way is to fix the limb in a plaster-of-Paris 
bandage. The limb is covered with a layer of sheet wadding with an extra amount of 
thickness over the patella. The gypsum roller bandages are applied in the ordinary 
way. The limb is to be held in the corrected position while the bandage is becoming 
hard, which should not require, with properly prepared bandages, longer than five min- 
utes. If necessary, the plaster can be reinforced by a strong strip of steel, secured by a 
bandage on the outside of the plaster bandage and removed after the plaster is thoroughly SECTION X ORTHOPÆDIC SURGERY. 
647 
hard. The easiest way to hold the limb in a proper position while the plaster is becom- 
ing hard, is for the surgeon to seize the foot with his hand, pressing upward, while an 
assistant pulls in an opposite direction downward on a strip of bandage placed over the 
thigh j ust above the knee. This loop of bandage is to be removed when the plaster 
has become hard. 
It is necessary that the plaster should hold the leg firmly and should extend as high 
in the thigh as possible. In addition to, or in place of, the plaster-of-Paris bandage, a 
Thomas knee splint can be used. 
Forcible manual straightening meets little difficulty in the simpler cases, but in the 
more obstinate ones resistance is encountered beyond a certain point, and an attempt to 
completely straighten the limb will leave a more or less complete subluxation of the 
tibia. This is due in part to the spasm of the ham-string muscles, which has pulled the 
tibia backward, but chiefly to the fact that owing to adhesions the flexed tibia is unable 
to slide forward over the condyles of the femur, as happens in normal extension. Rais- 
ing the leg simply crowds the anterior edge of the tibia into the condyles. To obviate 
this the head of the tibia should be pressed forward and upward to the same degree that 
the leg is raised. (Diagrams I and n.) 
Diagram i. 
Normal motion (flexion and extension) at knee-joint. 
Several means have been used to effect this. The writer has found the method illus- 
trated in the accompanying diagrams of use in the most obstinate cases. (Diagrams III, 
IV and v.) 
Pressure forward on the head of the tibia is exerted by turning the handle A ; this, 
by means of a screw force, pushes the plate C forward, working through the band B. 
The calf muscles protect the artery änd nerve from injurious pressure. Counter-pres- 
sure is secured by means of leather straps D and E, which are passed respectively over 
the knee and leg, protected by a thick layer of saddler's felt. Several straps will be 
needed at the knee to prevent loss of counter-pressure, as the limb is made straighter. 
Another strap, F, under the leg, secures the lower part of the leg. The side bars, bands 
and plate of the apparatus should be of strong steel. 
The apparatus is put on the limb in a flexed position (after rupturing adhesions by 
forcible flexion if that is needed), the head of the tibia is pushed forward as far as is 
advisable, and, by means of the end of the appliance, which serves as a handle, the leg is 
extended ; the pressure forward of the head of the tibia can be increased, if necessary, 
and the place of counter-pressure regulated, if necessary, by loosening such of the 
straps D D as extension of the limb may tighten too much. 648 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Diagram ii. 
Illustrating extension in contracted knee-joint. SECTION X-ORTHOPÆDIC SURGERY. 
649 
When the limb is partly corrected, strong downward pressure on the femur will be 
needed. This can be secured by means of a strap (Diagram v), which, passing over 
the knee (protected by padding) is secured below to the floor or to a strong rod, H, on 
which the operator or his assistant can place his foot, regulating the amount of 
pressure. 
Experiments on the cadaver which were conducted at the Harvard Medical School, 
through the courtesy of Drs. C. B. Porter and T. Dwight, showed that by means 
of this appliance the tibia could readily be pushed forward to any desired extent. 
On normal joints, the tibia can be pushed forward to a considerable distance with- 
Diagram in. 
Diagram iv. 
out rupturing the ligaments. The first to rupture was the posterior band of the 
crucial ligament. The tibia could be pushed forward over an inch without rupture of 
the anterior band of the ligament or the posterior capsular ligament. 
In the cases V and vi, on which the appliance was used, force to this extent was 
not required, and the subluxation was corrected without great difficulty. 
Clinical experience has shown that in osteoclasis the skin can stand, without danger, 
all the pressure needed in this procedure. In the case where the appliance was used 
no injury to the skin took place. 
Some difficulty was encountered in keeping the straps D D in position, and they 650 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
required some adjustment and watching ; and it appeared that they might exert injuri- 
ous pressure in cases with any existing inflammation of the synovial membrane, which 
would contraindicate the use of the appliance. In old contracted cases this trouble 
would not be encountered. The patella can be protected by proper arrangement of 
padding and adjustment of the strap. 
Diagram v. 
The patient, during the operation, should be, of course, completely anaesthetized, 
and the appliance should not be applied so as to exert pressure an unnecessarily long 
time. Some time, however, will be needed for properly stretching the ligaments, but, 
as a rule, a pressure of not more than a few minutes will be needed for complete reduc- 
tion of the tibia. SECTION X-ORTHOPÆDIC SURGERY. 
651 
The apparatus will be of use in a comparatively small number of cases, but when it 
is used, its efficiency will be found of value. 
The limb should be fixed after correction, as has already been described. 
The fixation bandage should be worn for a few weeks, and after this, for several 
months, a proper mechanical support is advisable. The time required for the use of 
crutches and support varies with different patients. 
In the following cases of right-angled contraction at the knee joint, occurring in 
adults, forcible correction was performed. Cases occurring in children are not here 
mentioned, except Case I. 
Case I.-Boy of fourteen, patient at Carney Hospital. Rectangular contraction fol- 
lowing old tumor albus many years before. Ending in a cure by anchylosis. 
Tenotomy. Forcible straightening ; separation of the lower epiphysis of the femur ; 
immediate fixation in plaster bandage in a nearly straight position. Patient heard 
from two years afterward, as having a useful leg. 
Case II.-Man, twenty-one years of age. Some contraction at the knee follow- 
ing old tumor albus ; apparently nearly well. Patient at St. Margaret's Infirmary. 
Forcible straightening ; fixation in ham splint and stiff bandage. Fixation bandage 
removed too soon. Not much improved. 
Case hi.-Lady, twenty-five years of age. Rectangular deformity at knee follow- 
ing puerperal rheumatic arthritis one year before. No motion at joint noticeable 
without an anaesthetic. No subluxation. Forcible correction, attended by a loud 
report and a sensation of tearing of connective tissue ; immediate fixation of the limb 
in plaster bandages. Complete correction of the limb. Patient heard from four years 
after the operation ; walks without cane, with a slight limp ; limb perfectly useful, 
but without motion at the knee. 
Case iv.-Lady, aged forty-five. Rectangular contraction at the knee, of one year's 
standing, said to follow slight injury. Tenotomy. Forcible straightening ; imme- 
diate fixation. Result-a straight limb, with some motion. Patient heard from three 
years after operation ; limb said to be useful. 
Case v.-Woman, twenty-one years old. Former tumor albus ; contracted knee 
since she was five years old. Forcible correction (without mechanical appliance) ; 
immediate fixation. Nearly straight limb, but without correction of the subluxation 
of the tibia ; useful limb. 
Case vi.-Woman, twenty-four. Former tumor albus ; right-angled contraction 
at the knee-joint for eighteen years. Marked backward subluxation of the tibia. 
Patient unable to step at all on the limb. Forcible correction with the help of 
mechanical appliance ; correction of the luxation ; contraction corrected ; immediate 
fixation. Marked genu-valgum followed, due to the lengthening of the internal con- 
dyle. This relieved by the McEwen operation. Straight limb. The limb was then in a 
relatively normal position and free from subluxation. Three months afterward she was 
discharged from the hospital. At that time she was able to bear nearly full weight 
upon the limb. She wore, however, a retention stiff bandage, and used one crutch in 
walking. At the present time (a year later) she is able to walk without crutch or cane, 
but usually uses a cane. 
BIBLIOGRAPHY. 
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189. 
Bauer. " False anchylosis and contracture ; tenotomy and forced extension. Recovery." St. 
Louis Med. and Surg. Journal, 1870, N. s., vn, 200. 
Detmold. "Forcible breaking up of adhesions in anchylosis of knee joint." N. Y. Med. Times, 
1852, n, 207. 
Hancock. "Angular anchylosis of knee joint; forcible extension." Lancet, 1853, i, 111. 652 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Hauner. "Ankylosis genu sinistri; brisement forcé." Oesterreich. Ztschr. f. Kinderh. Wien, 
1856-7, II, 421. 
Henry. "Forcible flexion of ankylosed knees." Lancet, 1859, II, 411. 
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Holston. "Straightening ... by forcible extension." Am. Med. Gaz., N. Y., 1858, ix, 
581. 
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Boston Med. and Surg. Jour., 1876, xcv, 478. 
Lloyd. "Laceration of an anchylosed knee." Med. Times and Gaz., London, 1858, xvn, 61. 
MacDonnell. "Contraction; rapid extension (several cases)." Med. Chron., Montreal, 1858, v, 
98 et seq. 
Nagel. "Rheumatische Kniecontract. geheilt durch das Brisement forcé." Deutsche Klinik, 
Berlin, 1856, vm, 436. 
Salzer. " Ueber Zerreissung der Art. poplitea, etc., in Folge gewaltsamer Streckung der Kniegelenk- 
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geheilt." Deutsche Klinik, Berlin, 1860, xii, 367. 
Stillmann. "Suggestions on the management of brisement forcé." J. Am. M. Ass., Chicago, 1884, 
il, 203. 
Wenz. " Gewaltsame Streckung, etc." Ztschr.f. Wundärzte und Geburtsh, Stuttg., 1864, xvi, 18. 
Wiskemann. " Zur Streckung und Mechanik der Kniegelenkscontract., etc." Berl. Klin. Wochen- 
schrift, 1882, xix, 365. 
Whitehead. "Notes of some cases of recent hip-joint disease, including two cases of excision 
and one of brisement forcé, and remarks on some others." Prov. M. J., Leicester, 1887, 
VI, 152; also N. Y. Med. Rec., 1886, xxx, 679. 
Marsh, Howard. "Dis. of Joints." 
Stillman. " Mechanical treatment of knee-joint disease." N. F. M. J., xlv, 37. 
Lampagnani. "Delle ankilosi." Arch, di ortop, Milano, 1886, ill, 97 
Oberst. "Vier Fälle von akuten Eiterungen nach Brisement forcé." Gentralbl. f. Chir., Leipz., 
1885, xii, 361. 
Gomez Pamo. " Dos casos de extension forzada de la rodilla." An. d. cirui., Madrid, 1883, n, 
135. 
Deakin. "On buttoning, or the forcible manipulation of stiff- or weak joint." Proc. N. W. Prov. 
and Oudh. Branch Brit. Med. Ass., Allahabad, 1883, II, 381. 
Black. "A possible danger in the forcible treatment of ankylosis." Kansas City M. Rec., 1884, 
1, 251. 
Knauf. "Die operative Behandlung der Ankylosen des Kniegelenkes." Jena, 1884, Pohle, 8°. 
Barwell. "Ankylosis after chronic joint disease." Lancet, 1884, il, 814. 
LaGrange. "Traitement de l'ankylose du genou." Paris, 1883. 
Sayre. "Amputation below knee joint in preference to brisement forcé in certain cases of deform- 
ity and ankylosis-two cases." J. Am. M. Ass., 1883, I, 325. 
Louvrier. "Nouv. traitement; mort par une cause étrang.; autres accidents." Gaz. d'hop., Paris 
1840, 2. s., ii, 66. 
Philipeaux. "De la valeur et desindication delà rupture, etc." Gaz. hebd. de Méd., Paris, 1865, 
2. s., il, 67. 
Bauer. "Clinical Lecture on contraction of knee joint and false anchylosis." Am. M. Gaz., N. Y., 
1858, ix, 193. 
Bauer. "Case of contraction of right knee joint; unsuccessful grad, extension and brisement forcé', 
sloughing; paralysis; repeated brisement after myotomy; failure; amputation and recovery." 
Phila. Med. and S. Rep., 1861-2, N. S., VII, 37. SECTION X-ORTHOPÆDIC SURGERY. 
653 
Bauer. " False anchyl.; unsuccessful attempts at forcible extension; amputation." W. Y. Med. 
Rec., 1867-8, n, 64. 
Stanley. "False anchylosis of knee joint . . . forcible extension." Lancet, 1853, i, 538. 
Cartade. " Etude sur le traitement de l'ankylose incomplète du genou par la rupture." Paris, 
1873, 4°. 
Chaboux. "De la rupture de l'ankylose, etc." Paris, 1879, 4°. 
Dubinsky. " Die sogenannte Streckung . . bei Contracturen und Ankylosen des Kniegelenkes 
mit vorzugsweiser Berücksichtigung der in der Dorpater chir. Klin. zur Behandl. gekom- 
menen Kniegelenkverkrümmungen." 8°, 1870. 
Langenbeck. "Die gewaltsame Streckung der Kniecontracturen, etc." 8°, Hannover, 1858. 
Morsdorf. "Ueber die Methode, durch gewaltsame Streckung, etc." 8°, Leipzig, 1867. 
Uhlig. "De contracturis artic. genu . . per celerem ac violentem extentionem." 8°, Leipzig, 
1853. 
Vergne. "Du traitement . . par le redressement brusque." 4°, Paris, 1875. 
Adams. "On the selection of cases for forcible movement in the treatment of stiff joints, and the 
method of procedure." Brit. M. J., 1882, n, 666. 
V. Bruning. "Ueber Kniecontractur und deren Streckung." Pest. Med.-chir. Presse, Budapest, 
1881, xvii, 88 and 109. 
Hay. "Case of stiff knee cured by forcible flexion." Phila. Med. Times, 1880-1, xi, 457. 
Bauer. "Angular contraction with fibrous anchylosis of arm." St. Louis Clin. Rec., 1879-80, VI, 
238. 
Bauer. "Joint diseases; old practices and recent views." St. Louis Clin. Rec., 1878, v, 205. 
Gamgee. "Treatment of ankylosis of knee." Brit. M. J., 1878, II, 689. 
Jones. " Tenotomy for contracted knee joint and forcible extension; the propriety of excision, etc." 
Lancet, 1879, I, 764. , 
Frank (P.). " De contractura et ancylosi artic. genu et coxæ, iisdemgen B. Langenbeckii methodo 
violenta extensione sanandis." 4°, Berolini, 1843, also Med. T. and Gaz., London, 1853, 
n. s. vu, 59, 134, 473. 
Adams. "On Restoration of motion ... by forcible extension." Med. Mirror, London, 
1865, ii, 193, 257. 
Küchler. "Ueber die gewaltsame Aufhebung der erworbenen Contracturen der Gelenke durch 
Händegewalt, ihre Anzeigen und die Verhütung von Zufällen." Deutsche Klinik, Berlin, 
1859, xi, 377, 388. 
Ollier. "Ankylose." Diet. Enc. de sc. Med., Paris, 1866, v, 183. 
Bauer and Whaley. "Cases of Contraction, etç." Am. M. Times, N. Y., 1861, ii, 209. 
Brodhurst. "On Forcible Extension, etc." Med. T. and. Gaz., London, 1858, xvi, 550, 597, 
and 649. 
Hawkins. " Forcible flexion in, etc." Lancet, 1859, n, 537. 
Kade. "Ueber Ankylosenbrechung." St. Petsbg. M. Ztsch., 1862, II, 1, 33. 
Laffan. "Forcible rupture, etc." Lancet, 1872, il, 882. SECTION XI-OPHTHALMOLOGY. 
OFFICERS. 
President: PROF. JULIAN J. CHISOLM, Baltimore, Md. 
VICE-PEESIDENTS. 
Prof. C. H. Abadie, m. d., Paris, France. 
W. A. Brailey, Esq., London, England. 
Prof. A. W. Calhoun, m. d., Atlanta, Ga. 
Prof. L. De Wecker, m. d., Paris, France. 
Prof. J. Hirschberg, Berlin, Germany. 
Prof. P. D. Keyser, m. d., Philadelphia, Pa. 
Prof. E. Landolt, m. d., Paris, France. 
Prof. N. Manolescu, Bucharest, Roumania. 
Prof. L. Mauthner, m. d., Vienna, Austria. 
P. H. Mules, Esq., Manchester, England. 
H. Power, Esq., f.r.c.s., London, England. 
Prof. D. S. Reynolds, m. d., Louisville, Ky. 
J. Tweedy, Esq., London, England. 
Prof. E. Warlemont, m. d.; Brussels, Belgium. 
Prof. E. Williams, m.d., Cincinnati, Ohio. 
SECRETARIES. 
Prof. Adolf Alt, m. d., St. Louis, Mo. | Dr. Eobert L. Eandolph, Baltimore, Md. 
Dr. J. A. White, Eichmond, Va. 
COUNCIL. 
Dr. S. C. Ayres, Cincinnati, Ohio. 
Dr. B. J. Baldwin, Montgomery, Ala. 
Dr. Ole Bull, Christianna, Sweden. 
Dr. F. Buller, Montreal, Canada. 
Dr. L. Conner, Detroit, Mich. 
J. Eichardson Cross, Esq., Bristol, England. 
Dr. H. Culbertson, Zanesville, Ohio. 
Dr. H. Ferrer, San Francisco, Cal. 
Dr. Galezowski, Paris, France. 
Dr. Gayet, Lyons, France. 
H. B. Hewetson, Esq., Leeds, England. 
Dr. A. G. Heyl, Philadelphia, Pa. 
Dr. F. C. Hotz, Chicago, Ill. 
Dr. W. V. Marmion, Washington, D. C. 
Dr. A. Mooren, Düsseldorf, Germany. 
Dr. J. Samelsohn, Cologne, Germany. 
Dr. W. H. Sanders, Mobile, Ala. 
Dr. A. G. Sinclair, Memphis, Tenn. 
Dr. E. Smith, Detroit, Mich. 
Dr. G. T. Stevens, New York. 
Dr. J. L. Thompson, Indianapolis, Ind. 
655 656 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
OPENING ADDRESS OF THE PRESIDENT, 
JULIAN J. CHISOLM, M.D., 
Of Baltimore, Md. 
Gentlemen and Colleagues.-My first duty is to express my very high appre- 
ciation of the honor conferred upon me to preside over so important a Section as that 
of Ophthalmology, and then to extend to you a hearty welcome to Washington. 
That man proposes, but is not always permitted to carry out his good designs, is 
strikingly illustrated in the absence from this chair of our good and beloved colleague, 
Dr. Elkanah Williams, who by universal consent was selected to organize this De- 
partment of the International Medical Congress. His thorough training, large 
experience, and fund of knowledge well fitted him for so important a trust. It is 
much to be regretted that ill health has forced him to relinquish what every one 
deemed a very fitting honor. We regard Dr. Williams with pride as the pioneer 
among specialists in the United States. 
It is curious to contemplate what radical changes in professional opinion a very 
few years produce. Thirty-five years ago, when Dr. Williams, after a careful 
preparation, announced that his practice would be restricted to the treatment of eye 
and ear diseases, it needed courage to face the universal condemnation and denuncia- 
tion of the medical profession. At that time, in the United States, the practice of 
ophthalmic surgery, the first-born of the specialties, was in the hands of itiner- 
ants of very unsavory reputation ; and a regular physician, however honest his pur- 
pose to prosecute a special line of study and practice, was so ostracized for his 
imprudence and independence that he had to seek again shelter in the body of the 
medical profession. 
How totally changed is all this to-day, when it is acknowledged that progress is 
only attained in medicine through special studies. No organ of the living body is 
now deemed so small as not to need the laborious work of well-trained investigators, 
who may by diligent application find out some of the many hidden wonders of 
creation. To-day, this Ninth International Medical Congress is to a large extent 
an assemblage of honored specialists, the brightest lights of the medical profession. 
These self-sacrificing members of a profession having for its motto "Charity," travel 
thousands of miles, at great personal expense, for the sole purpose of interchanging 
thought, disseminating information, and for intercommunion of friendship. All 
are enthused with one impulse-an ardent desire to find out how disease can be 
controlled, pain relieved, and life with health sustained. 
We will devote our days of reunion to the study of the Human Eye, in medicine a 
world within itself, and, so far, too vast to be thoroughly known, notwithstanding the 
exclusive and devoted study of numbers of the most original and brilliant investiga- 
tors. There are many things in relation to eye diseases which we would most gladly 
know, and which we expect eventually to fathom. The presence here of sp many dis- SECTION XI OPHTHALMOLOGY. 
657 
tinguished masters in ophthalmology sustains us in the belief that our present delibera- 
tions will have their weight in the much desired advancement of our branch of the 
medical profession. 
Our programme shows that there will be no lack of material for discussion, and 
the well-known names of the writers of the articles are a guarantee that the subjects 
will be effectively presented. There is no disease of the eye so thoroughly mastered 
that further information is not desired. Operations that are done daily, and with 
individual experience that extends into the thousands, are far from perfect. The 
fact that each one has his own method indicates instability and doubt. Eye surgery, 
although the most advanced of all the departments of medicine, because the longest 
studied as the pioneer of the specialities, is still full of obscurities. The most frequent 
of all eye operations, that for strabismus, has not yet fixed rales for its performance. 
When to operate and how to operate so as to insure retained and restored vision is 
not yet determined. 
So is it also in cataract operations. The desire to see again is so paramount with 
the blind that the ophthalmic surgeon cannot remain content until he can show 100 
per cent, of successes, after painless operations. The why and the wherefore of that 
terrible disease, glaucoma, is by no means clearly defined. While much has been 
discovered, a great deal more remains concealed. 
Microbes in the development of eye inflammations is a new study, already startling 
in its revelations and full of promise in the very near future. 
Errors of refraction in itself is so large a field for investigation that it threatens to 
subdivide the practice of eye surgery. We are not surprised to find, when we study 
the rich nerve supply belonging to the eye, and recognize the intimate relations of 
distant parts of the animal economy through the reflexes, that irregularities in eye 
construction and the effort induced in seeing clearly, cause disturbances in neighbor- 
ing organs. That the eyes should pain when the vision is faulty is readily understood, 
but the general practitioner does not readily grasp the fact that from eye irregulari- 
ties should proceed a class of symptoms often mistaken by them for cerebral, gastric, 
hepatic, spinal or neuralgic diseases. When, after the most varied and continued 
treatment, no permanent benefit has come to the patient, the adjustment of glasses 
for waning sight causes all of these bodily troubles to disappear as if by magic. So 
mysterious are these intercommunications and nerve connections, that some investi- 
gators believe that their observations will sustain them in avowing that many cases 
of epilepsy and chorea, usually considered as independent diseases, are of ocular 
origin. 
These and many other interesting subjects appear on the programme for dis- 
cussion, and will receive careful attention. 
It is very important that a good record of our proceedings should be preserved 
for the Transactions. To insure this, it is very much to be desired that those who 
favor the Section with their opinions should put the same in writing while still fresh 
in memory, and present a copy to the secretaries before the close of the day's work. 
This course, if universally adopted, will facilitate very much the accuracy of the 
minutes. 
I enter upon the serious duty of presiding over this distinguished body with many 
misgivings. Knowing too well my deficiencies, I rely with full confidence on your 
kindness and indulgence. 
Once more I bid you welcome, as friends and co-workers in the Section of 
Ophthalmology. 
Vol. Ill-42 NINTH INTERNATIONAL MEDICAL CONGRESS. 
658 
EYE TROUBLES IN THEIR RELATION TO OCCIPITAL DISEASE. 
LES AFFECTIONS DE L'OEIL DANS LEUR RAPPORT AVEC LA MALADIE 
OCCIPITALE. 
BY DR. MOOREN, 
Düsseldorf. 
In concordance with the results of clinical observation, physiology places to-day 
the centre of vision in the cortex of the occipital lobes. The first impulse to this local- 
ization was given by an observation of Huguenin, ip which the section demonstrated 
that a case of optic atrophy with amaurosis on the left eye, existing from the earliest 
childhood, was dependent on a defect in the cortex of the occipital lobes. The greatest 
extent of this occipital disturbance existed on the right side, on the left it was only 
visible in a slight degree. This fact became fruitful for physiological experiment as 
well as for clinical diagnosis. When Munk made the extirpation of the vision sphere 
in the occipital lobes on a dog, the animal was blind in both eyes, but the functions of 
the other senses remained intact. The voluntary and involuntary movements were 
only disturbed as far as they were dependent on the defective part in the perception of 
sight. The reflexes of pupillary activity remained entirely unaltered. This fact demon- 
strates that the light perception of the retina is transmitted by the optic nerve to 
the anterior pair of the corpora quadrigemina as perfectly as before the excision, excit 
ing in this reflex centre the specific energy of the oculo-motorius upon pupillary move- 
ments. The subjective sensation has completely ceased, every perception of vision is 
extinguished-evidence enough that both of these qualities are bound to the integrity 
of the occipital lobes, and that consequently, in these parts, w'hich are the terminal 
radiations of the optic nerve, the perceiving centre for light and vision is to be searched 
for. 
The total extirpation of one occipital lobe, which Munk executed at repeated times 
in the course of his experiments, always caused a complete binocular hemianopsia, 
opposite to the side on which the occipital lobe was taken away. 
The experiments of Munk are to be regarded in a certain sense as classical ; they 
control the clinical observations made by Hirschberg, Pooley, Pflüger, Hughlings Jack- 
son, Gowers and others. These cases, generally known in the literature and fully 
approved by the section following it, are more than sufficiently familiar to you. A 
greater number of cases are observed by the oculists of the old and new world. They 
are either not published or have not such a power of argument as those above men- 
tioned, because the consecutive confirmation of the diagnosis by the section is wanting. 
I, myself, had occasion to see in my practice forty-two different cases, fourteen with 
right-sided, nineteen with left-sided hemianopsia; in four cases there existed temporal, 
and in five nasal hemiauopic restriction of the vision field. My cases were dependent 
on the same causes as were found by other observers-at times hemorrhages, at times 
traumatic influences; again, syphilis of the brain, then a beginning tumor, etc. The 
time is too limited to dwell on the cases complicated with a participation of the inter- 
calar ganglions. I will only observe that hemianopsia depending on occipital lobe 
affections is never complicated with mydriasis or capillary apoplexy at the entrance of 
the optic nerve, as we find in truncus diseases: on the contrary, corresponding to the 
integrity of the anterior pair of the corpora quadrigemina, the pupillary movements are 
always intact, but the hemianopic restriction of the field of vision exists in the one 
case without any further complication, in other cases it is combined with reduction of 
the acuteness of vision, now with absent color perception, then, again, with hemianopic 
color defect. lu one word, the triple manifestation in the quality of disturbances is to be 
AUGENLEIDEN IN IHREN BEZIEHUNGEN ZU HINTERHAUPTKRANKHEITEN. SECTION XI-OPHTHALMOLOGY. 
659 
found in variable combinations and in variable intensity. It is the merit of Willbrand 
to have collected the different observations made in this sense. He formulates the 
results of his investigations thus: that the color centre is to be placed on the most 
exterior cortex of the occipital lobes. Beneath it we have the centre for the acuteness 
of vision-the centre for the sense of space, as it is called by Willbrand-and in the 
third layer exists, next to Gratiolet's visual radiations, the light centre, that is to say, 
the centre for the visual field. When we consider that the physiological destruction of 
each of these three different qualities depends on three different cortical strata, of which 
the one is superposed on the other, then we must understand that with the destruction 
of the lowest layer-the light centre-there must be lost at the same time the sight and 
the color perception. The destruction of the lower centre involves the impossibility for 
its conducting fibres to pass over to the two higher centres. On the other hand, it may 
happen that in a certain case there exists only a hemianopic restriction for the color 
perception, without any alteration in the acuteness of vision or in the extension of the 
visual field, because both centres reserved to the latter qualities had remained intact. 
The reality of such cases is demonstrated by the observations of Bjernum and Samel- 
sohn. A lateral restriction in the acuteness of vision does not occur because the narrow 
relation between the qualities of the color and space sense makes it necessary that the 
reduction in the acuteness of vision is always proportional to the impaired or eliminated 
color perception. 
Hemianopic restriction more or less approaching the point of fixation-now vertical, 
now slightly sloping-cannot alone be attributed to the individual variations in the 
decussation of the optic nerves; the seat and the extent of the occipital disease influences 
equally its configuration. The island-shaped defects, although homonymous regarding 
its position, but varying sometimes regarding its reciprocal size, and also the fact that in 
single cases the hemianopsia disappears completely, demonstrate this influence clearly 
enough. I, at least, observed a case in which the enormously impaired sight returned 
slowly in the course of a year, with absolute restitution in the originally pronounced 
hemianopic restriction of the field of vision, and in a second case, the result of apoplexy, 
there remained nothing except a small sector-like defect. 
Generally speaking, we must admit that such a restitution is exceptional, also in 
the cases in which the acuteness of vision is only slightly reduced. With the ominous 
symptoms of hemianopsia begins, commonly, the prostration of physical and moral 
energy ; the memory becomes daily weaker, and the sudden changes in spirits, mostly 
of a depressing character, are for the surrounding of the patient a great burden. Two 
or three years will pass before the final catastrophe takes place. I have seen only one 
case in which the intellectual power was satisfactory for three years; then the patient 
succumbed to a new apoplexy. 
All these disturbances have the stamp of chronicity. Notwithstanding, there are 
found neuropathic individuals who, under the symptoms of scotoma scintillans with 
serious attacks of hemicrania, pretend to see, from time to time, the objects half cut. 
As often as I had afterward occasion to examine the field of vision, I never found 
objectively in the patients an anomaly of this sort. 
On the other side, Munk contends that a partial extirpation of the occipital cortex 
gives origin to a disturbance of sight that appears under the form of an extended cen- 
tral scotoma. I have seen several cases which I believe must be interpreted in the 
light of Munk's proposition. Already, in 1866, I could, on publishing my ophthalmia- 
trie observations, point to cases in which the central defect seemed to me dependent on 
cerebral alterations. Although in the first moment the patients did not present any 
pathological change in the interior of the eye, a nerve atrophy took place very soon, 
or the patients perished by general paralysis, or a consecutive apoplexy. The form of 
the defect had the shape of a slightly compressed ellipse, occupying either the centre or 660 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lying with its vertex in the point of fixation. The horizontal extent of this defect 
amounts generally to one inch and a half or more. 
Although in the extent of the alleged defects the concomitant inflammatory symp- 
toms are of a high influence, it is evident that their real size must be based upon the 
anatomical substratum in the occipital lobe. The occipital limits of pathological 
changes were lately determined by Nothnagel with great precision, by the method of the 
smaller focus. After the observations of Haab, Huguenin, Feré, Seguin, this neurologist 
places the centre of optic perception in the cortex of the cuneus and the first occipital 
convolution. This localization finds its exact confirmation by a section made by Cursch- 
mann. By a fresh embolus in the three branches of the occipital artery of the brain- 
which, up to the moment of the disturbance, had been entirely intact-there was created 
a focus of softening in the cortex of the occipital lobe, especially in the cuneus. Hemi- 
paresis and hemianæsthesia being totally absent, the patient did not present any other 
symptom except a left-sided hemianopsia of both eyes. From this fact Nothnagel con- 
cludes that only the first occipital convolution must be regarded as the seat and cause 
of hemianoptic disturbances. In the diffusely affected second and third convolutions- 
that is to say, in the lobulus lingualis and fusiformis-he places the cause of psycho- 
logical blindness, since in his opinion there lies the field of optical memory, which never 
is connected with hemianopic disturbances. Many years ago, when I did not know, as I 
now do, that in the optical lobes is to be found the centre of vision, I saw a patient 
become suddenly incapable to read print that he could formerly read very well, 
although the acuteness of his vision was not altered, and the interior of his eyes did 
not present any pathological change. A second had typhus fever, which created dis- 
turbances in the parietal and occipital lobes, whose principal symptoms were mani- 
fested in heaviness of the legs, disturbed color perception and reduced optical memory. 
The patient died of bulbar paralysis two years after his first presentation. 
Based upon these rare observations I do not like to pronounce an opinion in regard 
to the anatomical substratum of psychological blindness. I might point to the fact 
that the occipital lobes can be involved by diffusely spread alterations, and, without 
being disturbed, give origin to complex symptoms that differ entirely from the 
above mentioned disturbances. I remember a patient who, convalescing from typhus 
fever, complained exclusively of intense pains in the region of the skull which corre- 
sponded to the anatomical situation of the occipital lobes; both optic nerves were 
atrophied to such a degree that it was not possible for the young man to read the largest 
number of Jaeger's scale, but the field of vision had assumed in both eyes a narrow, 
spindle-shaped configuration. At that time I did not appreciate sufficiently the im- 
portance of the color perception, which would have contributed undoubtedly to estab- 
lish an accurate diagnosis. But another case adds more proof to this. In the spring of 
1868 a boy of nine years presented himself to me, with double-sighted neuritis optica 
in the beginning stage of atrophy. The field of vision was reduced on the right side 
to a diameter of eight, and on the left side to two inches. On this side it was 
only possible to spell words in No. 17. With the right eye No. 8 was read with 
difficulty. A heavy fall on the occiput had occurred in the autumn of the year before, 
and from this moment the faculty of perceiving colors was completely extinguished. I 
could scarcely hope to obtain a result in point of amelioration of sight ; the terrible 
headache of the child induced me to undertake a treatment consisting of the continued 
use of lod. potassium and in the superficial application of a thin seton at the neck. 
On the eleventh of May the pains in the occiput had already ceased, and, to my great 
astonishment, an indistinct perception of colors began to show itself ; four months after- 
ward every restriction of the field of vision disappeared in the right eye, which, at 
that time, could read No. 1 with ease. With the left eye No. 13 could be read, 
and the field of vision had the same extent that the right one formerly presented. SECTION XI-OPHTHALMOLOGY. 
661 
The perception of colors had become perfect. The distinction between blue and lilac 
only was not fully marked. The suspended and afterward restored function of 
the color centre did not admit of any doubt in regard to the localization of the disturb- 
ance in the occipital lobes. Generally speaking, we can say that injury of the occiput 
and its consecutive disturbances of the sight are not uncommon. At this moment I 
have a young man in care, who, after an explosion, was so severely injured in the occi- 
put that he remained unconscious for six weeks. Then the patient complained of 
weakness of memory, obscuration of sight and continual dull pains in the occiput, 
which increased more when an effort of fixing an object was made. When I saw the 
patient for the first time, nearly one year after the accident, the left eye was completely 
destroyed by the above-mentioned accident. The right eye presented only the symp- 
toms of anæsthesia optica, with circular restriction of the field of vision, reduction of 
the acuteness of vision up to one-seventh; the complementary colors of green and blue 
were not seen. Regarding the development of the general and local symptoms I estab- 
lished the diagnosis of contusion of the occipital lobes. This was supported by a cica- 
trix found in that locality. The treatment directed in this case obtained the full result, 
so that all the subjective sufferings ceased and the acuteness of vision was again fully 
established. 
In a child of eight years, whom I took in treatment four years ago, the visual 
disturbances were infinitely greater than in the afore-mentioned case. Intolerance of 
light was complicated with concentric restriction of the visual field. Characters of 
the largest size, on small pieces of wood, were only seen by the aid of a loup, an 
attempt that had to be interrupted at every moment, because a gush of tears flowed 
from the eyes. All methods of treatment undertaken up to the present were without 
any success, and the boy was to be sent, for further education, to an institution for 
the blind. By carefully examining the child I noticed an extended flat depression 
at the left occiput, that had existed since his birth. With regard to all the other symp- 
toms I was convinced that the suffering of the child resulted from an irritation in the 
occipital lobes. My prognosis was, notwithstanding, extremely reserved, because it was 
quite impossible for me to see the interior of the eye ; every attempt to illuminate the 
eye was accompanied by a gush of tears and the strongest contraction of the pupils. 
I proceeded to the systematic use of mercurial inunctions, which were always for some 
days interrupted when the boy presented symptoms of weakness. I had the idea that 
such a medication would produce a favorable effect upon the physiological filtration of 
the walls of the blood-vessels, and that in this matter the most favorable conditions 
were created to obtain a resorption of exudations, if present in the region of the 
occipital lobes. After ten inunctions were made, each one with the dose of one gramme 
and a half, the child took a warm bath. This treatment, combined with the daily 
application of ice to the head during an hour and a half before going to bed, and the 
internal use of tinctura ferri and solutio Fowleri had, after three months, produced 
such an effect that the intolerance of light had disappeared, and a regular school in- 
struction could now begin, because the little patient was able to see the smallest 
print. The application of the ice and the internal medication were continued for the 
whole winter, and in the next summer the same treatment was repeated, as the patient 
had a tendency to become fatigued by prolonged work. After this a condition of the 
head and eye was established which in every sense might be called a normal one. 
Owing to the circumstance that the disturbance had taken its origin from the earliest 
childhood, the above successful treatment was repeated for the third time, in order to 
consolidate the excellent result, and twenty-five inunctions finished it. 
It will not be necessary to devote any more time to these clinical observations, as 
they demonstrate clearly enough the dependence on diffusely spread disturbances of 
the occipital lobes, and, on the other hand, show the difference of symptoms that result 662 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
from a real destruction of any part of the occipital cortex. The diffuse form of the 
affection does not present any complexity of specific symptoms. As we have already 
observed, the disturbances of sight manifested under such circumstances appears with 
a certain predilection, under the form of anæsthesia optica. With the pain in the 
occiput, which in the one case is more, in the other less pronounced, is mostly combined 
a rapid failing of the sight, sometimes the existence of subjective sensations of light 
or a high degree of retinal hyperæsthesia. In the one series of cases the ophthalmoscope 
does not reveal any changes in the interior of the eye, in other cases there are to be 
seen the symptoms of slight atrophy, and we can only exceptionally demonstrate the 
existence of a pronounced neuritis optica. 
After the experiments made by Prof. Adamkiewicz to determine the function of the 
different factors concurring in the compression of the brain, we may conclude that the 
symptoms of hyperæmia or inflammation only take place at the entrance of the optic 
nerve, when the pathological changes in the occipital lobes are sufficiently pronounced 
to excite a proliferation of the blood vessels. The presence of a tumor is not necessary 
to produce this result in the substance of the optic nerve ; on the contrary, a state of 
optic atrophy will principally arise where proliferation of vessels is absent and the 
development of connective tissue predominates. 
I beg you, gentlemen, to consider my remarks simply as a short sketch intended 
to call your attention to a subject of high practical value. You know, perhaps better 
than I can tell you, that a rational treatment in every form of disease will only be 
possible after the diagnosis is well established. 
I 
DISCUSSION. 
Dr. Gradle, of Chicago, alluded to a case of a child seventeen months old who 
had symptoms of scarlatina, opisthotonos and greatly impaired vision, soon after- 
ward becoming totally blind. He prescribed iodide of potash, and complete recovery 
followed, with restoration to sight. 
Dr. Dickinson, of St. Louis, asked which theory of the decussation of the 
optic nerve fibres Dr. Mooren adopted, total or partial. 
Dr. Mooren replied by drawing a diagram showing the distribution of the 
nerve fibres from the right side to the outer half of the right retina and the inner 
or nasal half of the left, and so with the other side. 
Dr. Marmion, of Washington, reported a case of a lady thirty-five years old, 
who had experienced gradual impairment of vision, accompanied with diplopia. 
He gave her mercury and iodide of potash. Ataxic symptoms showed themselves 
and she expired very soon afterward. At the autopsy, a large gumma of the right 
inferior lobe of the cerebellum was found. The color sense in this case was 
unimpaired. 
Dr. Bermann, of Washington, reported a case of hemiopia caused by caffein 
poisoning. He thought that the caffein acted here in producing anaemia of the 
occipital lobes of the cerebrum, finally producing atrophy. 
Dr. J. J. Chisolm presented to the Section for examination a man aged thirty- 
seven as illustrative of the paper just read. This patient exhibited a large swelling 
on the left side of the skull over and behind the ear. The swelling, somewhat 
globular in form, was nearly three inches across. It was elastic in feeling and seemed 
to be set in a cup of bone, developed in the posterior half of the parietal bone. All 
this side of the head was much enlarged, the asymmetry of the two sides of the 
head being conspicuous. The disease is now of two years' duration. In its incipi- 
ency there was much headache and a constant throbbing, not only very annoying to SECTION XI OPHTHALMOLOGY. 
663 
himself but very audible to others. At the end of six months, when the swelling 
became prominent on the head, the noisy pulsation ceased. None can be heard 
now. The vision of the right eye commenced to fail about this time. When he 
first came under Dr. Chisolm's observation there was still light perception in the 
right eye ; the left eye had vision. In each eye the ophthalmoscopic examina- 
tion showed neuritis ; outline of disc irregular ; surface white ; retinal vessels of full 
size, blurred at points, from the intraocular effusion. Although vision was good in 
one eye and nearly lost in the other, the ophthalmoscopic picture of the two optic 
discs were nearly identical. This examination was made seven months since. At 
this time he has lost light perception in each eye, and also hearing in the left ear, 
the one on the side of the tumor. His general health is good in every other respect. 
He has taken large doses of iodide of potassium and mercury for a long time, with 
no effect on the tumor. The cranial sutures on the left side of the head seem 
opened and are easily traced. The veins of the scalp of the left side of the head 
are very large and prominent, showing some interference with the deep venous 
circulation. He suffers no pain now, nor has he had nausea for a long time. 
According to the rule in such localized tumors, the corresponding ear and the oppo- 
site eye were the first to fail. 
PATHOLOGICAL ALTERATIONS OF THE RETINAL VESSELS. 
ALTÉRATIONS PATHOLOGIQUES DES VAISSEAUX RETINAUX. 
PATHOLOGISCHE VERÄNDERUNGEN DER NETZHAUTGEFÄSSE. 
BY DR. OLE BULL. 
I have long been aware that alterations of the retinal vessels play a greater part as 
effective causes of retinal diseases than is generally believed. This opinion I have 
sought to maintain in my treatise, ' ' The Ophthalmoscope and Lues, ' ' in which I have 
demonstrated that various symptoms can be explained only by supposing that patho- 
logical changes actually have taken place in the retinal vessels. 
Here, however, I will only deal with such affections as are characterized by the sud- 
denness of their appearance and in which no other ophthalmoscopical changes are seen 
than those of a disturbed circulation. Hitherto, such cases have been attributed solely 
to the existence of emboli. 
Affections of this kind are by no means infrequent. In my own practice I have, 
among 6500 patients, seen 18 cases, and among those one in which both eyes were 
attacked at different times. This gives a proportion of about three per mille* In eight 
of these cases referred to all of the retinal vessels were more or less obstructed, while 
in nine cases only some of them. I am, however, satisfied that the above-named pro- 
portion does not represent the true average frequency of such cases. Many cases of 
partial obstruction of the retinal vessels doubtless remain unobserved by the patients 
themselves, and many others pass unrecognized by the physician. In the two following 
cases the patients were at the time of examination wholly unconscious of their eye 
affections, although, as can be seen by the drawings, the vessels obstructed were of a 
considerable size, and had occasioned rather serious functional disturbances. 664 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case I.-Anna Hansen, married, age fifty-eight, came to my office November 24th, 
1883. Thirteen days previously she had noticed that her left eye suddenly became 
obscured. By examining the right eye, in which the patient told me that she had 
never experienced anything wrong, I found the lower main branch of the artery con- 
tracted for the length of one diameter of the optic disc. The artery in its contracted 
part appears thread-like. The contraction commences about two O. D. from the margin 
of the disc; the branch to the region of the macula is seen to extend from the middle 
of the contracted part as a white string. In the left eye the under main branch of the 
artery was visible only as a dark streak. Two of the upper veins-vena sup. tempo- 
ralis and nasalis-were seen to be much dilated for a short space. In the dilated space 
situated about two O. D. from the disc the veins appeared quite black. All the veins on 
the disc narrowed. Close to the disc several small patches of blood. Grayish discolora- 
tion in the region of the yellow spot. ( Vide Fig. 1 ; all figures taken in inverted image.) 
V right eye = J ; left = }. L = | R and i L. C * = J and J. The visual field much 
contracted in its upper part on the right side; on the left concentrically constricted. 
T, both sides normal. 
Heart action very irregular, the sounds reduplicated, so that the pulse cannot be 
counted by auscultation. Impulse much increased. She has been twice attacked by 
Fig 1. 
articular rheumatism. About nine months ago she was hemiplegic on the left side 
during eight days. A physician was not called in. 
Some days later the tension of the left eye increased. The pupil became dilated, 
and soon all symptoms of acute glaucoma were developed. As she could not remain at 
home she was taken into the State Hospital, where the eye, at last, was enucleated. 
Case ii.-Mr. T. M. Nass, fifty-four years, called on me 16th of June, 1885. He 
complained of his left eye, in which nothing can be seen but symptoms of slight irrita- 
tion of the conj unctiva. By ophthalmoscopical examination considerable changes were 
detected in the right eye, which, according to the patient's statement, was sound. 
From arteria temp, superior a broad, whitish stripe is seen to extend toward the 
macula. It is of irregular shape, partly surrounded by extravasations of blood. Several 
such, lying in a half-circle, are seen above the macula, which itself appears as a bright 
* L signifies the power of discerning light differences in a light room. To try this I have used 
either the photoptrical tables constructed by myself, or the rotating disc, with black sectors 
on gray disc (Pflüger). Color sense has been determined by Chromatoptrical Table. ( Vide 
''Transactions of Seventh International Medical Congress." London, 1881.) Plate I. 
T.GINCLAIR A SON, LITH. PH ILA. 
Pathological Alt erations of the Retinal Vessels . 
(Dr. Ole Bull.) Plate II 
T.SINCLAIR *. SO N, LlTM. PH ILA . 
Pathological Alterations of the Retinal Vessels . 
(Dr. Ole Bull.) SECTION XI-OPHTHALMOLOGY. 
665 
pearl. When the artery has crossed the vein and is divided into two branches the 
temporal branch is seen to be fusiformly dilated. The part dilated is of a dark-red 
hue (Fig. 2). V R |, L L aud C left and In dark room light perception 
but very little diminished. In the field of vision a curved pan-shaped scotoma, corre- 
sponding to the situation of the obstructed main branch. 
Auscultation of the heart indicated nothing abnormal. 
The patient has for some time suffered from bronchitis. 
In the course of one month the whitish stripe gradually disappeared. In its place 
the fundus became black-punctuated and the artery going down toward the macula 
appeared as a hair-like streak. V increased; 28th of July it was raised to f. I saw the 
patient 21st June, this year. V then = |; no scotoma. The branch formerly 
obstructed appeared rather narrow. 
By physicians many cases are undoubtedly registered under the diagnosis Idiopathic 
Retinitis, or, when of old standing, under Atrophy of the Disc. This has certainly 
happened several times to myself. By looking through my notes, made at the time 
when I had not become aware of the frequency of such cases, I find several cases which, 
had due attention been directed to them, would very probably have shown themselves 
Fig. 2. 
Fig 3. 
to have resulted from obstruction of the retinal arteries. In the two cases about to be 
mentioned I at first made the diagnosis: Atrophy of the Disc. 
Case hi.-Mr. W., druggist, twenty-six years; observed August 3d, 1882. Four 
years previously, while occupied with writing late in the evening, the patient noticed 
that he saw double. On waking next morning he felt a pain in his left eye. He 
immediately tested the sight and found it to be considerably lessened. Optic nerve as 
in atrophy. V R - f ; L T4f ; C left J for blue; otherwise |. Mapping the visual field I 
found a fan-shaped scotoma starting from the blind spot, thence extending to the centre 
and ending in a horizontal line passing through the point of fixation. As the form of 
the scotoma seemed to indicate atfection of a retinal vessel I repeated the ophthalmo- 
scopical examination, and found that arteriola macula inferior was wanting. (Fig. 3.) 
the patient told me that he always had been healthy. No heart affection; urine 
normal. Some years later, however, he was attacked by tabes dorsalis. 
Case iv.-Mr. R., thirty-one years; observed 4th of September, 1883. The patient 
asserts that the sight of his right eye had once been excellent. In 1869 he, for a while, 
felt a tenderness in this eye when moved. Some eight or fourteen days afterward, 
when the tenderness had subsided, he noticed that the sight was impaired. Optic disc on 
the right side bluish-white e pecially in its outer half. The arteriola macula inferior 666 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
wanting. VL};K|; C T'-f for blue and yellow; for green and red left side. 
From the macula a scotoma exactly like that in Fig. 3.* 
Concerning the actual cause of these affections, they have hitherto been most com- 
monly assigned to emboli. These may sometimes be the true cause, and some of my 
own cases might possibly be explained in this way. Thus, the following two cases:- 
Case v.-C. Simonsen, thirty-four years ; consulted me September 26th, 1869. Eight 
days before he suddenly became blind in his right eye. Nothing to be seen externally. 
T of the right eye perhaps somewhat increased. Excursions free. Ophthalmosc. : 
Smoky discoloration of the retina, in reg. m. 1. œdem. The macula itself appears as 
a faint, not well-defined reddish spot. Arteries of variable volume. Both in arteries 
and veins blood cylinders moving slowly in right direction. In several places the 
blood is seen to ooze through the vessels per diapedesin. 
By auscultation a loud presystolic murmur most audible at the apex. Urine 
normal. The patient died some months later. (Fig. 4). 
Case vi.-Helene Hansen; thirty-two years; observed 16th of September, 1882. 
About ten years previously she had been treated at the State Hospital for heart disease. 
Short time before she had suddenly become blind in left eye. During the last year she 
Fig. 4. 
has several times noticed a passing obfuscation of the left eye. Atrophy of the disc. 
Retinal vessels, especially arteries, thin and short. V R = f ; on the left perception 
of light in a small part outward from the centre. First sound protracted. (Fig. 5. ) 
It should, however, be generally known that not all symptoms of these affections 
can be satisfactorily explained by assuming that emboli form their anatomical sub- 
stratum. 
As to their etiology, we certainly find that many of the patients subject to these 
affections suffer from heart diseases, but in many others it cannot be ascertained. Thus, 
of 18 cases, I have been able to demonstrate the existence of heart disease in eight 
only. In some cases the source of the supposed embolus has been sought in the large 
vessels, when these have shown signs of atheromatous degeneration. (Karwat v. 
Marion, Null, Hoffman, Samelsohn.) There nevertheless remains a not inconsiderable 
number in which no disorders of the organs of circulation have been shown. In some 
*In medical literature I have found no similar case reported. Hirschberg only {Centrait), 
f. Prakt. Augenheilkunde 85) reports a case having recently occurred to a man aged sixty-nine 
years. He thinks that similar cases of partial embolism happen more frequently than any 
other. SECTION XI-OPHTHALMOLOGY. 
667 
cases phlebitis in other parts of the body has been taken as the cause of the embolus. 
(Walter, Schulin.) On the whole, negative proof that no source exists for an embolus 
cannot be adduced. The more so since diseases of circulatory organs, even when present, 
cannot always be ascertained. It rests with those who maintain embolus to be the 
actual cause, to prove its source ; failing to do this, their diagnosis loses one of its most 
important supports. 
Of Functional Disorders there is one symptom that, in many cases, precedes the 
real onset of the eye affection, namely, passing obscuration of sight. Most writers have 
attributed these temporary attacks to emboli having for a time caused an obstruction of 
the central artery. That a passing obfuscation of sight can thus be caused cannot be 
denied, but it is in the highest degree improbable that such partial obstruction of the 
artery should in so many cases precede the complete obstruction, and that, as a rule, 
several times in the same individual. This explanation becomes futile when applied 
to certain cases, as, for instance, that of Loring, in which the patient had innumerable 
attacks of passing obfuscation in the course of several years. 
The suddenness with which the symptoms occur has been correctly regarded as an 
argument in favor of the embolus. I have, however, seen a case in which the affection 
Fig. 5. 
came on. gradually. The alterations of the retinal vessels were in this case quite 
analogous to those generally assumed to be characteristic of embolus. 
Case vh.-Glinild Hal tan; unmarried; twenty-eight years; observed June 21st, 
1884. Five years before the patient was suffering from a violent headache of the left 
side. When this had lasted nine or ten weeks, she suddenly got a whistling sound in 
the left ear, and in the course of some twelve hours she gradually became almost 
blind in the left eye. The sight has since remained very imperfect, and she does not 
hear as well with her left as with her right ear. According to her statement, the left 
eye has been turned inward every second day. On both sides of the neck and under 
the arms are traces of suppurated glands. In the heart, a tendency to reduplication of 
sounds. Externally, nothing abnormal in the eyes except strabismus internus. The 
patient was under observation three days, and the degree of strabismus was found to 
be greatest on the first and on the third day. Ophthalmoscope : Right eye the disc of an 
atrophic appearance. The upper arteria temporalis constricted for the length of f O. D. 
The constriction commences close to the margin of the disc. Beyond the stricture the 
lumen is normal. The drum on both sides healthy. Eustachian tubes of good perme- 
ability. Watch in normal distance (1 meter) right side ; left in 16-18z/. Cranio-tym- 
panic leading to the right. 668 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In relation to the changes visible by means of the ophthalmoscope, it is well known that 
there are some which are difficult to explain by the supposition of embolus. Among 
these is a well-recognized and very frequent phenomenon, viz., that the arteries can be 
found filled shortly after the affection had been noticed by the patient. As Mauthner 
rightly remarks, it is difficult to understand how the circulation, being hindered by an 
embolus, can be more or less fully reestablished within a short time. If an embolus 
exists we must assume it to be thrust firmly into the lumen of the artery. We cannot 
possibly think that an obstructing body, carried into the vessels by the stream, should 
simply adhere to one side of the vessel. The pressure of the current must drive it 
forward until the vessel becomes totally obstructed, and it will then, within a short 
time, become fastened to the intima by an inflammatory process. Atrophy of the 
vessel beyond the obstruction, and not maintenance of its lumen with reestablishment of 
the circulation, would be the sure result. Some authors have endeavored to explain 
the reestablishment of circulation by supposing a communication brought about either 
through the retino-choroidal or through the retino-ciliary vessels. The former-as 
Professor Leber has proved-are too small to admit a speedy reestablishment of a col- 
lateral circulation. The latter (retino-ciliary vessels) are certainly extremely rare. 
It is also-as Professor Schnabel and Dr. Sachs have remarked-difficult to understand 
why the vessels, a collateral circulation having been established, should after a while 
become atrophied. Still more difficult it is to explain how the vessels can be con- 
stricted at intervals. Lastly, it seems to me inconsistent with the assumption of an 
embolus that one or more of the arteries can be found one day to be of normal lumen, 
and quite collapsed on the next. This is seen, perhaps, in most cases, and to harmonize 
this with the assumption of embolus the preposterous supposition would be necessary 
that a continuous immigration of emboli into the respective vessels took place, and 
that the same emboli were continuously absorbed. 
Such is, in brief, a summary of the objections that may be urged against the hypothe- 
sis that emboli are the essential cause of all or most of such affections. The force 
of those objections has been fully appreciated by some authors, but, nevertheless, oph- 
thalmologists continue to look upon such affections as embolic, mostly, it would seem, 
because the phenomena are still less explainable by the other hypotheses, such as post- 
ocular neuritis or bleeding in the optic nerve. 
Among my own cases, the following has led me to seek an explanation in changes 
occurring in the vessels themselves, rather than in an immigration of emboli. 
Case viii.-Mr. Krabbe; forty-eight years ; consulted me December 6th, 1881. 
The patient, a strong-looking man, stated that since the autumn of 1866 he had occa- 
sionally seen colored rings around gas lights, etc., and that this has of late happened 
more frequently than formerly. His health has been generally good. Once, however, 
while suffering from a boil on the perineum, peritonitis supervened, and was followed 
by phlegmasia alba dolens of the left leg. By this he was confined to bed for about 
nine months. The phlegmasia led to gangrene of the toes, which were amputated. 
Heart normal. Nothing abnormal could be detected in the urine. The pupils are egg- 
shaped, with the smaller end turned upward and inward. Camera ant. on both eyes 
narrow. Sensitiveness of the cornea on the left eye less than on the right. T normal. 
Right eye, hyperæmia of the disc. Left, glaucomatous excavation of the disc ; pul- 
sation observed in the trunk of the artery situated on the disc. All the arteries 
except a. nasalis inferior are seen to be constricted, appearing as hair-like streaks at a 
distance of about 1 O. D. from the margin of the excavation. The two branches of a. 
nasalis sup., at a short distance from the point of division, become again constricted 
for a considerable length. Macula appears as a rather large, light spot. (Fig. 6.) 
V T42- both eyes. C left, in field of vision sector-like defect downward and out- 
ward; the defect includes the blind spot. April 24th, 1882, V was a mere perception SECTION XI OPHTHALMOLOGY. 
669 
of light left; right T42. The left pupil much enlarged, its egg shape persisted. Later 
an attack of acute exacerbation of the glaucomatous process supervened in right eye. 
This was operated on in the State Hospital. I saw the patient 10th of August, this 
year. The arteries had become very much atrophied on both sides, but especially so on 
the left. V R. Amaurosis L. 
In this case I at first made the diagnosis embolic affections of the retinal arteries, 
supposing the source of the emboli to be in the affection described above. The con- 
striction of the arteries I ascribed to the pressure beyond the partially obstructed points 
having not been sufficient to overcome the contractility of the walls of the arteries. The 
peculiar condition of the art. nasal, inf. and its two branches caused me to abandon this 
rather hypothetical diagnosis. It is not at all likely that the weakened pressure beyond 
the second strictures in each of the branches of this artery should be sufficient to over- 
come the contractility of the walls, which, before the division, it had not been able to 
overcome. It is more probable that they were occasioned by spasm of the arteries them- 
selves, and consequently the functional disturbance might be most reasonably attributed 
to the ischæmia brought on by the spasm. Changes in the retinal vessels are also, by 
recent authors, believed to play a prominent part in the glaucomatous atrophy of the 
Fig. 6. 
retina, and I see that Prof. Schnabel lately has supposed that the hyaline degeneration in 
this disease is associated with spasm of the arteries. 
When I first had got the idea that the spasm of the arteries may be a factor in the 
glaucomatous process, it naturally led me to look out for the same cause in the cases of 
sudden functional disturbance for which emboli afford a by no means satisfactory 
explanation. Consequently I began, in all such cases, to examine the vessels very 
carefully for constrictions, which, especially when they take place beyond the limits of 
the disc, are apt to elude observation. The result has been that since that time I have 
seen five cases in which the arteries were partially constricted at intervals. Two of these 
I have already mentioned. In Case I the constriction was perhaps caused by embolus. 
The other case, VII, is better explained by supposing a primary suffering of the vessels 
themselves. So, too, according to my opinion, the following three cases :- 
Case ix.-Mrs. Myhre; fifty years; came to me September 8th, 1885. Fourteen 
days before, after having suffered from violent headache for one week, she noticed that 
a dimness overspread one side of the room. The dimness has since that time been 
continuous and increasing. Ophthalmosc. : R, symptoms of choked disc ; arteries narrow, 
veins comparatively wide. A minute examination was not made at once, as I contented 
myself with the diagnosis neuritis. V sees fingers, but cannot count them. Left eye 670 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
has always been weak. V = T4- H m. 3 D. Tested by colored glasses, she perceives 
the different hues. C left without glasses, normal. Heart, the second sound a little 
accentuated. Urine normal. During the following days the upper lids became œde- 
matous, especially on the right side, where the lid appeared more or less swollen all the 
time she remained under observation. September 24th. V begins to increase. She can 
count fingers at lz. Optic nerve pale, arteries narrow. October 8th. All arteries visible 
are constricted. Ou both of the main branches the constriction commences cire. 1 O. D. 
from the disc and is about half O. D. in length. A. mac. lut. is apparently of its 
normal lumen for a short distance (J O. D.) ; the rest is constricted to a fine streak. 
A. m. 1. inf. is contracted for its whole length ; so too art. nas. inf. On nas. sup. we 
see two constrictions separated by a short piece of normal lumen (Fig. 7). V = £s. 
T normal. October 22d. Art. tern. sup. is now of its normal lumen from its exitus, 
about 2 O. D. Puncture of the cornea was now done, but did not produce any visible 
alteration in the fundus. Light perception in dark room much lowered. November 
23d. Ophthalmosc. as before, V Visual field is indicated below. 
Case X.-Mrs. Anna Hansen; sixty-three years; observed October 15th, 1885. 
Fourteen years ago the patient had articular rheumatism. Over the heart there is now 
a slight systolic murmur audible in carotid. During the last year she has three or four 
times noticed a transient obfuscation of the left eye. Eight days ago she suddenly 
became blind in that eye. Disc very pale; all the arteries, except the lower main 
branch, contracted, some of them visible only as hair-like streaks. On nasal, inf. a well- 
defined constriction of about | O. D. is seen close to the disc. On temp. sup. two con- 
strictions are seen, separated by a piece of about J O. D. in length. In the lower part 
of the retina, between Y. S. and the disc, a not well-defined red discolored part. Macula 
itself appears as a light yellow spot surrounded by a red halo. Around the latter, retina 
grayish-blue discolored (Fig. 8). T of left eye a little increased. V perception of light 
and colors in a part temporally to the centre. V R f. Later the disc assumed a more 
dead color. The transition of the constricted parts of the arteries into the more dilated 
ones became more fusiform. 
Case XI.-Elise Hougsleien; fifty-nine; observed 27th January, 1886. Four weeks 
previously the patient had received a violent blow on the left cheek, where blue and 
yellow discolored spots still remain. Two days ago it appeared to her as if "downs 
floated before her eyes. " Since that time she has been blind in the right eye. The 
pupil on the right side appears a little wider than on the left. Ophthalmsc. : Over the 
fundus a slight veil. Some of the arteries hardly visible. Where the arteria. nas. sup. 
crosses the boundary of the disc it is seen to be constricted for the length of 1 O. D., and 
then again to assume its former volume. In the region of the macula an oval red spot, 
with a bright yellow dot in the middle. T normal. V | L. R fingers in a little place 
outward to the centre. With this eye she can see the different hues of colored glasses. 
Heart normal. The following day the cornea was perforated, and, according to the 
patient's statement, this operation was followed by some clearing up of the visual field. 
The artery going from the lower main branch outward appears on the disc after the 
operation, to be filled for a short distance, then to be contracted as far as to the margin 
of the disc. Thence the two branches into which it has been divided are seen filled 
rather far out in the periphery. The puncture was repeated next day, but uselessly. 
The ophthalmoscopic appearance remained unaltered for several days. When I last saw 
her, March 20th, 1886, the disc had become very pale. 
One of these three patients suffered from heart disease, and consequently we have 
in this a possible source of emboli; but if we would explain the case as an embolic 
affection, we should have to assume that an incomplete obstruction of the central artery 
had taken place three or four times in the same year. In cases IX and XI no disease of 
the organs of circulation could be shown. SECTION XI-OPHTHALMOLOGY. 
671 
Reviewing the whole, it seems to me that in affections of this kind no symptom 
exists which cannot be readily explained by assuming spasm in the arteries as the origi- 
nal cause of the disturbed circulation, namely, the passing obfuscations of visual field, 
admitted by all authors to be so difficult to explain in consonance with the assumption 
of emboli, the rapid reestablishment of the circulation, the changes of the lumen of 
the vessels, and, above all, the local constrictions of the arteries. By supposing spasm 
it is also rendered easily intelligible how the constant stream may sometimes much alle- 
viate the symptoms (Benson), or how inspiration of amyl nitrate may effect a cure 
(Noyes). I will here remark that spasm of the arteries has lately been mentioned by 
Prof. Schnabel and Dr. Sachs as a complication which possibly may play a part in the 
affections in question, and that Zehender, many years ago, has mentioned this cause in 
speaking of embolic affections. 
A high degree of spasmodic contractions without mechanical obstruction can cer- 
tainly produce an anæmia by which the whole or parts of the retina become, either for a 
time or constantly unable to perform their functions. Thus, in the case of glaucoma 
we find that the defect in the visual field corresponds to those parts of the retina sup- 
plied by art. temp, superior and the outer branch of nas. sup. However, as may be 
seen in anatomical specimens, the arteries can be actually obstructed. Judging from 
the ophthalmoscopic appearance, a real obstruction may have taken place in two cases 
in which I found a branch of the central artery to be dilated and colored a dark red. 
One of these cases I have already mentioned, namely, that from which Fig. 2 is taken. 
The second is as follows:- 
Case xii.-Mr. Weidemann ; thirty-three years ; consulted me 29th of August, 
1883. The foregoing day, while walking, he perceived a flaming light before his eyes. 
By testing each eye separately he found that to the right eye a large part in the centre 
appeared black. Ophthalmoscope: The arteries going to the nasal side considerably 
constricted, veins dilated. A branch of art. temp. sup. is seen to be dilated for 
a short distance, and of black color. Around parta vasorum a blood spot not well 
defined; it appears as if blood per diapedesin had oozed through the vessels. On differ- 
ent places blood patches; in the region of yellow spot a very large one, with serrated 
borders and of oblong shape. T perhaps a little diminished. V E = ; C and L 
respectively = J and f. No constriction of the visual field. Heart normal. During 
the following days the extravasations of blood gradually disappeared, leaving innumer- 
able black spots. V increased and was, when the patient left, 18th of October, = |. A 
little blood patch near the macula, situated close to a vein, was then the only visible 
morbid symptom. 
In such cases I believe that there might have existed a mechanical obstruction, 
because the changes visible by the ophthalmoscope can be explained in accordance 
therewith. But if in these cases there has been a real obstruction, and not a simple 
dilatation of the vessel, I cannot believe that the body constituting the obstruction has 
come from a place situated without the eye itself, because I could not find any disease 
of the organs of circulation in these very cases. I much prefer to believe that it has 
been formed in loco. Thrombosis, consequently, and not Embolus, must be the diagnosis. 
Many results of anatomical investigations can as readily be explained by the assump- 
tion of a thrombosis as by that of embolus. 
According to the most recent investigations of formation of thromboses (Bizossero, 
Hayem, Eberth and Schimmelbusch), it is more than probable that thrombi may be the 
result of abrupt spasmodic constrictions of the arteries. 
Finally, I will remark that we may find some cases in which the real cause of the 
affection must be regarded to be an inflammatory process of the walls of the vessels, 
consequently a Perivasculitis. This seems to have been the fact in the following cases. 
Finally, I will report a case whose diagnosis neither iritis nor thrombus would seem 672 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to satisfy. The real cause must rather be regarded as a circumscribed perivasculitis, 
of whose actual cause no opinion can be had. 
Case xiii.-Miss Erichsen ; aged twenty-nine ; observed 22d of February, 1887. Two 
days previously, at noon, she suddenly perceived an obfuscation in the upper part of 
her field of vision. This obfuscation has remained. Externally, nothing abnormal 
visible. When she suddenly raises her eyes she sometimes perceives bright spots like 
sparks. Excursions of the eyeball free. T normal. No pain, but a sensation of dull- 
ness in the head. There is a murmur with the first sound. Close to the margin of the 
disc the artery, and more especially the vein running downward, are seen for a length 
of I O. D. to be enveiled by a whitish lymph. The vessels appear rather narrowed. 
(Fig. 9). Beyond this, fundus normal. By perimetrical examination, a large defect 
unward and inward. During several days no change in the ophthalmoscopic appear- 
ance. Patient seen again on 28th of June. The artery and vein had become con- 
siderably more slender, and were outlined by white streaks as far as it could be seen, 
which was not more than 1 O. D. beyond the margin of the disc. V and visual 
field as before. 
Certainly in this case a systolic murmur was heard, but as the vein already the 
second day after the onset of the affection was found more enveiled than the artery, 
the diagnosis of embolus is not substantiated. 
So far as my experience goes, the diagnosis in these affections must be various. I 
have no doubt that the actual cause in most instances is to be sought in the retinal 
vessels themselves. Spasm is probably the most frequent cause. In some solitary cases 
the ophthalmoscopic appearance would lead to the supposition of a circumscribed vascu- 
litis. The diagnosis embolus should be reserved for those cases in which a source of the 
embolus has been ascertained, and in which it is sufficient to explain all the symptoms 
observed. 
DISCUSSION. z 
Prof. P. D. Keyser, of Philadelphia, asked if in any of the cases sight was 
recovered, and then reported a case of embolism in a man who recovered sufficient 
sight in a limited central field to see all ordinary objects, and to distinguish a man 
from a woman at a distance of 100 yards. 
Dr. Heyl, of Philadelphia, said that many changes in the retinal vessels were 
not due to embolism, but to defective blood tension, due, probably, to an imperfect 
system of anastomosis. He mentioned the case of a young lady whose subjective 
symptoms were those of embolism. The skin had a peculiar pallor ; nothing was of 
any service but local palpation or smacking the forehead, which, by its action 
on the supra-orbital vessels, improved the retinal circulation. He thinks, also, 
that glaucoma symptoms are due to some tremendous disturbance in the retinal 
circulation. Plate III. 
T.SINCLAIR * SON, LITH. PHILA. 
Pathological Alterations of the Retinal Vessels . 
(Dr. Ole Bull.) SECTION XI-OPHTHALMOLOGY. 
673 
HOT WATER IN THE MANAGEMENT OF EYE DISEASES-SOME 
SUGGESTIONS. 
EAU CHAUDE DANS LE TRAITEMENT DES MALADIES DE L'OEIL-QUELQUES 
SUGGESTIONS. 
HEISSES WASSER IN DER BEHANDLUNG VON AUGENKRANKHEITEN-EINIGE RATH- 
SCHLÄGE. 
BY LEARTUS CONNER, A. M., M.D., 
Of Detroit. 
In the management of a morbid state in any portion of the body three things must 
be considered by the intelligent practitioner, viz.: first, the feeding of the parts dur- 
ing a continuance of the morbid state, else death or disablement may occur from simple 
starvation ; second, the removal, in so far as possible, of the cause of the morbid state, 
and, third, the placing of the living matter of the part under such conditions as will 
most rapidly accomplish the repair of the disabled structure. The management of any 
disease which accomplishes these three things must be scientific and in the main satis- 
factory. 
Eye diseases are subject to the same general laws of physiology and pathology that 
govern the diseases of similar tissues in the rest of the body; hence their management 
falls under the same general principles. Anatomical and physiological peculiarities 
simply modify the details of management. 
All successful treatment of eye diseases is in its last analysis based upon its ability 
to accomplish one or more of these things. For instance, take the case of senile cata- 
ract. The morbid condition is a diseased lens (probably from starvation of the lens 
elements at first). However, when opaque, its management consists in its removal 
from the axis of vision. In doing this by extraction, care is taken that the feeding of 
the cornea be not shut off by too large a corneal incision, by too rough manipulation, 
or by an incarceration of a piece of the iris in the corneal wound. The reparative 
activities of the wounded parts are stimulated or assisted by the protection of the 
wound from all agents of inflammation, as germs, mechanical or chemical irritants, and 
by physiological rest to the wounded parts. 
No thoughtful man will question the fact that the same principles apply to every 
case of eye disease. But the moment we begin to discuss the agencies by which 
these principles shall be applied in the treatment of any particular case or disease, 
divergence of opinion at once appears. 
As a fact of experience, after more than ten years of careful observation and experi- 
ment, I am convinced that in the management of a large number of eye diseases, the 
use of hot water is a powerful agent in attaining the three things mentioned, viz. : the 
good feeding of the diseased tissues, the removal of morbid agents and the promotion 
of healthful repair. In the brief space allotted to a paper before this body, it is im- 
possible to present in detail the clinical evidence I have collected in support of this 
claim. I shall only hope to so present the matter as to induce others to give hot water 
a fair trial. Such trial will convince thoughtful observers that hot water deserves a 
more prominent place in ocular therapeutics than is usually accorded to it. 
In many instances it will accomplish all that is called for in the management of 
slighter forms of eye troubles, as mild blepharitis, mild corneitis, especially phlyc- 
tenular, mild conjunctivitis. I have known numerous cases in which, by a suggestion of 
one of my patients who had been taught the use of hot water, a goodly number of 
others had been cured of apparently similar troubles by it alone. But of these cases I 
do not now speak, further than to suggest, that in this manner the people have a safe 
and reliable substitute for quack remedies and nostrums and old wives' suggestions. 
Vol. Ill-43 674 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In more severe and grave affections it is used in connection with such other agencies 
as experience has demonstrated to possess undoubted value. Thus, the use of mydri- 
atics and the local abstraction of blood are the ordinary means of combating iritis. To 
these are added, in cases of specific iritis, the constitutional remedies for syphilis, and 
in rheumatic iritis such agents as soda salicylate, while in all cases the general health is 
carefully looked after. In their place these agencies are all indispensable, but in every 
case hot water will both promote the comfort of the patient, assist in dilating the pupil 
and shorten the course of the disease. In addition, there are some cases in which the 
other remedies have failed to cause any perceptible progress to recovery, that at once 
begin to improve as hot water is added to the treatment, and go on to a rapid 
recovery. I have witnessed this in so many cases seen in consultation, that I am sure 
it represents an important fact. The most skeptical wûll be convinced when he sees the 
diminished vascularity of the conj unctiva, the increased dilation of the pupil, feels the 
diminished tension that sometimes occurs when the deeper tissues of the eyeball are 
involved, and hears the grateful comments of the patient on the relief from pain and 
other discomfort. 
Similar results are observed from the use of hot water in both catarrhal and purulent 
ophthalmia, in ulceration of the cornea, and in many intraocular troubles of great 
gravity. In mild forms of glaucoma it promotes the comfort of the patient until such 
time as an iridectomy can be performed. In cases of acute dacryocystitis it is a most im- 
portant addition to other treatment and operative procedures. In all these cases it is a 
prominent factor in relieving the symptom of pain, but there are numerous other dis- 
eases of these same tissues in which there is little if any pain present, in which hot 
water is as important in promoting recovery as in those having pain as a prominent 
symptom. In this class are interstitial keratitis, true trachoma, corneal opacities, intra- 
ocular hemorrhage, turbid vitreous, choroidal diseases, etc. 
It will thus be seen that hot water is not ranked as a specific for any particular dis- 
ease, but only as an important adjuvant to the usual management of most eye diseases. 
Omitting personal idiosyncrasies and conditions when its use is impracticable, there 
are no morbid states of the eye upon which it may not exert an influence strongly in 
the direction of health. This claim is based upon clinical experience, physiological 
experiment, and well-known physiological and pathological laws. 
The history of the use of hot water in treating eye diseases is a meagre one. Little 
has been written concerning it. As a domestic remedy it has been employed from time 
immemorial. As such it has generally been used in the form of a poultice, and so does 
constitute a hot water application in the sense that I use it. Even in the profession 
it has commonly been employed by means of cloths, sponges, poultices, etc. In a 
purely empirical manner it has found favor and disfavor during all medical history, 
and probably long anterior. That it did not continue in use uniformly was probably 
due to the fact that its mode of action had not been determined, and the means by 
which it was employed did not always give favorable results. 
The data presented by medical history show that the divers results recorded by 
different observers bore a close relationship to the method they individually employed 
in using it. It is plain that if the method was such that the water when it reached 
the eye was not hot, the results of using hot water could not be obtained. Further, 
if sponges, cloths, or other substances were employed to convey the hot water to the 
eyes, we would have the effects of a mechanical irritant added to those of the hot water. 
Besides, as these substances speedily cool, the effects of warm rather than hot water 
were more likely to be obtained. 
In the American Journal of Medical Sciences, October, 1881, I called attention to the 
value of hot water in producing a more or less permanent contraction of the blood 
vessels of the eye. At that time I had for several years been using hot water for the SECTION XI-OPHTHALMOLOGY. 
675 
definite end of producing a contraction of the blood vessels in many diseases. Since 
then I have continued its use for this purpose with increasing satisfaction. Step by step 
I learned that hot water would do more than this, and meet other important indications 
in managing eye diseases. Of these I shall speak presently. That there may be no 
misunderstanding, I will briefly explain what I mean by hot water. By observation I 
found that water was hot to some persons at 110° Fahr., while others would bear equally 
well a temperature of 115° ; others 120° ; others still 130° or even 140°. It was found, 
also, that when persistently used for long periods, frequently during the day, that the 
temperature which could be endured was progressively greater. Hence it became 
evident that the actual temperature must be made to correspond to the peculiarities of 
the patient. In the beginning I found it convenient to direct the patient to apply the 
water as hot as the end of the forefinger would bear without scalding. To quiet patients' 
fears respecting possible injury to the eye from the hot water, I told them that the eye 
would not be inj ured by the heat of the water, unless the skin dripped from the testing 
forefinger. As a fact it appeared that eyes are able generally to bear with comfort 
water much hotter than can be borne by the fingers. 
Quite as important as the temperature of the water is the method by which it shall 
be applied to the eye. At first I directed the patient to sit with the head inclined over 
a large bowl of hot water, and with the hand gently throw the water against the eye, 
taking care that the hand itself did not touch the eye. This enabled the patient to 
apply hot water directly to the eye. But it soon became fatiguing, in cases where it 
was desirable to apply it for long periods at a time and at short intervals. It was also 
objectionable because of the liability of the water to be spilled, to the annoyance of all 
parties. It also was difficult to keep the water sufficiently hot. 
For special cases I devised a large rubber bulb, holding a pint or more, and so arranged 
that the eye of the patient could be placed in the large opening at the top. By a tube 
at the top, hot water constantly entered, and the cooler water as constantly escaped at 
the bottom, stop-cocks controlling the flow, as was necessary to keep the water at any 
desired temperature. A thermometer was immersed in the water so that the tempera- 
ture could be regulated with exactness. This apparatus gave excellent results, and was 
used in many experiments, as well as for therapeutic purposes. The objections 
to it were its expense, its not being at hand when needed, and its failure to fit perfectly 
every variety of face. Hence, for general practice, it could not be made available. 
Another method found serviceable was the construction of a clay dam on the patient's 
face, so that when lying flat upon the back the filling of the dam would keep the eye 
entirely covered with the hot water. The water was admitted and drawn off by rubber 
tubes, arranged in a convenient manner. A thermometer was also placed so that the 
temperature could be kept at a definite point, as in the preceding apparatus. In several 
cases of malignant gonorrheal ophthalmia this apparatus proved extremely useful, and, 
in my judgment, saved the patient's eyes. Still, the disadvantages of this method are 
insurmountable for general use. It requires too much care and intelligent watching, 
and so is limited to the few cases attended by proper conditions. 
The last method I shall mention is free from all of these objections, and leaveslittie 
to be desired. Briefly, it consists in the application to the eye of hot water by means 
of a common tumbler. The glass is filled to the brim, the head slightly bent forward, 
and the glass so applied to the face that a dam is formed with the face below the eye 
and the side of the nose, so that the eye is fully immersed in the hot water. As the 
mass of water in the glass is considerable, the water will remain some moments at the 
proper temperature. As it can be renewed in a second, it is possible, with a small 
amount of fatigue, to keep the eye immersed in hot water by the hour, if called for. 
It will be apparent that the water can be made aseptic or antiseptic as may be desired 
in any special case. Clearly, this method meets all the requirements for universal 676 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
application, as it is inexpensive, the apparatus being found everywhere within the limits 
of civilization. 
The use of hot water by any of the methods described is safe without the watchful 
care of the physician ; they may not accomplish all the good possible, but they will 
have done no harm. The same cannot be said of other and common modes of applying 
moist heat to the eye. Irreparable damage often follows the application of moist heat 
by means of some solid substance. Among the substances employed the most common 
is the poultice. As a general rule, this should never be applied to a diseased eye unless 
under the personal observation of a physician, if it is desired to obtain the benefits of 
hot water. With the greatest care, it is extremely difficult to get the good effect of hot 
water while avoiding the evil effects of the mode of application. In unskilled hands, the 
most dire results are frequently witnessed. All poultices cool soon, and in such a condi- 
tion they have none of the virtues of hot water, while they have the power of inducing and 
intensifying the very conditions which hot water tends to relieve. They dilate the 
blood vessels and render the circulation beneath them sluggish. Hence, if the cornea 
be suffering from lack of blood, they still further starve it and so tend to the destruc- 
tion of corneal tissue. The poultice in any of its numerous forms is an unsafe and 
unreliable means of applying hot water to the eye. 
In many cases the poultice mechanically irritates an eye already in an irritated con- 
dition. This would be objectionable if we were able to keep the temperature at the 
proper degree for a length of time. 
The poultice is a dirty affair, inconsistent with the aseptic principles of modern sur- 
gery, especially when it is applied to surfaces which have lost any portion of their 
epithelial covering. In it may be countless morbid germs, and under it may be devel- 
oped countless more poisonous elements. 
The compress is another form of applying moist heat to the eye. It is less objection- 
able than the poultice, in that it causes less irritation mechanically, is less likely to get 
cool, and far less likely to become the carrier of morbific material. As a substitute for 
pure hot water it may occasionally be used as a matter of necessity or convenience, but 
the results are, generally speaking, less favorable. Singularly, those who have used 
hot water in this form object to the use of hot compresses in acute affections of the con- 
junctiva and cornea, while they loudly commend their use in chronic affections of the 
same tissues. Apparently, this is due to the fact that chronic diseases bring the eye 
into such a state of toleration that it will suffer less harm from the mechanical irrita- 
tion of the hot compresses. Had these observers employed hot water in the manner 
suggested, they would have been quite as enthusiastic over its use in treating acute as 
of chronic affections of the eye. 
A form of compress sometimes called for in the treatment of ophthalmia of the new- 
born, is made of absorbent cotton. Watched, as are similar pledgets when used to apply 
cold to the same class of cases, they are safe and efficient, though less so than the water 
alone. As they are likely to be applied by the average nurse or attendant, they are 
dangerous in the extreme, as promotive of suppuration rather than the reverse. Espe- 
cially is this true if the cornea becomes involved in the disease. 
It will thus be seen that I make a marked distinction between the effects of simple 
hot water applied directly to the eye and the effects when any solid substance is em- 
ployed, as a poultice, compress, etc. The first I have invariably found beneficial and 
never harmful, while the latter often fails to do good and frequently does irreparable 
damage. 
We are now ready to ask, what are the local effects of hot water applied to the eye ? 
My first proposition is that hot water causes a contraction of the blood vessels in 
and about the eye. The proofs of this are many. 
(a) With the apparatus already described, I have carefully studied the effects of hot SECTION XI-OPHTHALMOLOGY. 
677 
water upon the human eye, and have always found that when applied for a sufficient 
length of time it bleaches the normal tissues. This can be seen in the eyelids and in 
the conjunctival tissues. The time required varies with different conditions and in dif- 
ferent persons, but by regarding these it can be obtained. The longer the application 
is continued the longer do the effects remain when the water is removed. 
(&) In operations upon the eyelids and external portions of the eye, as well as 
during the hemorrhage which sometimes complicates an iridectomy or injury to the 
eye, I have found that hot water most quickly and effectually controls the hemorrhage. 
What is still better, it stays controlled, while after using cold the hemorrhage is likely 
to recur speedily. 
(c) In cases of blepharitis, conjunctivitis, in iritis, in acute dacryocystitis and other 
inflammatory affections of the external portions of the eye, the same results have been 
observed to follow so generally that I have learned to expect them with the same cer- 
tainty that I do local anaesthesia from cocaine applied to the conjunctiva. If these do 
not follow, I know that the hot water has not been properly applied. 
(tZ) With the ophthalmoscope I have examined many eyes before and after the 
local application of hot water for from ten to twenty minutes, and found uniformly that 
the retinal vessels were found reduced in size. In a subjective way I first noticed this 
upon myself. After some very exhausting work during an attack of indigestion, my 
retinal vessels became so dilated as to seriously interfere with my distinct vision. 
Having in mind the properties of hot water under consideration, I placed my eyes 
in water at a temperature of 130° F., and at the end of ten minutes the disagreeable 
phenomena had disappeared. Shortly after this a gentleman applied to me for relief 
from a similar condition. With the ophthalmoscope I ascertained the size of the retinal 
vessels and made a drawing of the same. Then I caused him to use hot water locally, 
as described. At the end of eight minutes he affirmed that his eyes were all right. 
An ophthalmoscopic examination showed that the vessels were reduced to their normal 
size, and even less. A comparison of the drawing of the vessels before and after the use 
of the hot water was additional evidence of the truth of the point in question. Continued 
clinical observation of similar cases has given me great confidence in the power of hot 
water to control the action of such blood vessels of the eye as retain sufficient vitality 
to respond to local remedies. 
(e) Surgical, obstetrical and gynaecological practitioners all tell us that hot water 
contracts the blood vessels, checks hemorrhage and keeps it checked. The evidence 
here is abundant and conclusive. 
(/) Dr. R. H. Murray (Edinburgh Medical Journal, August and September, 1886) 
details some very accurate studies of cold and heat upon the blood vessels of the uterus. 
He found that water at a temperature of from 110° to 120° F. constricts blood vessels 
and arrests hemorrhage from small arteries. Water at from 60° to 100° dilates small 
blood vessels and promotes hemorrhage. Water at from 30° to 50° checks hemorrhage 
by constricting blood vessels, but this only temporarily. After water at these tempera- 
tures has lost its power to contract blood vessels, water at a high temperature is still 
effective. From these experiments it is clear that hot water acts very promptly, that 
it produces a long contraction of the blood vessels, that there is an absence of vascular 
reaction, that there is no exhaustion following its use, and that the parts avoid all shock. 
Our second proposition is, hot water will wash away or destroy or render less harm- 
ful morbific agents in and about the eye during the progress of many diseases. 
Concerning the first part of this statement there can be no difference of opinion. All 
will grant that hot water will wash out of the conjunctival cul-de-sacs, secretions, excre- 
tions, products of inflammation, foreign substances, etc., as readily as any other liquid. 
Few will doubt that it will do it better even than cool or cold water. As a mechanical 
detergent for the eye hot water stands first. NINTH INTERNATIONAL MEDICAL CONGRESS. 
678 
2. Water at a temperature of from 110° to 140° will certainly check some forms of 
putrefaction. It matters little whether it does this by rendering less active the germ 
agent which produces the mischief, or by repairing its damages, or by rendering the 
tissues less susceptible to its ravages. The practical end is the same. We have so 
frequently observed the changes in the secretions of the eye under the influence of hot 
water that we are positive as to the result. Concerning the exact modus operandi we 
are not in a position to express a positive opinion. Dr. Heyl (Archives of Ophthalmology, 
September, 1886) gives reasons for believing that hot water acts beneficially in purulent 
ophthalmia, by placing the tissues in a condition unfavorable to the growth of the gno- 
coccus of Neiser. The same thing is done by the application of nitrate of silver. Hence, 
he commends in this form of disease applications, every three hours, of a weak solution 
of nitrate of silver, carefully neutralized, with constant applications of hot water. 
Dr. George Sternberg (American Journal of Medical Sciences, July, 1887) gives some 
experiments made to determine the degrees of heat necessary to destroy different micro- 
organisms. He found that a temperature of 132° F. was fatal to the bacillus of 
anthrax, the bacillus of typhoid fever, the bacillus of glanders, the spirillum of Asiatic 
cholera, the erysipelas coccus, the virus of vaccinia, of rinderpest, of sheep pox, and 
probably of several other infectious diseases. As the eye will endure much higher tem- 
peratures without injury, as we have demonstrated, it is clear that at least some micro- 
organisms may be destroyed by the use of water of such a temperature as may safely 
be applied to the eye. The principle being established, further observation will deter- 
mine the limits of its application, and it will become a recognized factor in the manage- 
ment of such diseases of the external portions of the eye as are caused or maintained by 
microorganisms. 
Our third proposition is that the local application of hot water to the eyes in the 
manner described promotes the healthful activity of the living protoplasm or living 
matter. 
One function of living matter is to separate from the blood currents such elements 
as are required for the repair of worn-out tissues and elaborate them into tissue proper. 
Another scarcely less important function is to remove the broken-down or effete mate- 
rials. Upon the proper performance of these two functions the integrity of any portion 
of the body depends. That the regulation of the blood currents is essential to such 
performance is self-evident. Perhaps this may explain the quickening of reparative 
processes observable when the eye is suffering from conjunctival or corneal inflamma- 
tion. Still, I think we must look further for an adequate cause. Other remedies nota- 
bly cocaine, are capable of contracting blood vessels, but they also in some manner 
interfere with the nutrition of the parts, so that they are harmful in purulent, corneal 
troubles, and of doubtful titility in other conditions. 
It is well known that each portion of the body thrives best when kept at a given 
temperature. When it is enfeebled by disease a different and generally a warmer tem- 
perature is called for. In other cases a lower temperature is demanded, lest the parts 
be destroyed by the excessive heat. The temperature must be elevated or lowered as 
called for under such varying conditions. It would seem, from this statement of the 
case, that the natural application to an eye when its temperature was elevated by an 
acute purulent inflammation, would be cold. But I have often seen this temperature 
lowered nearly to the normal by the local application of hot water. When this can be 
done it is a safer line of practice. That it can be done in every case I cannot affirm, as 
my observation is limited to a few cases, but in none of these was an exception found. 
We have explained this effect by saying that a better circulation through the dis- 
eased parts was effected, some of the morbid materials were removed, and the living 
tissue placed in such conditions that it could act more effectively in resisting the 
encroachments of morbific agents, aud better repair damages. This is not singular as SECTION XI-OPHTHALMOLOGY. 
679 
applied to eye diseases, as it has been observed in many other organs, and to the student 
of general medicine may seem trite. 
Our fourth proposition is ' ' hot water has great power in relieving muscular fatigue 
and spaam." 
Like all other muscles, those of the eye often weary after excessive use. When 
ocular defects exist fatigue is earlier and more marked. For the relief of this distress- 
ing condition, I know nothing so efficient as hot water. In the researches of Dr. Mur- 
ray, already referred to, he gives some exact studies of the uterine muscle as acted 
upon by hot water. He found that the application of water at a temperature of from 
110° to 120° F. caused the muscle to contract almost instantly. The relaxation was 
from twelve to twenty times the duration of the contraction. Successive applications 
were followed at once by a response. The efficiency of the contraction greatly increased. 
The period of relaxation and maximal contraction was much increased. In four experi- 
ments there was a gain of four times the initial efficiency. Continuous application 
induces a high degree of contraction broken by secondary waves of partial relaxation 
and contraction. Thus, the applications of hot water actually increase the contractile 
power of the muscles. 
On the other hand, he found that water at a temperature of from 32° to 60° F. 
caused the muscle to contract slowly, produced a relaxation three times the duration 
of contraction, and destroyed the power of contractility except after a period of rest. 
Continuous application of the cold water produced rapid exhaustion of the muscle, so 
that it soon failed to respond, being completely relaxed. 
From these data it would seem evident that in cases where it is desired to increase 
the efficiency of the muscles of the eye, the use of hot water is clearly indicated, and 
that of cold contraindicated. It matters not how the exhaustion be induced, hot water 
is a most efficient agent in relieving it. Frequently, in cases of insufficiency, moderate 
in extent, of one or more of the recti muscles, we have seen it cease to trouble the patient 
after a continued use of hot water locally applied. In most cases, however, it is neces- 
sary to correct existing defects by the use of prisms, changing the insertion of the mus- 
cles, etc., the hot water affording only temporary relief. After operations for squint I 
always order the local application of hot water for a considerable time, in order to 
bring the muscles most quickly to their greatest vigor, and so enable me to ascertain the 
full effect of the operation. The liability to over-correction is thus materially dimin- 
ished, because the full effect of the first operation is more accurately determined before 
the last is performed. No doubt hot water induces these effects by other means than 
by its direct action upon the muscles of the eye, but to the latter we now direct atten- 
tion. 
Admitting the propositions advanced as substantially correct, what is their practical 
application to the management of eye diseases ? It seems to us that every thoughtful 
student of such cases will at once be able to designate numerous conditions in which 
the patient would receive great benefit from the local use of hot water. 
Active and passive congestions and inflammations, both without and within the 
eyeball, would all be benefited by so regulating the current of blood through the eye 
as to enable it to approach the normal standard. It is not claimed that hot water does 
this in every case, but it will materially assist such other remedies as may be employed 
for this purpose. In the external diseases there is always some morbific agent which 
this use of hot water will remove. And, finally, in every case the diseased tissues need 
all the assistance afforded by hot water to enable them to return to a normal condition. 
The list of extra- and intra-ocular inflammations is a long one, and need not be enumer- 
ated here. All will be more or less benefited by the common-sense use of hot water, 
to the extent of obtaining its physiological and pathological effects. 
Another class of cases in which the effects of hot water are very desirable are those 680 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in which muscular strains, weaknesses and pains form a part. Of course, the causes of 
these muscular derangements must be ascertained and, if possible, removed. This 
being done, most cases require no further attention, but, meantime, the hot water adds 
materially to the patient's comfort and expedites the recovery. Sometimes thjs can be 
but imperfectly accomplished or not at all. Here the regular use of hot water two or 
three times a day, for from ten to twenty minutes at a time, more or less, according to 
the nature of the case, will greatly add to the patient's comfort and materially enlarge 
the working capacity of his eyes. 
Another class of cases benefited by the local application of hot water are injuries 
to the eye. In such cases as admit of its use, hot water renders the patient more com- 
fortable and materially hastens the reparative process. 
Doubtless an occasional idiosyncrasy may interfere with the use of hot water in a 
special case, but I have seen few such cases. Almost invariably, aside from the trouble, 
the patients are so materially relieved by the applications that they are greatly pleased. 
Hence they are the more ready to endure the trouble called for by the treatment. 
I desired to detail typical cases, with the actual treatment in each, as illustrative of 
the use of hot water in the manner described. But time forbids. In conclusion, I 
present the following summary of the points I have endeavored to make plain :- 
1. The best effects of hot water in eye diseases can only be obtained when the water 
is so used that it comes into direct contact with the eye. In practice this is best done 
by means of a common tumbler, filled to the brim with water at the appropriate tem- 
perature, and so adjusted to the face that the eye is immersed in the water. 
2. By hot water in this connection is understood water at the highest temperature 
the patient can endure, viz., from 105° F. to 140° F. Lower temperatures produce quite 
other effects than those desired. 
3. The hot water must be applied long and often enough to accomplish its peculiar 
effects. 
4. The peculiar effects of hot water are (a) the contraction of blood vessels both 
within and without the eyeball, so as to approximate a size approaching if not equal to 
the normal. (6) The removal of some of the causes of disease, if such exist on the 
conjunctiva or other external portions of the eye, and the rendering of other causes 
less harmful, (c) The promotion of a greater reparative activity of the normal living 
matter about the morbid material, (d) The removal of muscular irritation or spasm, 
and the promoting of the normal vigor of the muscular tissue. 
5. Finally, hot water does its work without any shock to the nervous system, or 
without any loss to the actual energy existing in the eye, and without any possible harm 
to the eye. 
6. It is the one application that has no disadvantages or drawbacks aside from the 
trouble that it involves. 
DISCUSSION. 
Dr. Thompson, of Indianapolis, begs to differ, in some particulars, from Dr. 
Conner, and says that in all acute affections of the anterior portion of the uveal tract 
and in scleritis and episcleritis he finds poultices to be better than hot water. He 
would not, though, use a poultice in any form of acute conjunctivitis. 
Dr. Keyser, of Philadelphia, referred to Von Graefe's method of applying ice 
and cold in diphtheritic conjunctivitis. Of the latter disease he had only seen four 
cases in his entire practice. He generally employs steam directed against heavy 
compresses of absorbent cotton over the eye, for heat. 
Dr. Power, of London, announced himself in favor of dry heat, applied in the 
form of chamomile flowers or hops. He heated the leaves thoroughly, put them into 
a small bag and applied to the closed lids. SECTION XI-OPHTHALMOLOGY. 
681 
Dr. Eugene Smith, of Detroit, endorsed Dr. Power's statement as to the 
value of dry heat. He has often used chamomile flowers and hops with great benefit. 
Has never seen any good come from the use of moist heat in ulcerative keratitis, and 
frequently much harm. 
Dr. Huckins, of Los Angeles, Cal., agreed in the main with Dr. Conner, and 
said that he generally used salicylated cotton soaked in hot water and changed 
sufficiently often to maintain a state of comfort and freedom from pain. 
Dr. Blitz, of Minneapolis, always uses hot applications in corneal troubles, in 
iritis with synechiæ. He finds the pupil dilates more rapidly with than without 
the aid of heat. Pain is undoubtedly relieved thereby. 
Dr. Abadie, of Paris, thinks that the treatment of eye troubles with hot water 
has lost much of its importance. He no longer employs it in phlyctenular, croupous 
or purulent conjunctivitis. In croupous conjunctivitis he prefers cauterization with 
lemon juice, this latter rendering far better service than hot water. In corneal 
troubles internal medication and judicious antiseptic applications are far superior to 
hot applications ; in infectious ulcers of the cornea iodoform powder and corrosive 
sublimate solutions are far more efficient than simple hot water. In iritis, accom- 
panied with violent pain, hot applications are good, but even here injections of 
morphia, leeches, and above all, judicious internal treatment, e. g., quinine, or 
salicylate of soda, are all that is necessary. 
Dr. A. W. Calhoun, of Atlanta, G-a., uses as a means of applying heat to the 
eye a thin rubber bag filled with water, the water being of the required temperature. 
He alluded to the rubber coil of Dr. Buller, of Montreal, as being an excellent mode 
of application of heat. 
Dr. Hotz, of Chicago.-In applying heat to the eye, it does not matter how it 
is done. In all affections of the anterior part of the eyeball, wherever there are 
signs of venous stagnation, it is beneficial. In conjunctival affections, stagnation is 
indicated by oedema and chemosis ; in iritis by the engorgement of the vessels and 
the non-response of the pupil to mydriatics. Under such circumstances warmth will 
do good by relaxing the blood vessels, and so favoring the efflux of the blood and the 
absorption of serous effusions through the walls of the vessels. Hence, when we 
have stagnation of the blood, apply heat, and the feelings of the patient will tell us 
what temperature we must keep. 682 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
SECOND DAY. 
MICROBES IN EYE DISEASES. 
MICROBES DANS LES MALADIES D'YEUX. 
MIKROBEN IN AUGENKRANKHEITEN. 
BY H. POWER, ESQ. 
During the last five and twenty years great attention has been paid to the nature 
and actions of microbes. The starting point of our exact knowledge on the subject may 
be dated from the period of Pasteur's researches, in which he deposited in the Bureau 
of the Académie des Sciences of Paris three sets of flasks containing sterilized broth 
which had been for a moment opened and then hermetically sealed, near the ground, in 
Artois, on the lower heights of the Jura Mountains and near the Mer de Glace. Out of 
twenty flasks opened at each of these places, eight developed organisms at Artois, three 
on the Jura and one near Moulauvert. These experiments showed the relative number 
of the organisms in the three places, and their really great number was subsequently 
demonstrated by the well-known researches of Miquel at the observatory of Montsouris, 
at Paris. Tyndall showed that air, however abundantly it might be charged with 
floating particles, yet when once inhaled into the lungs issued moteless, and his observa- 
tion was of great importance in showing that such particles, whether dead or living, 
remain in the body and adhere to the walls of the respiratory passages. Then, still more 
recently, the careful investigations of Klein, Koch and others with pen-culture experi- 
ments, have demonstrated the absolute and relative number of the living forms in the 
air and their mode of increase when introduced into the body, as well as their intimate 
connection with many well-known forms of constitutional disease. The first note of 
microbes in the eye or its appendages was probably that of von Gräfe, who removed a 
small swelling from the canaliculus of an eye, which, on examination, was found to 
consist of fine filaments intimately interwoven, and was then thought to be identical 
with the leptothrix buccalis, though it has since, on good grounds, been differentiated 
from it. 
After that, and in the memory of many present, a large number of ophthalmic 
diseases have been found to be associated with the presence of special microbes, among 
which I may enumerate: chalazion, ciliary blepharitis, pterygium and trachoma, the 
forms of conjunctivitis that are seen in connection with diphtheria, vaccinia and variola, 
the conjunctivitis of jequirity, herpes comeæ, pemphigus and xerosis corneæ, keratitis 
and kerato-iritis, rodent ulcer, septic embolia resulting from endocarditis and metastatic 
pyæmia, optic neuritis, sympathetic ophthalmia and others. 
MICROBES OF THE EYE. 
My own observations have chiefly been made upon cases of kerato-iritis, with abscess 
between the lamellae of the cornea, occurring in those who were previously healthy, or, 
at least, not known to be suffering from disease, except that they were low and de- SECTION XI-OPHTHALMOLOGY. 
683 
pressed. Examinations were made of the material obtained from the abscess, abstracted 
with antiseptic precautions and carefully examined under Seitz one-twentieth oil 
immersion lenses. The result showed that there were numerous microbes. Some of 
these transferred by puncture, also with all antiseptic precautions, into the eyes of rab- 
bits, produced, when the cornea was punctured, inflammation, from which, however, 
after a month, almost complete restoration of transparency occurred, the dose having 
been a very small one, and the animals healthy and carefully tended. When all signs 
of inflammation had passed away, the corneæ were removed immediately after death 
and carefully examined. A few isolated microbes were still to be found, but required 
careful searching to be discovered. 
A point that has not been much dwelt upon either in regard to the etiology or to the 
prophylaxis and treatment of some of these affections, has recently been strongly 
insisted upon by Hesse, and in papers read by Dr. Percy Frankland before the Society of 
Arts and published in the journal of that Society. They relate to the distribution of 
the microorganisms of the air, and were made in a suitable and convenient spot on the roof 
of the Science Schools at South Kensington. These observations support those of Miquel 
in showing that microbes are much more common at certain seasons of the year than at 
others, so that, while adopting Hesse's method, four colonies only were obtained from 
ten litres of air in January, there were no less than 105 colonies in August, while on* 
certain days, as, for example, on June 8th, 1886, which was a shilling day at the Great 
Exhibition, the number rose to 554. In contrast with this are the observations of 
Fischer, who has shown that in eleven out of twelve experiments made at sea, at a 
distance of 120 miles, the air was absolutely germ free. 
Hesse and Frankland's experiments further demonstrated that living germs are 
remarkably heavy, and when the air is at rest or only slowly moving, rapidly sink to 
the bottom of the vessel. This was well shown by drawing air at the rate of a litre in 
two or three minutes through a glass tube three feet long lined with a layer of agar- 
agar, when it was found that bacterial colonies appeared abundantly a few inches 
from the mouth of the tube, more rarely at a foot and scarcely at all in the more 
remote parts, and it was noticeable that the spores of moulds were much lighter than 
bacteria, their colonies being found much further up the tube. 
I desire to call the attention of the Section to the immense importance of these facts 
in the prophylaxis and treatment of ophthalmic disease of an infectious nature, and to 
the duty which devolves on every medical man to impress on the municipal and sani- 
tary authorities the necessity of abolishing all underground dwellings and to the open- 
ing up of spaces in the more crowded parts of great cities, and the provision of places 
of recreation for the people. Having practiced for nearly forty years in London, and 
having been in constant charge of the same ophthalmic hospital, I can testify to the 
effects of the general improvement in the sanitation of that city. It is true that we 
were never so troubled with infectious ophthalmic diseases, such as trachoma, diph- 
theritic ophthalmia and erysipelatous, as I believe some of Our neighbors on the conti- 
nent have been, but I am satisfied that the number of cases now presenting themselves 
is much less numerous than was the case in my earlier days. The improvement in 
this respect runs parallel with the general advance in civilization, with the improved 
water supply, with the opening of new streets through bad localities, but, above all, by 
the closing of all underground cellars as places of residence. 
The great weight and speedy sinking to rest of the microbes with which the air is 
charged when the air was allowed to rest, clearly demonstrated by Dr. Frankland's 
researches, is highly suggestive, and should, in my judgment, be utilized in our efforts 
to prevent the excursion and to cure the effects of various infectious diseases. Children 
suffering from trachoma should not only be segregated from others, but should be sent 
to the seaside or into the country, or, at least, removed from basement and lower stories 684 
to the upper rooms of houses, and should be kept as far as possible in the open air. I need 
hardly point out the importance of these and similar observations upon the necessity of 
cleanliness in all operations on the eye. Instruments should not only be sharp but 
absolutely clean, and forceps should especially be attended to. Sponges should almost 
be disused; their place can be taken with absorbent wool. 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Dr. Abadie, of Paris.-The question raised by our eminent colleague, Mr. Power, 
is so important that I will ask your permission to touch upon it still further, from the 
standpoint of an ophthalmic surgeon. Pathogenic microbes play a considerable rôle 
in our operations, and demand, in consequence, our closest attention. The instru- 
ments, our hands, all the immediate surroundings of the patient and of the surgeon, 
should be the objects of the greatest care on our part. The place of operation is 
also of great importance, as is shown by the varying successes of those who operate 
in private hospitals, and of those who operate in the general hospitals, of operations 
in the city and of those in the country ; also, the advantages that one has of oper- 
ating in a room specially designed for the purpose and far removed from pathogenic 
surroundings. And here allow me to lay great stress upon the question of disinfection. 
We should have aseptic conditions and not make antisepsis our law, as is the case in 
the general surgical clinic. If we have asepsis, we will not have consecutive sup- 
puration, but reunion by first intention. And then, too, antiseptics, by doing the 
work incompletely, may bring on a violent suppurative inflammation which will end 
in loss of the eye. In other words, and to condense my ideas into one practical 
example, I never, after a cataract operation, employ means for removing pathogenic 
germs. And if you leave some-germs, notwithstanding your antiseptic solutions, 
you will, in all probability, have an erysipelatous inflammation, and thereby, 
undoubtedly, compromise the result of the operation. This shows us, then, that the 
fluids we use at an operation must not be so much germ-killing in their nature, as 
that they should be absolutely free from pathogenic germs. Finally, if after all our 
care suppuration ensues, we must employ every means to arrest its development 
by using the most powerful germicides. Among these latter I give the first place to 
the galvano-cautery. Of course, in using this means suppuration is generally 
arrested and the cornea saved, but the pupil is hidden by the scar and an iridectomy 
later on is necessary. Sometimes, after a strabismus operation, some part of the 
operator's armament not having been thoroughly aseptic, violent suppuration is set 
up which can become exceedingly dangerous. Then it is necessary to powder the 
parts well with iodoform, and if the suppuration persists, to resort to the galvano- 
cautery. If, in spite of every means employed, suppuration persists, then the ques- 
tion of enucleation comes up. If you consult your statistics, you will find that even 
death sometimes supervenes as a result of the enucleation. You open a way for the 
pathogenic germs straight into the orbital tissue, and thence into the brain. It is 
certainly preferable here to eviscerate and use strong antiseptics during the operation. 
Dr. Manolescu, of Bucharest, thought that much depended upon the knowledge 
one has of the surroundings, and the promptness with which we act. 
Dr. Heyl, of Philadelphia.-I wish to call attention to a few points in reference 
to the bacterial infection of the eye. Two errors have evidently grown out of the 
application of principles developed by mycologists :- 
1. The supposition that, because a certain method will sterilize a flask of fluid, 
therefore, it will do the same for an infected tissue. SECTION XI OPHTHALMOLOGY. 
685 
2. That one single anti-parasitic will answer under all circumstances. This is shown 
not to be so by several clinical experiences :- 
(а) The purulent ophthalmia due to infection with the gonococcus of Neisser. 
There, I believe the palpebral conjunctivæ to be the culture ground of the coccus, 
while the elevations of the scleral conjunctiva, which girdle the cornea and the corneal 
ulcerations, are due to the mechanical accumulation of the cocci. 
(б) The diphtheritic conjunctivitis, which, in clinical course, may be allied with the 
purulent ophthalmia, and the culture ground be looked for in the palpebral con- 
junctivitis. 
(c) A form of epithelial mycosis described by Leber in connection with hemera- 
lopia. Here the culture ground is the sclero-corneal epithelium. All these forms 
demand a particular method of treatment. Heat is useful in all of them. 
(cZ) Another form of mycotic infection is that of the hypopyon keratitis. Here, 
I believe the starting-point of the infection is an abrasion of the corneal epithelium, 
the culture ground being the corneal lymph. In this case the iodoform is the proper 
antiseptic, while it is hurtful at least in the purulent ophthalmia. 
Dr. B. J. Baldwin regrets very much that Mr. Power did not present the sur- 
gical aspects of his bacterial pathology. Bacterial infection, he believes, is peculiar 
to large hospitals. In 80 cataract operations he has had five failures-two from sup- 
purative keratitis and three from insidious iritis coming on thirteen days after the 
operation. 
Dr. Landolt, of Paris, thought it of the greatest importance to avoid crowded 
hospitals in operations. Even private houses may have in them pathogenic 
germs. He uses a corrosive sublimate solution at every operation, to the strength 
of 1 to 5000. 
Dr. Dudley S. Reynolds, of Louisville, said :-The question of septic poisoning 
of wounds has been studied with great profit. When a person comes to my clinic 
requiring any sort of operation, I first require the hands and face of the patient to 
be thoroughly washed with soap and water, after which a solution of corrosive 
sublimate, one grain to the pint of water, is used for sponging the part to be oper- 
ated on. If it be a case of cataract, and the patient has inspissated mucus in the 
lash, or any discharge whatever from the conjunctival surface, I refuse to operate 
until the patient is fully recovered and the eye absolutely free from abnormal 
secretion. If the patient is feeble, nervous and dyspeptic, I will not operate until 
the state of the general system is, to my mind, favorable for the support of the 
reparative processes necessaiy after an operation. Always after an operation I wash 
the eye thoroughly with a solution of corrosive sublimate-1 to 5000. In all oper- 
ations I wash my sponges in a solution of carbolic acid, half a drachm to the ounce 
of water. In this solution I also wash my instruments. Just before operating, I 
dip my knives and scissors into the corrosive sublimate solution, and wipe them on 
clean lint. Practicing these precautions, aseptic conditions may be relied upon ; 
provided, however, the surgeon does not permit an assistant to handle the instru- 
ments at the time of operating. I have now a record of 146 cataract extractions 
without a case of suppuration. In fact, I have not seen half a dozen suppurating 
wounds in three years. I should not incline to recognize an iritis coming on thirteen 
days after extraction of a cataract as being, in any sense, due to local infection. 
Dr. P. D. Keyser, of Philadelphia, uses a boric acid solution, and has seen great 
reduction in the relative frequency of suppuration after operations. 686 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Galezowski, of Paris, has seen suppuration of cornea and iris after a cha- 
lazion operation. He sees that the patient is perfectly clean and his surroundings 
aseptic. 
Dr. Eugene Smith, of Detroit, operates in the surgical amphitheatre in the 
presence of his class. He uses a boric acid solution, and never has any fear of 
suppuration. 
OPERATIVE TREATMENT OF POSTERIOR SYNECHIA. 
TRAITEMENT OPÉRATOIRE DE LA SYNECHIE POSTÉRIEURE. 
OPERATIVE BEHANDLUNG DER HINTEREN SYNECHIEEN 
PROFESSOR PETER D. KEYSER, M. D., 
It is a well-known fact that posterior synechiae, especially when numerous and 
firmly bound down, are of serious detriment to the vitality of an eye. It is true that 
cases exist of isolated adhesions in which the eyes are perfectly free from any irrita- 
tion or serious consequences, but it will be found in these that the attachment of the 
iris is generally only a small point at the mere extreme pupillary edge, and from the 
elasticity of the texture the iris is not drawn much upon in the action of dilatation and 
contraction of the pupil. But when the adhesions are more numerous and extensive, 
the incessant dragging of the membrane during the action of the iris, under the stimu- 
lant of changes of light, as well as in accommodation, disturbs the circulation and 
innervation, causing inflammation to occur in the part ; and which will constantly 
recur as long as the adhesions remain. With every attack of recurrent inflammation 
the adhesions are liable to spread and increase in number, thus laying the foundation 
for further and more serious trouble, until, eventually, the whole pupillary margin is 
adherent to the capsule, and thereby cutting off the communication between the 
anterior and posterior chambers, which is essential to the proper nutrition of the media 
of the eye. If these adhesions are not removed when a cause of recurrent inflam- 
mation, the irritation will be continued, and the inflammatory process gradually 
extend over the entire uveal tract through the iris, ciliary body and choroid, and thus 
spread over the entire ball, causing its total loss, with, at times, danger of sympathetic 
affection and loss of the other eye. 
When it is found that these adhesions are so permanent as to resist the action of 
mydriatics or the alternate use of myotics and mydriatics, it becomes necessary to use 
operative procedure to free the eye from these dangerous influences. The removal of a 
piece of the iris, as in iridectomy, is not always desirable, especially in cases where the 
adhesions are isolated, solitary or numerous, and even extensive but partial, and the 
centre of the capsule transparent. For such cases substitutes of various methods have 
been proposed, and seemed to present a history of brilliant results for awhile, but, 
gradually, all of the methods presented have gone into disuse, not from any defect in 
the methods, but from the defect in the instruments recommended, endangering the 
capsule as well as iris in the delicate manipulations during the operation. Streatfield 
presented his hook spatula, then Weber, with his hook, won some success. Then, to 
remove the danger of rupture of the capsule, Passavant recommends tearing the adhe- 
sions loose by grasping them with a pair of iris forceps, made without teeth at the end, 
so as not to injure or wound the iris. 
Philadelphia, Pa. SECTION XI OPHTHALMOLOGY. 
687 
After an experience of many years with the above methods, I have found that that 
of Streatfield is the best and most successful with a careful and reliable operator, but 
the danger lying in the instrument of Streatfield is that, it being so thin, the point of 
the hook on the side is liable to become bent or spring out of its level plain, and thus 
be a cause of either rupturing the capsule or catching the iris. This occurred to me 
after some previously successful operations. The point got out of position very slightly, 
not so as to be perceived, but enough to be fatal to the operation. Weber's hook is too 
large, making it difficult to get behind the adhesions, and with neither of these instru- 
ments can you manipulate from the nasal side. Passavant's operation is excellent for 
one or two small adhesions, but not for more extensive ones or a series of them. It is 
too troublesome and difficult to get patients to undergo several operations, which will 
be necessary if the attachments are numerous. There is also danger of iritis from the 
pressure on the iris by the forceps. All three of these methods and instruments require 
too large an opening in the cornea, so that the aqueous is lost, making the operation 
more difficult--the desideratum being to keep the aqueous in and the anterior cham- 
ber full, so that the iris can readily retract under the action of the mydriatic after the 
adhesions are torn loose. 
To remove these difficulties and dangers, I had, some years ago, an instrument 
made which answers every purpose, and with which I have had most brilliant success. 
It is so shaped and curved as to permit its entrance in any part of the cornea without 
any hindrance from the prominence of the brow, nose or cheek bone. It is also so 
perfectly smooth, and without any sharp points, that it will pass over the capsule and 
under the iris without the least danger of injury to either. 
The method of operation is that recommended by Streatfield. Atropia instilled in 
the eye to dilate the pupil as much as possible, so as to put the adhesion on the stretch, 
then cocaine is instilled to benumb the eye (local anæsthesia). A very narrow flat 
knife or cutting needle is used to make a small opening in the cornea, which must be 
drawn out without losing any or very little aqueous ; then introduce the instrument 
for corelysis, passing it gently and delicately between the iris and capsule above the 
point of adhesion, after which draw it down with a slight lifting motion. In this way 
one or more, or a broad attachment, can be loosened in one operation. I have in this 
manner, and with this instrument, detached adhesions covering nearly one-half of the 
pupillary margin. Remove the instrument from the eye with the loss of as little 
aqueous as possible, then instill atropia solution, gr. iv : £j, every ten minutes for one 
hour, then twice or thrice daily. A simple bandage (Liebreich's) or shade is sufficient 
over the eye. 
DISCUSSION. 
Dr. Galezowski, of Paris.-The subject that our eminent colleague has just 
treated is so important that I would like to speak a few words in connection with an 
operation fraught, as it is undoubtedly, with a certain amount of danger and with a 
great deal of difficulty. You all know how difficult it is to stop an acute iritis, how, 
notwithstanding antiphlogistic, anti-syphilitic treatment, together with mydriatics, the 
disease persists ; and as regards iridectomy during the acute stage, I have seen my 
old master, Desmarres, practice it, and, indeed, I have done the same myself, but 
I must confess that I was often disappointed and it ended in occlusion of the pupil, 688 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
and of course the sight was compromised. For the past few years I have adopted 
the following treatment : when I find that the disease obstinately resists all medica- 
tion I puncture the anterior chamber. By this means I usually put a stop to the 
inflammatory process, and frequently, with the aid of internal remedies, bring about a 
cure. Later on, after all inflammatory phenomena have subsided, and I convince 
myself that the anterior synechiae are not too numerous, I make an iridectomy, 
which under these circumstances gives excellent results. 
ON THE MOST SIMPLIFIED METHODS OF CATARACT 
OPERATIONS. 
DES MÉTHODES LES PLUS SIMPLES POUR L'OPERATION DE LA CATARACTE. 
ÜBER DIE MÖGLICHST VEREINFACHTEN METHODEN DER STAAROPERATIONEN. 
BY DR. MOOREN, 
Düsseldorf. 
Since the beginning of my ophthalmological activity, in the year 1855, the methods 
of cataract operations have been subjected to many modifications. Regarding the 
amount of labor imposed upon the International Congress, it cannot be my intention 
to enter into a history or criticism of the cultivated methods, because I would have to 
repeat things generally known. I confine myself to giving a résumé, as short as pos- 
sible, of the methods exercised in my own practice. I cannot boast of having invented 
any new instrument ; only I dare say that my instrumental apparatus is as simple as 
can be imagined, founded upon 5119 cataract operations executed by my hand ; between 
them 2800 sclerotical extractions after Graefe's method. It is very well known to you 
that the combination of the extraction with the iridectomy, so essential in this and 
other methods, was based principally on the idea of avoiding an iritis, in order to pre- 
vent the consecutive destruction of the cornea. The progress of the antisepsis has also, 
in this regard, produced a great revolution, because the main point of success has ceased, 
in so eminent a manner, to be found in the technical execution of the operation ; and, 
therefore, the greatest stress is now laid, with justice, upon the removing of all kinds 
of infectious factors, whether they result from the secretion of the conjunctiva and the 
lachrymal ducts, or have been brought by external influences of even' kind, for instance, 
by instruments, want of cleanliness, etc. The notions of cleanliness and disinfection 
must here be regarded as identical. Generally, it may be immaterial what remedy is 
to be used to ensure the disinfection ; only, according to my experience, the use of 
carbolic acid should be avoided, because to its application there is always inherent an 
influence more or less irritant for the eye. When a cataract operation has to take place, 
the patient must have washed his face carefully with strong soap water, and after this 
a few drops of a solution of cocaine are to be put in the eye, to obtain insensibility. 
Immediately before operating, the everted conjunctiva of both eyelids is washed out 
carefully with a 3 per cent, solution of boracic acid. After this, the equally disinfected 
stop speculum, to keep apart the lids, is introduced. We may dispense with this instru- 
ment, if a clever assistant fulfills this requisite. Four years ago, I had occasion to 
operate, in this manner, at Berlin, in Professor Hirschberg's clinic, when that eminent 
oculist assisted me. I learned from my friend that the best disinfection for instruments SECTION XI-OPHTHALMOLOGY. 
689 
would be to place them in a basin filled with alcohol. Aside from the stop speculum, 
my only instruments are Graefe's knife, known by its linear shape, and a simple pair 
of forceps to fix the eyeball. The instruments are taken directly out of the vessel filled 
with alcohol. After having executed the flap extraction in former years exclusively, 
with upper section of the cornea, I now prefer, for the last three years, to locate the cut 
downward. As soon as the corneal section is finished, the same knife will be intro- 
duced again, backward, in the anterior chamber, to open the capsule with its point 
through the intact pupil. Hereafter the assistant turns slightly the stop speculum, and 
favors, in this manner, the exit of the lens, a procedure the effect of which will be 
augmented when the operator exercises an easy pressure, with the forceps, upon the 
sclera at the same time. A fixation of the eyeball with the forceps must always be 
abandoned when the patient begins to be restless, in order to avoid an escape of the 
vitreous body. For this purpose, the instrument must be without any lock. Generally, 
the operation is finished in one minute. The cortical masses escape under the repeated 
light rubbing of the lids over the cornea, after the removing of the stop speculum. 
Then the eye and lids are washed again with disinfected cotton, saturated with the 
same solution of boracic acid. Immediately afterward, the closed eyes are sprinkled 
with iodoform powder. Upon this, the imposed cotton layer is preserved in its position 
by a simple adhesive plaster, reaching from one temple to the other. I cannot empha- 
size enough this method of bandaging, because it prevents the patient from pressing 
the cornea wound if, by chance, he moves the back of his head on the cushion. After 
two days the eye is cleaned and the first bandage renewed. It is not advisable to con- 
tinue the application of the sticking-plaster longer than four days, because there are 
patients whose skin is so sensitive that erythema, or, in exceptional cases, erysipelas, 
might take place. 
The mentioned method of operation can be applied where the form of cataract 
requires its extraction. If the patient presents a high degree of atheromatous degenera- 
tion, it will be better to perform an iridectomy three weeks before the extraction, 
because I have observed seven cases in which consecutive glaucoma forced me, some 
weeks after the regular extraction, to perform the iridectomy, by which I had to give 
up the round pupil which I had obtained by the former cataract operation. If I exclude 
in these cases the hardness of the temporal arteries, there were not any symptoms 
which would have predicted the sudden development of such an occurrence. I only 
had the satisfaction that the alleged cases escaped, with one exception, from the final 
destruction of sight. 
When I have to do with a one-eyed cataract patient I perform always the combined 
operation, except when the form of cataract gives me a priori every guarantee of a good 
result. I have practiced this method in many hundred cases, for many years, and have 
gained the conviction that there is none that can be compared with it, regarding the 
certitude of success. The number of losses in these cases, which often enough offered 
most unfavorable chances, was so small that it averaged between 6 per cent, and 6 J per 
cent, at a time when the disinfection was not yet known. 
It is evident that the presence of cataracta accreta requires everywhere the com- 
bined operation, although after the varying circumstances the iridectomy may be 
executed in the moment of the extraction or some weeks before. In these cases 
there exist very often deposits on the anterior capsule wall, forbidding to open the cap- 
sule with the point of the knife, because the remaining roots of capsule would always 
be followed by the development of a compact cataracta secundaria. It will be the best 
to take away the deposits of the anterior capsule wall with a fine pincette, and often it 
happens, that under these circumstances the cataract follows with the capsule at the 
same time to the tractions of the pincette. 
As often as the series of cases mentioned requires the combined operation, I perform 
Vol. Ill-44 690 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the iridectomy in the upper part of the iris, and can afterward lay the linear cut for 
the extraction in the intact texture of the lower part of the cornea without exposing 
the patient to the influence of a dazzling light. 
I must now claim, gentlemen, your attention to another form of cataract that 
requires a different form of operating. I mean the corneal extraction, so-called in 
contrast to the sclerotical one, which finds its application in soft cataracts. The tech- 
nical difference in the two methods consists mostly in the choice of the knife, and in the 
manner of opening the capsule. Also, here the same instrument will be sufficient for 
both indications. The manner after which I perform the operation I have not changed in 
thirty years. Under strict observation of the same precaution in disinfecting the field 
of operations and the required instruments, I fix the eye on the lower margin of the 
cornea with the pincette and introduce the triangular lanceolate knife from the upper 
corneo-scleral limit in the anterior chamber, opening with its point the capsule as soon 
as the instrument has passed over the pupillar ring. When I then make with the 
handle of the instrument a slight movement backward, the larger part of the knife 
rests upon the external edge of the wound as upon an hypomochiion, and causes the 
softened lens to glide over the blade of the instrument. It is a very extraordinary 
exception that during this manipulation a part of the iris protrudes, because it is 
returned by the back of the instrument. When, in spite of this, such an event takes 
place, the protruded part of the iris must be cut off, because the slightest contusion of 
this membrane can give origin to the development of a state of protracted irritation or 
inflammation. This method of operation cannot be too highly recommended. I per- 
formed it, up to the end of July, in 657 cases, in the first years of my activity, in com- 
bination with iridectomy, but now in no other way than I described. If it would be 
possible to eliminate the traumatic cases, there would exist scarcely any loss. I shall 
never change it in favor of another now known method. This procedure is everywhere 
practicable where the lens is of soft consistency. It may happen that the cataract, 
although soft, presents a considerable coherence, or involves at the limit of a more 
advanced age a nucleus, a circumstance which prevents the lens from escaping through 
the corneal wound. In this case it would be advisable to enlarge the wound by draw- 
ing the lanceolate knife from one side to the other; it is certain that now the lens glides 
with greater ease through the enlarged opening. In a few cases this manoeuvre was not 
followed by the expected result, so that I was forced to give the wound a larger exten- 
sion by introducing Graefe's linear knife between the cornea and iris. The necessity of 
this exceptional procedure happens only when a trauma has caused an iritis, that 
always affords to the lenticular masses an uncommonly great coherence. In such a 
case the simultaneous execution of an iridectomy is advisable, and it becomes absolutely 
necessary when a foreign body, for instance a fragment of iron, is imbedded in the lens, 
because we risk, without iridectomy, that the foreign body is brushed away by the iris 
in the very moment of extraction, and remaining in the interior of the eye, becomes 
the cause of a highly dangerous inflammation, that not seldom gives origin to sympa- 
thetic affections. 
From the other side we meet with cataracts, which, although more or less soft, 
have not yet arrived at a state of entire maturity. They can be matured in a rela- 
tively short time by practicing, with Graefe's linear knife, a split in the anterior part of 
the lens without entering in the deeper parts. In this way the cataract ripens in a 
few days and can be removed by corneal extraction without any danger. The discission 
with the needle, in the old meaning of the word, is abandoned by me for more than 
twenty years, because it is a procedure uncertain in its results, and under certain cir- 
cumstances insidious in its consequences. This method has never deserved the enthusi- 
astic admiration with which it was extolled by the followers of the old school. 
Graefe's linear knife is in its use not restricted for ripening soft cataracts; it is an SECTION XI-OPHTHALMOLOGY. 
691 
equally valuable instrument in every other form of cataract, to bring them to maturity, 
when three weeks before an iridectomy was performed. These hard forms of cataract 
are mostly reserved to the sclerotical extraction. As I already observed at the Inter- 
national Congress of Copenhagen, I performed this system of operations at any age. 
The operation was performed in two cases at the age of seventy-six and seventy-eight 
years with the same perfect success as in younger years. When in a given case the 
patient presents a decidedly pronounced atheromatous degeneration of the arteries, the 
operation must be carefully avoided, because we risk the outbreak of glaucoma acutum. 
I had to make this experience by the loss of one eye of an old lady. Only I had 
the consolation that the first eye was perfectly cured by the mentioned method, when 
on the second the glaucomatous inflammation broke out in consequence of a severe cold, 
in a moment when the patient was more than eight hundred miles away from me. 
Another operator of great reputation in Germany had the misfortune to see his patient 
lose both eyes because the atheromatous degeneration of the arteries had not entered 
into his calculations. Although I had cultivated the method of artificial maturation 
with such exceedingly brilliant results during more than twenty years, I have adopted 
for the last three years Förster's method. It does not require such a minute attention 
on the part of the operator, and is preferable for the patient, because he has not to sacri- 
fice so much time. The puncture of the anterior chamber can be carried out with any 
pointed instrument we may have at hand. It will then be sufiicient to rub the cornea 
for a certain time over the closed eyelids to obtain the desired result. The introduction 
of special instruments, so highly praised by some oculists, is abandoned by me com- 
pletely, because I had the misfortune to make with it some very disagreeable experi- 
ences. A patient, in whose eyes I performed the maturation by introducing a curved 
spoon in the anterior chamber, presented, a short time afterwards, an insidious chorio- 
iritis with hypopyon. The affection could only be checked by a long-continued treat- 
ment and the consecutive execution of an iridectomy. Finally, I had to be satisfied 
to obtain moderate sight in one eye; the patient refused tobe operated upon in the other 
one. In a second case the first eye was perfectly cured, the second became phthisic. 
A third patient escaped with a partial leucoma. Every one will conceive that I aban- 
doned a method which had brought me greater losses than all the artificial maturations 
in former years. To-day I am completely convinced that these insidious coincidents 
must be attributed to instruments not treated sufficiently with antiseptic solutions. 
Since I changed the method, I have not seen any case that took an unhappy turn. 
Easy as may be the artificial maturation under normal circumstances, it cannot be 
denied that cataracts complicated with chorio-iritis require the greatest precaution. In 
two cases which were aggravated with chorio-iritis and presented cataracts of hard 
forms with fine radial stripes, the puncture of the anterior chamber had to be repeated 
three or four times before I could observe any progress in the development of cataract. 
One of these cases required a year before the maturity was perfect, and in the second 
I was obliged to extract the semi-transparent lens fifteen months afterward; the cataract 
had remained stationary. The results were in both cases perfect. In a third case I 
could neither obtain a result by a twice-repeated puncture, nor by splitting the ante- 
rior capsule, that was repeated three times without any success. The following morn- 
ing the capsule wound was already so densely agglutinated that further operation 
appeared to me to be dangerous. I will add that these three cases had been subjected, 
many years ago, to the iridectomy, and were all distinguished by the malignant form of 
the complication. 
The different cataract operations that I performed during so many years were executed 
without ever administering chloroform. The use of an anaesthetic is to-day still less 
necessary, because the instillation of some drops of a cocaine solution insures to the 
patient the desired insensibility. The after treatment of cataract patients consists only 692 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
in the careful observation of physical and intellectual rest. It is always an exception 
when the application of ice compresses has to take place during twelve to twenty-four 
hours. 
This exposition regarding .the technical execution of cataract operations would be 
insufficient if I would forget the iridotomy, an operation that was revived by Dr. 
deWecker, and can be regarded as a necessary complement to every kind of cataract opera- 
tion. When in the course of acute or latent iritis an extensive agglutination between the 
iris and the residues of the cataract masses has taken place or led to an occlusion of the 
pupil, there is not any method of operation that, under apparently desperate conditions, 
can create such brilliant results for the restoration of sight as the iridotomy. I per- 
formed the operation 424 times in cases that came partially from my own, partially 
from the practice of other oculists. I never performed the operation after the com- 
plicated prescriptions and with the complicated apparatus invented by Dr. de Wecker, 
but from the first to the last case in such a way that the point of Graefe's extraction 
knife was introduced through the cornea and the anterior chamber directly into the iris, 
enlarging by saw-like tractions the formed aperture to such an extent as corresponded 
to the wants of a given case. The split in the iris, linear in the first moment, takes in 
a short time a round or elliptic shape, so that the new created pupillary aperture resem- 
bles a natural one. It may happen that the operation must be repeated two 
or three times in longer intervals in eyes that are already approaching the 
limits of a beginning phthisis, before the desired result can be obtained. If with a 
natural consistency of the eyeball and a perfect technical result, the new pupil begins 
slowly to close, then the suspicion will not be unfounded that the cause is to be searched 
in the presence of latent syphilis. It is evident that an anti-syphilitic treatment has to 
take place before the operation can be repeated. I do not hesitate to call the introduc- 
tion of iridotomy by de Wecker an operative advance of the first rank, because the 
operation can bring help where formerly we would have said : lasciate ogni speranza. 
If you wish it so, gentlemen, my method of iridotomy is nothing else than a sort of 
linear discission, capable alike to ripen a cataract, to operate on a cataracta membra- 
nacea, and not less useful in many forms of cataracta secundaria. 
My exposition, which I have given you, does not pretend to be complete; it simply 
will explain in short outlines that we can reach the greatest results with the most simple 
instruments. 
DE L'EXTRACTION DE LA CATARACTE SANS IRIDECTOMIE, ET 
DU MOYEN DE PRÉVENIR LES COMPLICATIONS. 
THE EXTRACTION OF CATARACT WITHOUT IRIDECTOMY, AND THE MEANS OF 
PREVENTING COMPLICATIONS. 
ÜBER DIE STAAREXTRACTION OHNE IRIDECTOMIE, UND ÜBER DAS MITTEL ZUR VER- 
HÜTUNG DER COMPLICATIONEN. 
PAR LE DR. GALEZOWSKI. 
Permettez-moi de vous parler de la nécessité qu'il y a à revenir à l'extraction de la 
cataracte à grand lambeau sans iridectomie, par conséquent à l'ancienne méthode fran- 
çaise à grand lambeau, et de supprimer, au moins dans la grande majorité des cas la 
méthode combinée de Graefe. 
Le sujet que je vais traiter devantvous, est des plus intéressants, vous l'avez mis vous 
même dans le programme du Congrès. Il s'agit de savoir quel est le procédé d'opéra- 693 
SECTION XI-OPHTHALMOLOGY. 
tion de la cataracte qui doit être adopté comme le plus avantageux, et si les complica- 
tions qui se produisent à la suite de l'opération sont faciles à guérir. 
Je vous parlerai, si vous le permettez, de mon procédé, qui n'est qu'une modifica- 
tion de la méthode de David. 
C'est en 1882 que j'ai fait ma première communication à ce sujet à la société de 
chirurgie de Paris, à l'époque où tout le monde restait fidèle à l'ingénieuse méthode de 
de Graefe. A ce moment je ne faisais l'extraction à lambeau que dans des cas isolés, 
je dirai presque exceptionnels. 
Aujourd'hui, cinq années d'expérience ont ratifié mes premiers essais, et je puis 
vous dire, Messieurs, que ce procédé peut et doit occuper la première, la principale place 
dans l'opération de la cataracte. 
La méthode d'extraction avec iridectomie commence à perdre de plus en plus de1 
terrain ; en Europe comme en Amérique on commence à se persuader qu'il est plus 
naturel et plus avantageux sous tous les rapports de ne point toucher à l'iris dans cette 
opération. 
Dans le dernier numéro de Juin, 1886, The American Journal of Ophthalmology, le 
docteur Culbertson publiait un article sur les résultats satisfaisants de l'extraction de 
la cataracte faite d'après mon procédé. Ce travail porte pour titre : Four Cases of Gale- 
zowshi's Method of Cataract Extraction; the Last Slightly Modified, p. 149. 
En France, Messieurs Parcas et Abadie ont adopté l'extraction sans iridectomie pour 
un certain nombre de cas de cataracte, et avec des modifications différentes. Mais il 
faut avouer que la grande majorité des chirurgiens n'ose pas abandonner la méthode 
combinée de Graefe, et craint de pratiquer l'extraction à grand lambeau. Il existe 
partout une certaine hésitation et une sorte de crainte dans la généralisation de cette 
méthode. 
C'est pour dissiper cette crainte que je viens vous apporter des nouveaux arguments, 
qui vous prouveront d'une manière saisissante, que les inconvénients qu'elle présente, 
sont presque nuis en face des avantages qu'elle procure. 
Je n'ai pas besoin de vous décrire ce procédé, je vous dirai seulement, que c'est à 
l'aide du couteau de Graefe, qu'il faut tailler un grand lambeau cornien, mais en 
modifiant sa forme et un peu sa position. Ce n'est pas, en effet, un grand lambeau 
sphérique, à la périphérie de la cornie qu'il faut placer, comme faisaient nos prédéces- 
seurs. Mais il faut donner à la plaie une forme ellipsoïde, tenant juste milieu, entre 
celuide de Graefe et de David ; il ne faut pas la plaie descendre jusqu'au diamètre trans- 
versal de la cornée, ni qu'elle aille non plus s'avancer trop près du bord sclérotical. 
C'est en rapprochant la ponction et la contreponction de la sclérotique mais n'engageant 
jamais le couteau dans cette dernière membrane, on arrivera à tailler le lambeau elli- 
psoïde que je recommande, et qui est le point capital du succès. L'iris dans ces cas 
n'empêchera pas la sortie du cristallin, aussi volumineux qu'il soit, et on ne sera pas 
obligé de l'exercer. 
Mais on m'objecte à cela, que sans iridectomie on s'expose à avoir de nombreuses 
complications et*que le résultat définitif de l'opération n'est pas aussi complet que celui 
qu'on obtient par la méthode allemande, en faisant une entaille dans l'iris. On 
s'expose, notamment dit-on, à avoir la hernie très fréquente de l'iris avec staphylomie 
consécutive, l'iritis et la cataracte secondaire, c'est à cet objet que je veux répondre 
aujourd'hui, en vous montrant, mes chers confrères, comment on peut éviter ces acci- 
dents et comment y porter remède lorsqu'ils se produisent. 
Permettez-moi maintenant de vous signaler quelques points que je considère essen- 
tiels dans mon procédé opératoire sans iridectomie. Le danger de l'ancienne méthode de 
David était la forme de la plaie, grand lambeau circulaire, longeant la sclérotique, qui 
rendait la cicatrisation difficile et provoquait la suppuration et la hernie. Dans mon 
procédé que je vous recommande, cette forme est semi-elliptique, et son étendue ses 694 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
»proportionnelle au volume du cristallin. Mais ce qui importe surtout, c'est que la ponc- 
tion et la contre-ponction doivent être placées, non pas dans la cornée transparente 
comme le faisait David, mais dans le bord de sclérocornien opaque de la cornée, comme 
cela se faisait de Graefe. 
Un autre point important dans mon procédé, c'est de placer le sommet de lambeau 
à deux millimètres et quelquefois même deux et demi millimètres. Par ce moyen 
j'évite la hernie de l'iris. 
Le troisième point de mon procédé que je considère aussi très important, est la dis- 
cission de la capsule, immédiatement après la ponction cornienne, avant de taire la ponc- 
tion, et elle est pratiquée avec la pointe même du couteau de Graefe. La discission de 
la capsule avec le couteau à cataracte avant la contre-ponction est selon moi une des con- 
ditions importantes du succès de l'opération; depuis plus de 15 ans je l'ai adoptée dans 
mes opérations de la cataracte et je ne saurais trop la recommander. 
Mais lorsque la capsule a subi un dégénérement certain, grasse ou autre et qu'elle 
est devenue d'un opaque résistant, il est inutile alors d'essayer à la déchirer, et il faut 
dans ces cas la saisir, après que le lambeau sera terminé, avec une pinu pupil lain et 
l'extraire. 
Ce procédé présente des avantages incontestables mais il n'expose pas moins à quel- 
ques accidents et à des complications, et c'est de ces complications que je vais m'oc- 
cuper. 
Les complications les plus fréquentes que peut amener le procédé sont les suivantes : 
(1) Hernie de l'iris. (2) Suppuration de la cornée. (3) Iritis. (4) Cataracte secon- 
daire. 
1. Hernie de VIris.-C'est une complication qui peut se produire, lorsqu'on fera une 
plaie trop périphérique ; c'est pour cette raison que je tiens à recommander, à ce que le 
sommet de la plaie ne soit pas trop rapproché du bord sclérotical, ce qu'on obtiendra 
en donnant à l'incision la forme semi-elliptique. 
La hernie de l'iris est souvent produite par la faute du médecin lui-même, je dirai, 
presque par sa trop grande curiosité de savoir comment se comporte l'œil et la plaie dès 
le lendemain de l'opération. Il ouvre l'œil, pour examiner la plaie, recommande au 
malade de regarder en bas ; ce dernier est nerveux, irrité, fait un effort pour exécuter 
ce mouvement, qui provoque une écartement du bord de la plaie, évacuation de l'hu- 
meur acqueuse et la hernie de l'iris. C'est pour cette raison je vous recommande, Mes- 
sieurs, de ne pas ouvrir l'œil opéré avant cinq ou six jours. 
A quoi peut servir, en effet, l'examen de l'état de la plaie dans les premiers cinq 
jours après l'opération. L'état des paupières nous indique suffisamment s'il existe ou 
non une inflammation ; il suffira donc de changer tous les jours le bandage, et si l'état 
des paupières et les autres symptômes éprouvés par le malade indiquent une inflamma- 
tion, on pourra appliquer le traitement antiphlogistique et attendre avec l'examen de 
la plaie, j'acquiers qu'on peut supposer son adhérence et sa cicatrisation bien avancée. 
2. Suppuration Partielle ou Totale de Lambeau.-Je dois vous déclarer, Messieurs, que 
sur plus de 700 opérations de la cataracte, faite par ce procédé de passé cinq ans, je n'ai 
pas vu plus de deux suppurations par 100. Mais pour éviter, eu général cet accident, 
il faut avoir recours à la méthode antiseptique très sérieuse. Soigner bien les instru- 
ments, employer les latraces soit avec le sublimé à la dose d'un gramme pour 10000, 
soit l'acide borique. 
A ce propos, permettez-moi de vous communiquer et recommander l'application 
directement sur la plaie d'une plaque de gélatine antiseptique que j'ai introduite en ma 
pratique depuis pl us de deux ans, et à laquel le j'attribue les grands succès dans mes opé- 
rations. Ce sont des plaques gélatinées préparées avec le sublimé, que j'ai l'honneur de 
mettre sous vos yeux. Je l'introduis entre les paupières immédiatement après l'opéra- 
tion, et je fais le pansement habituel par-dessus les paupières. Cette gélatine roule sur SECTION XI-OPHTHALMOLOGY. 
695 
la plaie et reste 18, 20 ou 24 heures avant de se dissoudre. Pendant ce temps, l'humeur 
acqueuse remplit la chambre antérieure et les larmes, qui contiennent, comme j'ai prouvé, 
des microbes, ne s'introduisent pas dans la plaie et n'amènent pas de suppuration. 
3. Iritis.-Je l'ai observée de temps en temps chez mes opérés. Cela tient souvent à 
la constitution syphilitique, rheumatismale, goutteuse, glycosurique. C'est pourquoi il 
faut faire, dès que cela se produit, un traitement antiphlogistique, antisyphilitique 
énergique, antigoutteuse, ete. 
Mais, ce sur quoi j'insiste, c'est de ne pas employer dans les premiers trois ou 
quatre jours après l'opération ni atropin, ni aucun mydriatique, de crainte de provo- 
quer la hernie de l'iris, qui serait plus dangereuse que l'iritis elle-même. 
4. Cataracte Secondaire.-Cet accident peut se remontrer assez souvent dans l'extrac- 
tion sans iridectomie, mais y a-t-il pour cela une raison quelconque à avoir des inquié- 
tude pour le résultat définitif de l'opération? Pas le moins du monde. Si la cata- 
racte secondaire devient apparente dans la première semaine après l'opération, il fau- 
dra attendre avec une nouvelle opération, jusqu'à ce que toute trace d'inflammation 
ais disparu. Alors, une simple discission de la cataracte suffit le plus souvent pour 
rétablir la vision. 
Maintenant, que j'ai fini ma communication sur l'opération de la cataracte, per- 
mettez-moi de vous exprimer toute la joie que j'éprouve à me trouver au milieu de 
vous, malgré les péripéties d'une traversée orageuse; j'ai pu enfin réaliser un rêve 
longtemps caressé, et je suis heureux de pouvoir saluer un des plus grands peuple du 
monde, et les plus éminents ophthalmologistes. 
OPÉRATION DE LA CATARACTE. 
OPERATION FOR CATARACT. 
PAR LE PROF. N. MANOLESCU, 
De l'üniversity de Bucharest, Roumania. 
L'extraction de la cataracte, depuis quelque temps est revenue sur le champ des 
grandes discussions ; et comme elle est l'opération la plus importante de la chirurgie 
oculaire, je crois qu'aujourd'hui c'est bien l'occasion pour exprimer nos opinions là 
dessus. 
Mon opinion, en ce qui concerne l'opération de la cataracte sénile, est la suivante : 
L'extraction simple mérite toute notre attention ; c'est à elle que devra s'arrêter la per- 
fection de la méthode de l'extraction. 
Elle est encore beaucoup plus facile à exécuter : on peut se passer dans certaines cir- 
constances même de l'assistance et à la rigueur, on peut encore la faire, en ne se servant 
que du couteau linéaire. 
Ce n'est pas la même chose que j'ai à dire de l'extraction combinée : celle-ci s'exé- 
cute, comme vous savez très bien, avec plus de difficulté et encore nécéssite l'ablation 
d'un morceau d'iris, ce qu'il serait à désirer d'éviter, je l'avoue carrément. 
Mais en jugeant, l'extraction simple et l'extraction combinée, au point de vue du 
résultat optique total ou mieux, au point de vue du service optique satisfaisant rendu 
au plus grand nombre d'opérés, avec grand regret, j'avoue, je ne partage pas l'opinion 
de M. Galezowski, que je compte permis mes Maîtres. 
DIE STAAROPERATION. 696 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Mon opinion est qu'actuellement c'est encore à l'extraction combinée que nous 
devons nous adresser, comme procédé général d'extraction. 
Si la vue totale ou en somme obtenue par le procédé simple était même supérieur à 
celle obtenue par le combiné, je suis persuadé que cette somme-là de vous est partagée 
injustement entre les opérés, sans pouvoir faire autrement. 
Cette injustice dérive surtout de l'enclavement de l'iris, qui est fréquent ; on ne 
connait pas encore précisément ni les conditions qui le favorisent, ni celles qui le défa- 
vorisent ; les mesures que l'on préconise comme préventives ne sont pas sûres et parmi 
celles que l'on reconnaît favorisant l'enclavement, et que l'on pourrait éviter, il y en a 
qui se présentent quelque fois inopinément et avec la force nécessaire pour ouvrir une 
plaie que l'on croyait même définitivement fermée. 
Cette complication post-opératoire, cette bête noire, comme l'appelait Crittcbet est 
cause de beaucoup de dégâts dans l'organe visuel ; il ne s'atrophie que lentement ; 
presque toujours il nécessite des opérations secondaires, souvent il est le point de départ 
des troubles traphiques s'étendant en arrière, ou en avant, dans les parties de l'œil et 
toujours il produit un fort astigmatisme. 
En règle générale, je puis dire que plus il est heureux celui qui a échappé à cette 
bête noire, plus il est malheureux, celui qui n'a pas pu éviter cette complication. 
Il y a encore des reproches à faire à l'extraction simple, mais tous ceux-ci, j'en suis 
complètement d'avis, resteraient d'une importance très secondaire, si l'enclavement de 
l'iris pouvait être combattu. 
Eo tout j'ai pratiqué 109 extractions simples et j'ai fait tout mon possible pour les 
exécuter correctement : j'ai visité les cliniques en Europe où l'on préconise l'extrac- 
tion simple, comme procédé général et j'ai mis à l'épreuve tout ce qu'on a dit qu'il 
prévient l'enclavement de l'iris; j'ai même fait des essais personnels dont j'aurais 
l'honneur de vous parler ; pourtant j'ai la douleur de ne pas pouvoir partager l'opinion 
de mes vénérés maîtres de Paris. 
Je cherche encore la consolation pour les enclavements, qui selon ma statistique 
s'élève à 30 pour 100, dans des dispositions particulières à mes opérés, à un manque 
de repos que des courbatures musculaires, qu'on voit très communément dans mon 
pays, ne leur ont pas permis de garder la tranquilité nécessaire. 
J'ai dit, Messieurs, que j'ai pratiqué 109 extractions simples et que dans quelques 
cas j'ai fait des essais personnels pour m'opposer à l'enclavement de l'iris, permettez 
moi de vous les communiquer sommairement. 
J'ai enregistré d'abord 37 cas, dans lesquels j'ai fait simplement l'extraction simple, 
sans instiler rien, ni dans la chambre antérieure, ni dans les culs-de-sac conjonctivaux 
et sur ce nombre j'ai 25 résultats sans le moindre enclavement de l'iris ; 12 enclave- 
ments plus ou moins grands à la suite desquels il y a quatre mauvais résultats permet- 
tant aux opérés à se conduire difficilement, et huit médiocres (permettant seulement à 
se conduire) après une guérison lente etjnterventions chirurgicales secondaires. 
Dans 21 cas, j'ai fait le lavage ézérinique, d'après la méthode de Mr. de Wecker et 
le résultat a été le suivant : huit enclavements plus ou moins gros, qui ont causé quatre 
résultats médiocres. Je dois noter que sur les 21 extractions il y a eu cinq résultats 
médiocres mais un à la suite des restes corticaux. 
Dans 14 cas je n'ai fait qu'instiller de l'ézérine un pour 100, une ou deux fois dans 
le sac conjonctival. Sur ce nombre j'ai enregistré quatre enclavements, dont le résultat 
a été trois fois médiocre et une fois mauvais, par irido-choroïdite consécutive. 
Daus une série de 33 extractions simples j'ai recouru, contre l'opinion générale, à 
l'instillation des mydriatiques et spécialement à l'atropine (trois pour 100) dans quel- 
ques cas immédiatement avant l'opération, et aussitôt après ; dans d'autres cas, après 
l'extraction seulement. Le résultat est beaucoup plus satisfaisant au point de vue 
des enclavements. J'ai enregistré huit enclavements plus ou moins gros, dont la suite SECTION XI-OPHTHALMOLOGY. 
697 
a été six résultats médiocres et deux mauvais, par irido-choroïdite et infiltration de la 
cornée. Dans quatre, j'ai fait l'extraction après avoir pratiqué 24 heures avant, l'arra- 
chement du nerf nasal externe (opération de M. Badal). Je me demandais si ce 
arrachement ne pouvait pas avoir une influence sur la circulation de l'œil, puisque on 
a vu qu'il abaisse temporairement la pression intra-oculaire en cas de glaucome, et par 
conséquent s'il ne pouvait pas défavoriser la hernie de l'iris. Le résultat est le suivant: 
un enclavement sur quatre cas. 
Comme vous voyez, dans ma statistique la grande cause des résultats médiocres ou 
mauvais c'est l'enclavement iridien ; dans d'autres statistiques ce sont les inflamma- 
tions consécutives dans le tractus uveal, et pour avoir obtenu de bons résultats on a 
du faire beaucoup de discissions. 
Ce sont, je crois, au moins des difficultés très désagréables, surtout aujourd'hui 
quand le monde sait qu'il réussit du premier coup. 
Messieurs, si jusqu'à ce qu'on trouve un moyen sûr contre l'enclavement de l'iris, 
je ferai, comme procédé général, l'extraction combinée à l'iridectomie, c'est parce que je 
suis persuadé que la brèche iridienne n'empêche nullement d'avoir l'acuité visuelle 
satisfaisante, pour tout travail, et que cette brèche iridienne me permet d'être plus sûre 
du résultat que je poursuis, puisque l'enclavement de l'iris, grâce à elle, ne peut pas se 
présenter qu'exessivement rare et alors très partiel, et puisqu'il m'est beaucoup plus 
aisé de nettoyer la chambre postérieure. J'emploie presque toujours la pincette à dents 
pour enlever un lambeau de la capsule antérieure. 
Encore cette brèche iridienne, pendant la durée de sa guérison, rend l'opération de la 
cataracte très peu pénible pour les malades, parmi lesquels il y a beaucoup dont le pre- 
mier mot est celui-ci : Mais Docteur, on dit que je dois me soumettre à la torture de 
rester immobile pendant plusieurs jours? 
Je me suis fait, Messieurs, la conviction qu'un bien opéré par le procédé combiné, 
peut même quitter la clinique avec un bandeau bien fait et revenir le lendemain. 
Mais je dois ajouter ce qui me préocupe au plus haut degré pendant l'opération: 
C'est de faire une jolie pupille artificielle, je veux dire qu'elle ne dépasse pas en lar- 
geur quatre millimètres ; qu'elle ait les côtés parallèles, que l'iris soit bien coupé jus- 
qu'à son insertion, et ça va sans dire, qu'elle soit faite à partie supérieure. 
Pour obtenir une pareille pupille je ne cherche pas, comme on le faisait de tout 
temps, le sphincter de l'iris ; mais je pince l'iris du milieu de ses fibres radiaifes et je 
ne donne le des pince-ciseaux qu'au moment que j'aperçois au bord de la lèvre 
inférieure de la plaie un trait noir. 
Et comme c'est la condition essentielle d'une jolie pupille, je tâche de prendre 
l'iris dans la chambre antérieure même, je veux dire que s'il venait à prohiber, je le 
fais rentrer et cette maneuvre qui consiste dans un léger massage de la plaie est des 
plus simples et sans danger aucun. 
Vient-on à prendre l'iris en dehors du milieu de ses fibres radiaires, alors la pupille 
sera plus large du côté de l'insertion iridienne ; mais l'éxécution de cette pupille, très 
favorable à la coaptation, est un peu douloureuse, par le tiraillement qu'on exerce du 
côté de l'insertion de l'iris. 
Ce n'est pas encore finir ma préocupation ; j'éloigne soigneusement, au moyen de 
la spatule en caoutchouc, l'iris des angles de la plaie et je passe, de la même manière, 
la spatule entre les lèvres de la plaie, ainsi que j'ai vu faire mon Maître de Wecker. 
Je lave de nouveau l'œil avec une solution de sublimé corrosif trois pour 100, dont 
un courant, que j'exprime d'une pelote d'ouate imbibée, passe plusieurs fois sur 
l'œil, et pendant qu'il est plongé dans cette solution, j'applique un bandeau occlusif, 
c'est-à-dire, de l'ouate imbibée de la même solution, remplis le cavité orbitaire, un 
goutte-perche couvre largement l'ouate et puis une bande légère et longue de trois à 
quatre millimètres fixe le tout sur l'œil. 698 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Le lendemain, je change généralement le bandeau que je trouve propre et chaud. 
Grâce à ces précautions, que je viens de dire, je trouve que l'extraction combinée, 
excessivement rare peut se compliquer par l'enclavement d'iris dans les angles, que 
par conséquent la pupille conserve, sans changement sensible, la forme qu'elle a au 
moment de l'opération ; que l'enclavement de la capsule, que je ne considère pas du 
reste très grave, se présente aussi très rarement (sur 1386 extractions combinées, je ne 
l'ai vu que trois fois ; une fois il y a été cause d'irido-choroïdite et deux il a retardé 
seulement la guérison qui a eu lieu avec une bonne acuité visuelle). Grâce à ces pré- 
cautions, je crains encore moins 1'Ophthalmie sympathique ayant le point de départ dans 
la plaie faite dans l'angle irido-cornéen et dont je n'ai pas encore des exemples bien nets 
enregistrés. Du resteje considère l'ophthalmie sympathique après l'extraction, n'importe 
qu'il soit le point d'infection de l'œil opéré, absolument identique, en ce qui concerne 
les conditions de sa présence, à toute ophthalmie sympathique éclore en dehors de l'ex- 
traction de la cataracte. 
Pour ce qui concerne la suppuration, le grand danger après l'opération de la cata- 
racte, j'ai moins de raison à croire que l'extraction combinée y exposerait d'avantage. 
Au contraire, je crois, qu'un lambeau conjonctival donne plus de vitalité, par con- 
séquent plus de résistance à la plaie contre des causes nocives. 
Du reste, je ne cesserai pas les essais pour pouvoir arriver moi aussi à acclamer le 
procédé de l'extraction simple qui doit faire, je le repète, l'objet de nos aspirations. 
WHAT IS THE BEST AFTER-TREATMENT FOR IRIDECTOMIES AND 
CATARACT EXTRACTIONS. 
QUEL EST LE MEILLEUR TRAITEMENT POUR LES IRIDECTOMIES ET LES 
EXTRACTIONS DE LA CATARACTE. 
WAS IST DIE BESTE NACHBEHANDLUNG FÜR IRIDECTOMIEEN UND 
STAAROPERATIONEN. 
BY T. E. MURRELL, M. D., 
Of Little Rock, Ark. 
All surgeons will grant the one indispensable requisite to primary union in wounds 
in any part of the body, viz., a perfect and unmolested coaptation of the divided surfaces. 
The main object of all dressings is to this end, to which modern surgery would also add 
asepsis or antisepsis. A solution of continuity of tissue iu any muscular or elastic 
structure must needs be forcibly retained in proper position by sutures, or bandages, 
or both, but for no other purpose would the surgeon use them, unless to retain some 
antiseptic agent in contact with the wound, to guard against the intrusion of germs. 
If a rigid structure is severed, as one of the long bones, it must be held in proper 
position until union is firm, so as to obviate deformity, and so, to overcome muscular 
tension, splints and counter-extension become necessary. If a surgeon makes a clean 
incised wound in the eyeball, does he not observe the same general principles of 
surgery ? 
Then the question arises as to the best method of securing perfect and immobile 
adjustment of the lips of a corneal incision, for whatever purpose made, where primary 
union is desired. If one will carefully study the structure of the eye and its appen- SECTION XI-OPHTHALMOLOGY. 
699 
dages relative to this point, he can hardly fail to see that much of the interference 
in the way of bandages and dressings, as now commonly practiced following operations 
on the globe of the eye, is largely, if not altogether, unnecessary. 
If a healthy eyeball is enucleated and an incised wound made in the cornea, the 
lips of the wound fall together in the most exact manner, so that the globe preserves 
its figure perfectly, provided no unequal force is brought to bear on the outer surface 
at any point. This inherent tendency in the outer tunics of the eye-the sclerotic and 
cornea-to retain their proper curvature is very striking, and nothing but some dis- 
turbing force will overcome it. When the eyeball is in situ with all its attachments, 
there may arise influences that will disturb its normal rest, and the chief of these is 
muscular action. If the cornea or conjunctiva is offended, and at the same time the 
eye is forcibly retained in a fixed position, violent muscular spasm of the ocular 
muscles is likely to occur, which may, if there be an opened globe, force out the con- 
tents of the eye. But, on the contrary, if the eye is free, and the muscles, both the 
recti and obliqui, move harmoniously, the eye is rotated with an even force, and no 
tendency to gaping of a wound in the cornea is witnessed. Every operator has, doubt- 
less, observed this after an iridectomy or extraction, when he has requested the patient 
to move the globe voluntarily in different directions. 
Since, therefore, the harmonious action of the eye muscles does not disturb the equi- 
librium of the globe, unless, of course, their movements are extreme, the question 
occurs-is it necessary to retain, or is it wise to attempt to retain, the eye in a fixed 
position after an operation has been performed upon it; or is it ever so retained ? Will 
compress bandages secure quietude of the eye without great danger in such cases ? 
My impression is, from close observation and careful questioning of my operated cases, 
that although both eyes are snugly bandaged, there is very frequently a rotation of the 
globe underneath the lids. If, then, bandaging the eyes does not perfectly insure 
against rotation of the globe, even though both eyes are so closed, what good do band- 
ages accomplish, and what good reason can be offered for dressing the unoperated eye 
as well ? If we choose, however, to close the unoperated eye also when we come to 
apply dressings after, say, an extraction, it matters little what dressing is used on it, 
but for the operated eye it does matter immensely. We know that the eyelids when 
gently closed, so as to obliterate the palpebral fissure, form a most exquisite mould of 
the front of the globe. The slight but uniform tension of the orbicularis palpebrarum 
over the nicely adjusted tarsal cartilages keeps up such an even pressure on the cornea 
as to nicely balance it against the elastic cushion in which the globe is imbedded pos- 
teriorly. The conjunctiva is so perfectly even and soft that no friction whatever can 
occur in the movements of the cornea against it. 
When the lid margins just touch there is formed, therefore, over the front surface 
of the globe of the eye a splint of the most perfect evenness and exquisite adjustment. 
Instead of any tendency to displace the lips of a corneal wound, therefore, the lids 
offer the greatest barrier to such displacement and serve to retain most perfectly their 
accurate coaptation. 
In the rotation of the cornea under the lids it meets with no unevenness to disturb 
its perfect symmetry, or to endanger its being in any way distorted. Hence, absolute 
fixity of the eye, even were it possible, is not called for. It will be observed that the 
normal curvature of the lids has been relied on to maintain this perfect adjustment of 
a corneal wound, and to secure the unaltered shape of the globe. What more do we 
want, therefore, in dressing an eye with a corneal incision, than to secure passive closure 
of the lids ? No doubt every eye surgeon will say this is exactly what he does. Let us 
examine the ordinary bandage and cotton, or charpie dressing, and see if they fulfill 
these indications. In order to retain the lids in a quietly closed position, it is necessary 
to exert a slight pressure either directly on the central portion of the upper lid over the 700 
apex of the cornea, or else between this and the rim of the orbit, as some do by care- 
fully filling in around the globe with the dressing, to produce, as they claim, equable 
pressure. 
All pressure on the globe after an iridictomy or extraction is inimical to the best 
results, however evenly applied, but more so when unevenly applied, as it almost neces- 
sarily is by any mode of bandaging. 
If the pressure happens to be greater over the apex of the cornea, the globe is flat- 
tened and the lips of the corneal incision displaced ; or, should the pressure be too equa- 
torial the globe is laterally compressed, its contents forced forward, and the corneal 
wound caused to gape. Again, if too little firmness in the pressure exists, the lids are 
not sufficiently supported and are liable to voluntarily or involuntarily open, as I have 
had my patients to tell me actually occurred. This may be the result of fixing the 
bandage too loosely in the beginning, or by its yielding or being slipped out of position 
by the movements of the patient's head on the pillow. Some authors put great stress 
on the nice adjustment of an elastic bandage to the eye after an extraction, offering the 
consoling suggestion that the skill can only be acquired by experience. But I have, 
after the most artistic application of the bandage, been somewhat shocked on the fol- 
lowing morning to find it misplaced and gathered into strings over the eyes. This may 
occur in any very restless patient. 
I have had some headstrong and self-willed patients to deliberately push the bandage 
off in hot weather, to cool the eyes. In very warm weather the bandage and dressing 
often become uncomfortable, and I have frequently, in answer to complaints on this 
score, removed all dressings and bathed the eyes freely with cold water, to the very 
great satisfaction of the patient. Another objection to this form of dressing is, by the 
retention of the secretions and the saturation of the material next the eyes with the same, 
and by the heat produced, septic processes are liable to arise and endanger the eye. 
Conjunctivitis of a greater or less degree is almost certain to occur in very warm 
weather. Or, if there is a blennorrhœa of the lachrymal sac, infection of the eye 
is eminently prone to occur. Some have discarded bandages, and rely, instead, upon 
long strips of adhesive plaster passed from the forehead to the cheek to hold the dressing 
in place. All the main objections to the bandage are applicable to this. 
As has been stated, fixed retention of the lids in a passively closed position until 
perfect union in the corneal wound shall have taken place accomplishes all that can be 
accomplished in the way of dressing, and whatever will do this without endangering 
the normal exquisite balance of the globe against the smooth lid surface will answer all 
the requirements of rational surgery. 
Nothing answers the purpose so nicely as a narrow strip of thin isinglass plaster, 
extending from one lid surface to the other. By this means the lids are passively held 
closed, all tendency to action of the levator palpebræ superioris is successfully controlled, 
and there is no unequal pressure on the cornea or globe, n® accumulation of heat, no 
retention of secretions, and, consequently, no necessity of daily or thrice daily chang- 
ing the dressings. Too much stress cannot be put upon the perniciousness of so often 
disturbing a wound or its surroundings, where primary union is desired. 
In addition, this simple dressing allows of free and repeated inspection of the lids, 
by which we can judge of the healing process. What material is used, and just how 
applied, does not matter very greatly, so it is pliable, adheres well, and does not 
exclude light or preclude thorough inspection of the eyelids without disturbing it. 
For myself, I have been in the habit of using a light strip of isinglass plaster, while 
Dr. Chisolm, I believe, uses the same, but a piece large enough to pretty much cover 
both lid surfaces. Dr. Michell prefers gold-beaters' skin, of which he applies only a 
very narrow strip in the manner I have suggested. 
As it is universally agreed that a well-béhaving wound should not be molested 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION XI-OPHTHALMOLOGY. 
701 
while reparation is going on, it is best not to disturb the eye in any way until sufficient 
time has been allowed for healing, when it should be finally removed and the eye set at 
liberty. . 
The mode of dressing an eye after an extraction or iridectomy having been decided 
upon, the question arises as to what other elements figure more or less conspicuously 
in the final success or non-success of the case. One of these is as to bodily restraint. 
Is the customary rule of confining patients for a number of days in bed at all neces- 
sary ? It has been generally so claimed, and almost universally practiced, but recent 
experiences go to prove it altogether a mistake. With the lids closed by an adhesive 
strip, the globe of the eye is equally supported in all directions ; so that whatever com- 
fortable position the body may assume, whether prone or erect, will in no manner inter- 
fere with the condition of the eye. So that it may be considered safe to allow the 
patient to assume whatever position affords him the most grateful sense of physical com- 
fort, whether sitting or reclining, so that all strained positions or violent motions are 
avoided, and which such patients are not likely to attempt. These liberties may be 
granted immediately following the operation, and, according to the large experience 
of Dr. Chisolm, no harm whatever, but only comfort and gratitude, have come of it, 
thus establishing the entire innocence of such procedure. 
Another subject of much and vital importance in the after management of operated 
cases, especially extractions, is, in how far does fight influence the result, favorably or 
unfavorably. Just here has been almost universal agreement hitherto on the accepted 
belief that fight is an irritant to the eye, and if an irritant it should be excluded fol- 
lowing operations, so as to afford as complete quiescence to the eye as possible. 
But, unless some morbid process has engendered a photophobia, ordinary diffused 
daylight is not an irritant, but is more grateful than its entire absence for a lengthened 
period. By rest to the eye after an operation, which it requires as well as any other 
organ after a surgical procedure, is meant complete abeyance of all muscular effort, 
such as convergence and accommodation, and absence of all retinal labor in picture 
forming and transmission. This, for the eye, is complete rest. The lids alone afford 
sufficient protection against any possible excess of light, and yet they are sufficiently 
diaphanous to allow of the penetration of sufficient light to the retina to afford it its 
natural stimulus, and to obviate photophobia and depression of spirits. As any one 
knows, he can look directly toward the sun through his closed lids, without detriment 
to the eye, and yet with closed lids he can readily distinguish any change in the degree 
of illumination of a room. The total withdrawal of light, however, for a period of 
several days has a most pernicious influence over both body and mind. On the eyes it 
has the effect of exciting a chain of morbid phenomena, whereby there is finally a com- 
plete abhorrence of it, and attempted exposure to it inflicts the most excruciating dis- 
tress. There is a great difference in the effect of conscious and unconscious darkness 
on the eye. If consciousness is wanting, as in lethargic sleep, the eyes may be kept 
in profound darkness for days without consequent photophobia, but it is not so if 
normal hours of sleep are observed and lucid intervals exist during which the nervous 
functions are all aroused and alive to environments. 
If the eye has for some days been confined in almost utter darkness, a very moderate 
degree of illumination cannot, for a while, be comfortably borne. And, moreover, as 
is well known, the dungeon is the worst of punishments, leading in some instances to 
madness, and acute mania has been known to occur in the after-treatment of extraction 
by confinement in the dark for several weeks. Many of our cataract cases are old 
people, who are very impatient of restraints of all kinds, and often particularly unwill- 
ing to confinement in the dark. In fact, this of itself, they have often told me, was 
their greatest dread of the operation, and having once experienced it, often prefer hav- 
ing only the one seeing eye rather than submit to the same punishment in order to 702 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
obtain vision in the other. Personal experience has satisfactorily proven to me that 
iritis making its appearance about the fifth or sixth day after an extraction is offener 
due to the brief exposure of the eye to the light during the first examination than to any 
other cause. There is almost invariably a scringing and shielding of the eye and a gush 
of tears, on the attempt to make anything like a careful examination of an eye four or 
five days confined in the dark, and often within a few hours after the patient complains 
of pain, and then follows iritis. In proof of the position here taken, iritis is far more 
infrequent under the methods here advocated. 
Discard all bandages, discard all thick dressings, allow full diffused daylight in the 
room occupied by the patient, and as a reward there will be rarely an iritis, and never 
photophobia unless there is iritis. But, on the contrary, when the adhesive strip is 
removed after healing has occurred, the patient will complacently open the eye, delib- 
erately look about him and out the window without the slightest manifestation of dis- 
comfort. It requires about five days for firm union to take place in the corneal wound, 
so that it is best that the eye be not disturbed in any manner whatever until the end 
of this time. If all goes well there is no necessity for it. The lids are free to inspec- 
tion, there are no pent-up tears or mucus, and any accumulations in the inner can thus 
can be easily removed with absorbent cotton. 
In one case of incurable dacryo-cysto-blennorrhœa, extraction was performed and 
the discharge from the lachrymal sac very carefully and frequently removed from the 
inner canthus with absorbent cotton from day to day until the sixth day, when the eye 
was liberated perfectly healed, with nothing more than a hyperæmic condition of the 
conjunctiva. Who would have dared seal this eye after the usual method and have 
taken the consequences ? At the end of five, six or seven days, as we may judge advisa- 
ble from the patient's reparative powers, we may remove the adhesive strip and let the 
eye go free. W ithin two or three days the patient may be allowed to go out of doors 
with perfect impunity. As a rule, with this method of treatment, the eye will be only 
moderately red on first opening it, in some instances scarcely at all injected, the iris 
bright, with no indications of inflammation, there will be no lachrymation or shrinking 
from the light, and the patient will at once want to test his sight. The time of conva- 
lescence is reduced about one-half over the system by dark room and bandage, the 
patient often being ready to dismiss in one week from the time of operation, ten days 
being about the average time he should be kept under observation. 
When an iridectomy is performed, less care and less restraint are called for. As will 
be seen, by this method cataract cases are treated with less restraint than has been 
usual with iridectomies; but now iridectomies are no longer house patients. They 
come to the surgeon's office to have the iridectomy performed and, with only the oper- 
ated eye dressed, they walk or ride home by the guidance of the other eye, with instruc- 
tions to call at the office in two or three days for examination. If all goes well the eye 
is set at liberty and the patient discharged on the fifth or sixth day. Ordinarily, no 
trouble whatever occurs in these cases, but speedy and smooth healing in a few days 
may confidently be looked for. Of course, if the eye operated on is more or less degen- 
erated, or in a glaucomatous condition, more watchfulness of the case is demanded, so 
as to be able to deal with any complications that may arise. But in a smoothly-made 
iridectomy in a sound eye there is no more risk in performing it in the surgeon's office, 
and treating it altogether aß an out-door case, than there is in dealing with a squint 
operation in the same way. 
While following an iridectomy there appears to be almost no risk in allowing the 
fellow eye to be at liberty, the greater disturbance of the globe by an extraction seems 
to offer some objections to this apparently reckless procedure. But if, as has already 
been declared, ordinary voluntary movements of the eye do not tend to disturb its sym- 
metry, there may exist a harmlessness in it beyond the expectation of those who have SECTION XI OPHTHALMOLOGY. 
703 
not tried it; and as facts always take precedence of hypotheses, the experience of Dr. 
Chisolm in some fifty or sixty extractions, in which he has boldly let the unoperated 
eye go free, seems to afford satisfactory evidence that our former views have been ill- 
founded. 
What can be more gratifying to both patient and surgeon than to be assured of a 
system of dealing with so important an operation by methods at once so simple and so 
satisfactory. It strips a once formidable undertaking of nearly all its horrors, and 
inspires both surgeon and patient with a confidence hitherto not attainable with all the 
dread of slow convalescence, dark rooms, confinement in bed and expectant iritis and 
long-continued photophobia. Certainly a bright era has dawned upon those unfor- 
tunately afflicted with cataract, since with cocaine to take the place of chloroform or 
ether, the operation can be performed painlessly and absolutely free of danger to life, 
and the necessary care following the operation is reduced to such perfect simplicity and 
conformity with almost every comfort, that it is no longer to be dreaded, even by the 
most timid. 
I do not in this paper, the purpose of which is to set forth the advantages and sound 
principles in this system of after-treatment for cataract and iridectomy operations, pro- 
pose to act as historian, but feel it my duty to accord thanks where due. 
Personally, I am indebted to Dr. Charles E. Michell, of St. Louis, for those import- 
ant innovations-the simple strip to close the eye and the admittance of abundant light 
into the room the patient occupies. Dr. Michell has also for many years performed 
iridectomy as an office operation, dressing only the operated eye, and his suggestions 
first led me to adopt it. With his experience in iridectomies thus treated with so little 
restraint, I wonder that he did not fall upon a freer method of dealing with his cataract 
cases, it having been his custom until quite recently to confine his patients to bed for 
eight or ten days, for the one naturally suggests the other. 
Dr. J. J. Chisolm, the worthy President of this Section, was the first to remove 
bodily restraints and to allow the patient to sit up or lie down immediately after the 
operation, much as his personal comfort should incline him. He also took the initiative 
in closing only the eye upon which extraction had been performed, and of emancipating 
the fellow eye from all dressings and restraint. These two important additions to the 
other methods have wonderfully added to the comfort and gratification of cataract 
patients ; for introducing and establishing the safety of which, and for his very liberal 
promulgation of these methods in all their details and his experiences with them 
through the medical press, whereby they have become so generally and thoroughly 
known, that any operator may intelligently test them if so disposed, he is entitled to 
the thanks of every ophthalmologist. 
DISCUSSION. 
Mr. Power, of London.-I must acknowledge myself an adherent of that method 
of operating for cataract in which no iridectomy is done. I divide the cornea at the 
sclero-corneal junction, making a rather large opening. As soon as the section is 
made, the capsule is lacerated with a cystotome, and the lens is gently tilted till it 
escapes. What cortical substance can be removed is then cleared out with a curette. 
A drop of eserine (2 per cent.) is then instilled and the eye is tightly bandaged. Of 
the four accidents mentioned by Dr. Galezowski I do not find that hernia of the iris 
is very common, and think that the less the eye is examined and tortured, the 
less likely is it to occur. Suppuration of the cornea is to be avoided by atten- 
tion to the general health, and by care in securing perfect cleanliness. I think 
iritis is more apt to occur after an iridectomy than when that proceeding is not done. 
The true bugbear of cataract is undoubtedly secondary cataract ; but surely those 704 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
who practice iridectomy do not mean to say that they do not meet with a similar 
difficulty; and in both instances it must be dealt with in a similar manner, with one 
or two needles. In conclusion, I think we should, if possible, operate without iri- 
dectomy, but if it be found difficult to replace the iris after the section, or if much 
cortical matter be left, or if adhesions exist between lens and iris, then it is easy to 
do the iridectomy. 
Dr. Landolt, of Paris, said:-If I differ in some respects from our eminent col- 
league, Dr. Mooren, I am glad to say that in the main I am of his manner of thinking, 
and from what he has said I draw these two conclusions : 1st, That there does not 
exist, and there will never exist, a single unique method of cataract operation. 2d. 
That it is necessary to pay the greatest attention to the general condition of the 
patient, and that in by far the majority of cases we shall be compelled to hold 
on to iridectomy. Each of us has experienced an epoch, in which we tried 
to simplify the operation for cataract, and it ended by our returning to the 
methods of our fathers. As regards myself, I went through this epoch in 1878, 
at which time I performed all my cataract operations without iridectomy. I had 
some superb results, and again some misfortunes, and finally I came to the con- 
clusion that the operation with iridectomy was, in the strictest sense, the most 
satisfactory. I do not see that antisepsis and the discovery of cocaine have, in 
the true sense of the word, reduced the cataract operation to the point where we 
can call it simple. The dangers are, from my standpoint, adhesions of the iris and 
the great difficulty of keeping sufficiently clear the field of operation. To avoid 
the first danger I determined, at the beginning of my career, to make the incision 
-as first conceived by Liebreich-as far from the corneal border as possible. But 
I very soon found that this method was associated with great risks. As regards 
the method of incision, I always make the sclero-corneal incision, whether I do the 
operation with or without an iridectomy. But I shall relegate this method of cataract 
extraction (without iridectomy) to those cases which are absolutely favorable, abso- 
lutely simple, absolutely ripe. And here allow me to make clear an evident misun- 
derstanding between Mr. Power and myself. Neither myself nor any one of my 
colleagues who perform the operation with iridectomy pretends to assert that this 
procedure is an absolute guarantee against iritis and secondary cataract, but experience 
has taught me that these complications occur far less frequently than when the 
iridectomy is left out. And one word about the iridectomy. I consider as dan- 
gerous a too small iridectomy-one, in a word, that is not in proportion to the cor- 
neal incision. In such a case the danger of prolapse of the iris is exceedingly great. 
And then, as regards the excision of the iris, which it is often necessary to make 
the second or third day after the so-called "simple operation:'' it is by no means 
comparable to the iridectomy we make prior to the exit of the crystalline lens. In 
this subsequent excision there remains always an anterior synechia, with all its 
accompanying dangers. Finally, it has been said in this discussion that the subli- 
mate solution is irritating to the eye. I declare as an absolute fact that the sublimate 
solution-1 : 5000-that I have used in my practice for years, is by no means 
irritating, and is perfectly antiseptic. 
Dr. Abadie, of Paris.-The question of operating in cataract with or without 
iridectomy has agitated our minds a great deal nowadays. It does not seem to me 
that the question 'should be so divided, but rather the distinction should be made 
between those cases which should be operated upon with iridectomy and those where 
iridectomy is useless. For a considerable time have I endeavored, as far as possible, SECTION XI-OPHTHALMOLOGY. 
705 
to operate without iridectomy, and my efforts were crowned with success in those 
cases where the cataract was simple and had arrived at perfect maturity, and in this 
kind of cases I assert that this method is superior to all others. Unfortunately, at 
this date we can no longer, as in the time of Daviel, wait for the cataract to com- 
pletely mature. Now, the patient, just as soon as he finds he can no longer read or 
walk about alone, comes to us and demands an operation, and we cannot refuse him. 
In such cases, gentlemen, the operation without iridectomy does not give such 
satisfactory results as the combined operation. The evacuation of the cortical 
mass is difficult and incomplete. The iris is bruised, and we very frequently have 
a prolapse, and a second operation is almost unavoidable. Hence, in all forms of 
cataract which have not reached perfect maturity an iridectomy is indispensable. 
Dr. MäRMION, of Washington, said that he had listened with a great deal of 
interest to the arguments in behalf of the two methods-with or without iridec- 
tomy ; but, said he, nothing that I have yet heard has shaken my faith in the 
iridectomy. The percentage of successes is undoubtedly in favor of the combined 
operation. Among the many arguments in favor of the latter operation is the free 
exit it gives to the cortical substance. 
Dr. Dudley S. Reynolds, of Louisville, said :-It is evident that extraction 
may be done without iridectomy in carefully selected cases. I do not think the 
experience of the gentlemen who have read the exhaustive essays, nor of those who 
have taken part in the discussion, tends to establish any universal rule. In well- 
matured cataracts in persons whose eyes are otheiwise sound, and in a good state of 
general health, the pupil may be widely dilated with cocaine, which, of course, 
should always contain either carbolic acid or corrosive sublimate. In such cases the 
operation should be performed with great care. I use in such cases Graefe's knife, 
which I aim to introduce, as nearly as possible, in the plane of the anterior surface 
of the iris, and passing the point of the knife well over the pupillary margin, I 
suddenly depress it, so as to prick the capsule, taking care not to allow the knife 
to penetrate deeply into the lens, lest it may be dislocated. I make the puncture 
in the capsule as the knife advances, and, passing the point on, when I come 
to the sclero-comeal juncture I raise it; pressing the blade upon the iris, I 
make the counter-puncture. Advancing the blade by a sawing motion, I stop and 
allow the aqueous humor to escape slowly before the section is completed. I aim 
not to turn the edge of the knife forward into the cornea, but to cut as nearly as 
possible in the plane of the anterior surface of the iris. Having proceeded in this 
way to the completion of the section, I find that the central incision of the lens cap- 
sule allows it to tear in different directions, and the difficulty in removing the cortical 
substance is not so great, nor is the iris so apt to prolapse where the section is made 
as I have described. If, however, I contemplate iridectomy when I begin the 
operation, I use Beer's knife, making the section upward and puncturing the cap- 
sule with the point of the knife as it advances through the anterior chamber. I 
attach great importance to this method of opening the capsule, as it seems to me 
fraught with less danger than the introduction of the cystotome. I never use fixation 
forceps, nor permit the hand of an assistant to touch the patient's eye. In fact, I 
have no use for an assistant. When the eye is once impaled upon the knife with 
which the section is made, the touch of the finger places it entirely at the command 
of the operator. If aseptic conditions are secured, the dangers from cataract 
extraction seem to me reduced almost entirely to secondary inflammations of the iris 
and ciliary body. The dressing I employ after extraction has been simplified some- 
Vol. Ill-45 706 
what after the suggestion of Dr. Michel], of St. Louis, and in accordance with the 
experience of our President, Dr. Chisolm, of Baltimore. I now use a small bit of 
absorbent cotton and a single piece of adhesive plaster drawn from the cheek to the 
brow, the cotton being used simply to take up the tears and any other fluid that may 
escape from between the lids. If the eye shows the least sign of irritation, I 
remove the dressing daily ; otherwise, I permit it to remain until I think the wound 
has well united. 
Prof. P. D. Keyser remarked that, as experience was a good teacher ; and as he 
had operated considerably over two thousand times for cataract ; and as the natural 
result of the meeting of so many together was to give experience and exchange views 
on subjects, he desired to say that it was impossible to express whether the extraction 
of cataract should be made with or without an iridectomy ; that the operator must 
examine his case carefully, to see what kind of a cataract he had before him, and be 
the judge of what is best to do. During his number of years' practice he has made 
operations according to all of the methods recommended, and his experience is that 
where the lens is completely hard, that is, with little or no soft cortical, it can be very 
readily and well extracted without an iridectomy. But where there is much soft cortex 
an iridectomy is preferable, making it easier and surer in freeing the eye of all foreign 
substances. He notices that Dr. Mooren recommends the iridectomy downward, 
which is, in his idea, the improper position. There are some persons who cannot 
be made to look down ; this he has specially noticed in the Irish people. Before 
the introduction of cocaine, not using any anæsthetic, he often made the iridec- 
tomy below, with such persons ; but the upper section is much preferable, for many 
reasons well known to the profession. In all cases of sluggishness in the iris to 
dilate promptly and widely on the instillation of atropia, he invariably makes pre- 
liminary iridectomy ; for with such patients he has always found that iritis follows 
the operation of extraction if made, with or without iridectomy, in one sitting. As to 
Forster's method of ripening immature cataracts for operation, it has not been for- 
tunate in his hands. He found, in many cases, that the rubbing, or manipulation, 
caused a low grade of iritis which formed posterior synechiae, and such are not desirable 
concomitants in the operation for extraction of cataract. In the opening of the cap- 
sule, he desires to remove as large a piece as possible from the centre, and to accom- 
plish this he had a cystotome made, with the fleam or cutting part at right angles to 
the stem of the instrument. Introducing it through the incision of the cornea, he 
makes a horizontal cut in the lower part of the capsule and, catching the membrane 
on the end of the instrument, draws it up and out of the corneal incision far enough 
to snip off a piece with the scissors. Sometimes the capsule is drawn up in a fold, 
so as to be easily grasped with forceps and thus drawn out for cutting off. In cases 
of cataracta Morgagni (s. cataracta lacta), when the lens is broken down into a 
chalky, milky liquid, it is desirable to remove all this substance from the eye, and 
not let any remain to float around and irritate and set up inflammation. To accom- 
plish this, he always makes an upward iridectomy, and opens the capsule at its 
extreme upper periphery with a v. Graefe's cataract knife. In this way the capsule 
remains like a sack, with only an opening at its upper end, just at the mouth of the 
incision through the cornea. All of the broken, disintegrated lens matter readily 
flows out. If any remains, it lies in the capsule harmless, while dissolving in the 
aqueous. An operation can easily be made afterward on the capsule, at any time 
it becomes opaque. He operated in this way on an old negro woman, at his clinic, 
three years ago, and the capsule is still perfectly transparent and vision excellent. 
In relation to Dr. Galezowski's method of operation without iridectomy, he 
NINTH INTERNATIONAL MEDICAL CONGRESS. 707 
SECTION XI-OPHTHALMOLOGY. 
desired to ask if he ever had a prolapsus of the iris with consequential glaucoma after 
the extraction. He desired this information for the reason that, in 1875, he operated 
on a man, by the method of de Wecker, without iridectomy, and on the second day 
a prolapsus occurred, accompanied with great pain and hardness of the eyeball. To 
reduce the protruding iris he instilled eserine, and discovered that the tension was very 
soon diminished. This was his first discovery of the anti-glaucomatous effect of eserine. 
He communicated it to Dr. de Wecker, who mentions the subject in an article on eserine 
in the Annales d'oculistique and in Zehender's Monatsblätter für Ophthalmologie. 
He has found the mercurial solutions irritating, and uses always the boric acid 
solution as a cleansing liquid. He always examines the urine of his patients for 
albumin before operating, and, if found, postpones the extraction until the albumin 
is removed by treatment, or declines to operate. He has found that inflammation 
of a serious nature invariably occurs after an operation with patients suffering with 
albuminuria. 
Dr. J. L. Thompson, of Indianapolis said :-I have been greatly interested by the 
remarks of the distinguished essayists, as well as by those of the eminent gentlemen 
who have participated in the discussion. 
No one operation suits all cases. With numerous other plodders in this field, I 
have clung to the advice given by Dædalus to his son, as he was escaping from the 
Cretan labyrinth, "to take a middle course," and have, therefore, avoided the 
extreme peripheral section of the renowned von Graefe, as well as the more central 
one of Liebreich, and now, in most cases, make a similar one to that of the veiy 
eminent gentleman, Galezowski, of Paris. 
A majority of us cannot number our cataract extractions by the thousand, and are 
therefore constrained to keep in known and well tried paths, leaving the experiments 
to gentlemen of the large cities of the world. For my part I would rather be certain 
of restoring the greatest number of my patients to useful vision than to get a smaller 
per cent, of very brilliant ones at the risk of loss of vision. 
I usually, in senile cases, make a broad iridectomy ; consequently, rarely have 
the iris imprisoned in the incision. When I meet with a failure, it is usually from 
capsulo-iritis or from iritis, and that even after the thirteenth day, from malaria and 
other exciting causes. 
Suppuration of the cornea I now rarely meet with, and this is doubtless due to 
the use of the mercurial solution, which is now so universally used. 
Dr. Baker, of Cleveland, Ohio.-After witnessing operations for cataract 
extraction by the leading American, English, German and French ophthalmologists, 
some years since, I came to the conclusion that as an operator with average skill 
and experience in these cases, I could not take the responsibility of performing the 
operation without an iridectomy. In order to avoid as far as possible the objec- 
tions to an iridectomy, I have performed the operation as suggested by Wolf, of 
Scotland. Instead of making a large iridectomy and thus leaving the pupil key- 
hole shaped, I remove a small portion of the iris and leave the pupil oval after the 
operation. 
With regard to the opening of the capsule, I believe with Dr. Reynolds that this 
is a very important part of the operation. I make the incision in the capsule at the 
periphery, corresponding as nearly as possible with the corneal incision; I am careful 
to remove all the cortical substance from the incision, but if there is a small portion 
retained within the capsule I do not resort to the spoon to remove it, as it will soon 
become absorbed and do no harm. 708 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Many operators do not use enough care in delivering the lens. They seem to 
be in a hurry and deliver it as quickly as you can wink. It should be done slowly 
and disturb the contents of the eye as little as possible. I never touch the cornea 
with the finger scoop or other instrument while delivering the lens, and in this way 
add much to the comfort of the patient after the operation, as it prevents much of 
the disagreeable smarting always present when the epithelium of the cornea is 
disturbed by rough handling during the operation. I always follow the precaution 
mentioned by Mr. Power this morning, of using a new knife for every operation. A 
good, clean, sharp knife is of very great importance. 
Dr. Swan M. Burnett, of Washington, had been lately doing all his extractions 
without iridectomy, and they amount now to twenty-three. lie was so well pleased 
with the results that he should not return to the method with an iridectomy until 
bad results drove him to it. He did not believe that in all cases it would be found 
to be best, but he had recently extracted a black cataract with an immense nucleus, 
and a Morgagnian cataract by this method, and with good results in both cases, showing 
the wide range of applicability of the method. It was least applicable to lenses with 
much soft cortical, but only a few days ago he had successfully operated on such a case 
in this way. He had worked out some of the remaining cortical with antiseptic fluid, 
and he believed that such a procedure, if properly done, was not dangerous. The liability 
to iritis and other complications he did not consider greater without than with an 
iridectomy. He also thought that there was a great advantage gained when we 
could assure timid patients that the operation for the restoration of sight would be 
entirely painless without general anæsthesia, as it certainly is with cocaine and with- 
out iridectomy. It was his opinion that the good results by this method are better, 
and the bad results were not worse, than with iridectomy. 
Dr. Eugene Smith thinks we cannot settle upon a method which is applicable 
to all cases, but as far as he himself is concerned, he thinks the iridectomy should be 
performed. 
Dr. F. Valk, of New York.-The question before the Section being the advisa- 
bility between the operation of cataract with iridectomy according to the method of 
Graefe, or without iridectomy according to Galezowski's method, it seems to me that 
we may have an operation which may combine both methods, that is, without an 
iridectomy and with the advantages which an iridectomy gives. For this purpose 
the past few months I have operated with a little instrument called an iris retractor, 
with which I draw back the iris to the position of full dilatation, and while holding 
it in that position, by a few gentle strokes of the spoon on the lower part of the 
cornea, the lens easily passes through the section. As it escapes, the ends of the 
retractor are raised and the iris passes backward to its position. We then retain a 
clear, round pupil. 
Dr. J. J. Chisolm stated that in his cases of extraction without an iridectomy 
he was still fearful of increased tendency to iritic complications. Although he has 
had the good fortune to lose no eyes by this method, he has not turned out a single 
case with an absolutely free pupil. They are more or less central and look well, but 
will not dilate regularly under atropia. In two cases he has had a hernia of the iris, 
although he had used liberally eserine drops after the extraction. He preferred to 
make a small iridectomy, only cutting off by one snip of the scissors so much of the 
iris as is drawn out by the iris forceps. 
He uses freely to the eye operated upon a biniodide of mercury solution, 1 to 
15,000. He operates under cocaine. After the speculum is inserted he floods the SECTION XI-OPHTHALMOLOGY. 
709 
eye with the mercurial solution, so that it comes in contact with every part of the 
conjunctival surface. After the operation is completed and before the speculum is 
removed, the eye is again flooded with the antiseptic liquid. He has seen this fluid, 
along with bubbles of air, flow in and out of the anterior chamber as the movements 
of the speculum would make more or less pressure upon the eyeball, gaping the corneal 
wound. Although he has seen no inflammation follow upon this accidental admission 
of the mercurial solution into the eyeball, he has never intentionally washed out the 
aqueous chamber. 
He laid great stress upon two points in the after treatment of cataract extraction 
cases. The first was the closing of only the eye operated upon, leaving the other 
eye open for the guidance of the patient. The second was the closing of the eye 
operated upon by a slip of isinglass plaster, so diaphanous that light would readily 
pass through it to the retina. He treats his cataract cases in light rooms, from 
which sunlight only is excluded and in which friends can read to patients. He 
feels convinced, from a large experience, that the eyes are stronger and much less 
sensitive after cataract extractions since he has abandoned compresses, bandages and 
dark rooms. The comfort to the patient by leaving one eye open is immense. 
Experience has shown to him that the usual restraint practiced by surgeons on their 
eye patients is not only unnecessary but harmful. He does not now put his cataract 
extraction patients in bed. After operation they sit up till bedtime, getting up in 
the morning and dressing themselves, as is their daily habit. For a week they are 
confined to their rooms but are allowed to see their friends, walk about and eat their 
meals without being fed, thanks to the eye that is left open. His experience proves 
that if light is not excluded during the treatment, the eye, when exposed, will not 
inject nor weep. The exposure hastens convalescence. Unless some inflammation 
should occur, which is seldom the case, the original piece of isinglass plaster is not 
removed till the fifth day; after that time no dressing is used. Unless the symptoms 
call for it, he does not remove the primary dressing to inspect the eye. He believes 
that the daily inspection of the cornea, when not called for by the symptoms, is 
meddlesome and not without danger. His cases do not require smoked glasses for 
indoor use at any time in the treatment, because the eyes have never been made 
sensitive by the exclusion of light. 710 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THIRD DAY. 
RESTORING THE NORMAL POSITION OF THE TARSAL BORDER 
IN TRICHIASIS OF THE UPPER EYELID. 
RESTAURATION DE LA POSITION NORMALE DU BORD TARSAL DANS LA 
TRICHIASIS DE LA PAUPIERE SUPERIEURE. 
WIEDERHERSTELLUNG DER NORMALEN STELLUNG DES TARSALRANDES BEI TRICHIASIS 
DES OBEREN AUGENLIDES. 
BY DR. F. C. HOTZ, 
Chicago, Ill. 
The free border of the upper eyelid forms with the tarsal conjunctiva nearly a right 
angle, and therefore stands also vertically upon the surface of the eyeball, and the eye- 
lashes form with the free border an angle of at least 90 degrees. Owing to this position 
of the free border, the distance between the globe and the eyelashes is equal to the whole 
thickness (or height) of the lid border; and as long as this maintains its normal position 
the eyelashes may be considerably deflected from their normal directions before they 
come in contact with the cornea and cause any annoyance to the eye. In patients, for 
instance, who have suffered from ulcerative blepharitis we often find the growth of the 
eyelashes greatly disturbed, many being abnormally curved downward ; but they seldom 
touch the cornea unless at the same time the lid border is more or less inverted. But 
when the free border has lost its upright position, becoming inclined or ' ' inverted, ' ' 
the eyelashes brush over the cornea, even though the angle they describe with the free 
border is not changed, and thus prove that they grow out in perfectly normal order and 
direction. Their relatively faulty direction to the eyeball is not the result of faulty 
growth, but the unavoidable consequence of the inversion of the lid border, because by 
this inclination the ciliary edge, together with the eyelashes, is necessarily brought 
down in close proximity to the cornea. 
And this is just the condition of the tarsal border in trichiasis as we commonly 
find it, after trachoma. By tissue waste and shrinkage on the conjunctival side 
of the lid the posterior (or conjunctival) edge of the border is retracted, and the latter 
itself is turned down, so much so, that in the worst forms of trichiasis its surface is 
pretty well on a level with the tarsal conjunctiva; and, coming in contact with the eye- 
ball, and being constantly bathed with the lachrymal fluid, it becomes red and moist, like 
the conjunctiva. It really seems as if the free border had wasted away and the con- 
junctiva extended closely to the eyelashes. But on careful inspection we can convince 
ourselves at once that the free border has lost nothing of its breadth, but only its normal 
position; and we also find the eyelashes, though they may be scanty and ill-developed, 
depart very little, if at all, from their normal position in relation to the lid border; their 
faulty relation to the eyeball being the inevitable result of the inversion of the free 
border. 
If we keep these facts before our eyes; if in this perverted position of the free 
border of the eyelid we recognize the chief anatomical feature of trichiasis, it should SECTION XI-OPHTHALMOLOGY. 
711 
certainly lead to the conclusion that in trying to remove the deformity of the eyelid 
we must direct our main efforts toward restoring the free border to its original posi- 
tion. If this can be accomplished the eye is not only relieved of the mechanical 
irritation by the cilia, but the eyelid recovers an absolutely normal appearance, and the 
result is far superior to that attained by operations which try to divert the eyelashes 
alone from the eyeball by transplantation. 
Since the anomalous position of the free border has been brought about by the 
retraction of its posterior edges, the reposition might be attained either if the poste- 
rior edge be brought down again to the place it occupied before the retraction, or if the 
anterior (or ciliary) edge be set back just so much as the posterior edge has been 
retracted. In either case the free border would regain, its upright position. But the 
first plan is impracticable, for we have no means to overcome permanently the retraction 
of the posterior edge. I could not before this assemblage enumerate the many unsuc- 
cessful attempts which have been made in this direction. 
The other plan, however, is quite feasible, and I will now explain, by means of the 
accompanying diagrams, how the reposition of the tarsal border can be accomplished. 
Let Fig. 1 represent the section of the upper eyelid, with its free border (c a) inverted ; 
take out the wedge-shaped piece b ad, so that the piece b a c can be turned on the point 
Fig. 1. 
Fig. 2. 
a until b a comes together with d a. What effect will this rotation have on the position 
of the free border and eyelashes? Fig. 2 will give the answer ; the posterior edge (a) 
of the free border (c a) is the centre of a circle, consequently the lines c a, b a and d a 
are radii of this circle, and if the segment b c of this circle is equal to b d, the angle c a b 
is equal to bed; and when, therefore, b a moves to d a, the line c a will make an 
equivalent rotation and come into the position before occupied by b a. In other words, 
the free border (c a) is turned up so that it forms again an almost right angle with the 
conj unctiva (a g) ; and as the eyelash (£) follows this upward rotation of the tarsal 
border without the angle i c a being changed, it is turned away from the eyeball and 
resumes a direction more or less parallel to the conjunctiva. 
You will observe that the principal condition of success in this operation consists in 
making the posterior edge (a) the turning point, ' ' the hinge, ' ' on which the free border 
is to be turned; and that, therefore, the wedge must be excised in such a way that its 
sharp edge is placed as nearly as possible to the junction (a) of the free border with the 
conjunctiva. This is the point which distinguishes this method from the grooving 
operations of Streatfield and Snellen. Their object was to straighten an assumed 
incurvation of the whole cartilage, and for this purpose they removed the wedge from 
the central portion of the lid. But if the removal is made at any other place than at a; NINTH INTERNATIONAL MEDICAL CONGRESS. 
712 
if, for instance, it be made at g (Fig. 1), it cannot rectify the position of the free border; 
the whole piece, g a c, would be turned and lifted away from the globe, only to sink 
down on it again, because it could not stay in the air, but has to rest on a solid founda- 
tion ; and when the lid comes down again on the eyeball, the eyelashes will again 
brush over the cornea as before the grooving, because this had not altered the position 
of the free border of the eyelid. 
But the reposition of the free border alone does not restore the perfectly natural 
appearance of the eyelid. For in trichiasis the fibres of the orbicularis muscle are 
crowding down against the eyelashes, and the skin has become more or less relaxed, so 
that it hangs heavily over the ciliary edge, making this look unnaturally thick, round 
and baggy. To make the effect of the operation perfect in every respect, it is necessary 
to remove this unsightly appearance of the lid. Skin and muscle must be slightly 
drawn upward and fastened to the upper border of the tarsal cartilage, to render their 
shifting down again toward the free border impossible. 
For this reason I do not incise the skin near the free border where I propose to 
groove the cartilage, but make a transverse incision parallel and just a little below the 
upper border of the cartilage (at h, Fig. 1). A few strokes of the scalpel sever also the 
tarsal portion of the orbicularis muscle from its portio orbitalis, and expose the upper 
border of the cartilage with its aponeurotic fascia. A narrow strip (three to four milli- 
metres wide) of the muscular fibres immediately below the upper tarsal border is 
excised; the rest of the orbicularis muscle, however, is left, but together with the skin dis- 
sected off from the external surface of the cartilage all the way down to the roots of the 
eyelashes. Skin and muscle of the lid are thus converted into a flap which is attached 
to the lid along the free border only. Turning this flap down upon the lower lid I hold 
it between the thumb and index finger of my left hand, pushing the top of the index 
finger up under the upper lid just beyond its free border. At the same time an assistant 
seizes the upper border of the cartilage with a forceps, and I make a transverse incision 
through the whole thickness of the cartilage, following closely the line of the roots of 
the cilia, and directing the course of the knife toward the posterior edge of the free 
border, so that if the incision was continued through the conjunctiva it w'ould just sever 
the junction of the lid border with the conjunctiva. To avoid cutting through the con- 
junctiva I cut the cartilage on my index finger, believing its feeling gives me the best 
information about the thickness of the tissues lying between it and the knife; this feel- 
ing is the most accurate gauge by which I can tell when the incision is deep enough. 
This incision finished, a second one is made, from two to four millimetres above the first, 
in such a slanting direction through the cartilage that it meets the first incision just at 
the posterior edge of the free border, and if both these incisions are made with care and 
precision, the wedge of cartilage they inclose can be taken out in one piece. The size 
of the wedge varies in different cases; but as a general rule, it may be laid down that 
the wedge will always be sufficiently large if its base is about as wide as the distance 
between the first incision and the ciliary edge of the lid (b d = b c, Fig. 2). If the wedge 
does not come off in one piece the sides of the groove must be carefully trimmed to look 
smooth and even. 
Though we should try to avoid cutting through the conjunctiva, this accident will 
occasionally happen even to the best and most painstaking operator. These small, acci- 
dental buttonholes in the tarsal conjunctiva neither delay the healing process nor 
vitiate the success of the operation. 
The wound is finally closed by three or four sutures, which I apply in the following 
manner: After the needle has been passed through the cut edge of the tarsal skin I 
seize the upper border of the cartilage with a toothed forceps and transfix it with the 
needle so that it reappears through the tarso-orbital fascia just above the cartilage; and 
finally, I pass it through the upper cutaneous edge of the wound. The loops of these SECTION XI-OPHTHALMOLOGY. 
713 
sutures enclose only the cut edges of the skin and the upper border of the cartilage, and 
when they are tied the skin of the eyelid is drawn up to and united with the upper 
border of the cartilage. This traction removes the abnormal relaxation of the skin and 
also relieves the ciliary edge from the pressure of the muscular fibres, while at the same 
time it turns the free border up and brings the edges of the groove in the cartilage in 
close coaptation. But the sutures must not be tied before the bleeding has ceased, and 
the whole wound, particularly the groove in the cartilage, has been carefully cleansed 
from all coagula and thoroughly irrigated with the antiseptic lotion (sublimate or car- 
bolic acid), which has been employed all through the operation. 
Gentlemen, this operation may seem rather complicated and tedious, but I can 
assure you that it takes much less time to perform than to describe it, and the perfect 
results you attain by it will make you feel that your time was spent for a good pur- 
pose. If you only aim to relieve the eye from the injurious contact of the lashes, you 
may accomplish this object probably by simpler methods. But I put a higher standard 
upon plastic operations on any part of the face, and certainly the operations for trichi- 
asis belong to this class. I am not satisfied that the operation merely relieves the 
inj urious consequences of trichiasis without regard to the subsequent appearance of the 
eyelid ; my ideal of a perfect operation for trichiasis is that operation which relieves the 
troublesome effects, and at the same time restores to the eyelid its normal beautiful 
contours and natural appearance. And this standard is attained by the operation I have 
the honor to present to your kind consideration. 
DISCUSSION. 
Dr. Dibble, of Kansas City, said : I usually modify the operation of Dr. Hotz, 
by dissecting the ciliary border. Here we have generally a degeneration, a bagginess, 
and by dissecting here we induce absorption, which leaves the ciliary border much 
thinner. 
Dr. S. J. Jones, of Chicago, said, it is well known that nearly all of the many 
different operations that have been proposed from time to time to meet the vary- 
ing requirements of these cases give temporary relief from this serious condition. 
It is, however, desirable to secure more lasting results, and time alone can test the 
value, in this respect, of any operation. Dr. Hotz had not made clear, in his state- 
ment, regarding the danger to the integrity of the eyelid which attends the dissec- 
tion of so large a flap in the primary operation, nor the amount of the deformity of 
the parts which results from it, but he had stated that the operation may be 
repeated with safety on the same eye. 
Dr. Jones said that he had subsequently seen several of the patients on whom 
Dr. Hotz had operated, in which the result had been much less satisfactory after the 
lapse of a period varying from a few months to one or more years, but he was not 
aware whether, in those cases, the operations had been performed in accordance with 
the modification which Dr. Hotz says he now practices and advocates. 
Dr. J. L. Thompson, of Indianapolis, said : Greatly as we are indebted to Dr. 
Hotz for the very ingenious and beautiful operation which he has described, I am, 
after years of observation, fully convinced that a recurrence of the trouble frequently 
follows them all. Occasionally we do meet with cases where the tarsal margins are 
so uneven-here with hypertrophy, there with atrophy ; nipple-like projections and 
attenuated bunches of ciliæ-that a combination of many methods has to be prac- 
ticed, and, in spite of all these, a return takes place. And I am as positive of this 
as I am of the revolutions of the earth upon its axis, that there never has, and 
never will be, this side of the Lethean stream, any one operation suitable to all cases. 714 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. Keyser said that he was in entire concordance with Dr. Thompson, namely, 
that there can be no specific method of operation. He has had excellent results in 
very severe cases by a method recommended some time ago by Prof. B. A. Pope, of 
New Orleans, in which he splits the lid and removes carefully the cartilage, thereby 
permitting the conjunctiva that has been contracted and drawn in such a manner as 
to curve inward, to straighten out and face down the length of the outer flap. A 
fold of the outer skin is drawn slightly up and held in position a few days, by either a 
plaster or sutures. 
Dr. G. E. Frothingham, of Michigan, said : Notwithstanding the experience 
of the last speaker, he thought most ophthalmologists would feel obliged to resort to 
surgical interference in all aggravated cases of entropion. The question of great 
importance for them was to consider and determine what method of operation would 
give the best result in the majority of cases. He had been much interested in the 
mode of operating presented by Dr. Hotz, and had, for the first time, seen it prop- 
erly presented. He had, for some time, made a similar operation, but he had 
made the first incision through the integument lower down than Dr. Hotz seems to 
have done, though, as he understood the operation from reports he had seen in the 
journals, he had supposed Dr. Hotz also recommended it. Few of these cases could 
be treated successfully without removing the wedge-shaped piece of the tarsal cartilage, 
and he had often removed, with advantage, some of the redundance of muscular 
tissue which had been drawn down to the free border of the lid by the long-continued 
blepharospasm. The incision through the skin recommended by Dr. Hotz has 
the advantage that it comes higher up on the lid, and when the eyes are open the 
scar would be largely concealed, and add much to the cosmetic value of the opera- 
tion. Another point of especial importance is, that it allows us, without unduly evert- 
ing the lid, to stitch the integument, when drawn up, to the underlying palpebral 
fascia, to which it will become attached during the process of cicatrization, and thus 
become fixed, and to a considerable degree resist the future action of the orbicularis 
to drag it down toward the free border of the lid. He had had experience that 
convinced him that an important advantage could often be gained in this way, and 
he considered it one of the most valuable features of Dr. Hotz's operation, which 
was the best method he knew of for the majority of cases, and one which reflected 
much credit upon the Doctor. 
Dr. J. J. Chisolm desired to know why Dr. Hotz now discarded the outcurving 
of the cartilage, which seemed to be the strong point in his operation for entropion, 
as published a few years since. 
Dr. Hotz.-I have not dropped my former method, as the chairman seems to 
think. I have retained the sutures, which are its chief feature ; but I have added 
what I regard an important feature for the aggravated cases of trichiasis. What I 
have abandoned is the idea that the incurvation of the cartilage is the anatomical 
basis of trichiasis ; and the change of my views on this point has led to the change 
in grooving the cartilage, which I demonstrated here. 
Because in former years I followed Snellen's and Streatfield's precepts for groov- 
ing, I am not surprised to learn that some cases I had operated on proved to be fail- 
ures ; in speaking of the difference between Snellen's grooving and mine, I referred 
to this very point, showing why, after Snellen's operation, the recurrence of trichiasis 
must be expected. I myself saw such relapses, and spoke of the fact in a paper giv- 
ing my experience of three years with my former operation ; it was those failures 
which induced me to persevere in my endeavors to improve the method and to trace SECTION XI-OPHTHALMOLOGY. 
715 
the causes of these failures. Even after my present improved method, I shall look 
forward to learn of an occasional recurrence of trichiasis ; for the eyes have not 
received from me an immunity from trachoma. And should they be seized again by 
this disease, it is clear that the causes which had once produced trichiasis caused it 
again. But should it recur, my operation can be repeated, as I said, "with impu- 
nity." I meant to say that " it can be repeated over and over on the same eyelid 
without mutilating it. ' ' In all my experience I have not observed any dangerous 
consequences connected with the operation or with its repetition. 
Dr. Frothingham is mistaken if he thinks I had formerly made the incision lower 
down. In my second paper on entropion operation, I touched upon this very point, 
because I had found several surgeons insisting upon making the incision very low 
down, like in Arlt's operation. This is a grave mistake, because you never can cover 
the whole surface of the lid with so narrow a strip of skin, and, therefore, the 
sutures are placed in the middle of the lid, instead of the upper border. This mode 
will always lead to an unsatisfactory result ; you must preserve the skin of the eye- 
lid to cover it, for as soon as you drag down the heavy skin from above, you over- 
load the lid, and its movements are embarrassed by the increased weight. Only 
when there is an actual superfluity of tarsal skin it may be trimmed down to the 
proper extent. I trust no one has received the impression that I regard my opera- 
tion as infallible. What I contend, and what I have been striving for, is that it 
should be adopted in place of those barbarous methods which mutilate the eyelids, 
and are a disgrace to ophthalmic surgery. 
TREATMENT OF ENTROPIUM. 
TRAITEMENT DE L'ENTROPION. 
BEHANDLUNG DES ENTROPIUMS. 
BY BARTON PITTS, M. D., 
St. Josephs, Mo. 
Since the introduction of the process of electrolysis for the permanent removal of 
cilia, operative procedure for the relief of entropium is by no means as frequently 
required as formerly. When there is a slight thickening of the lids with a tendency 
to turn inward, bringing a few eyelashes against the cornea, causing irritation and 
injury to the eyeball, some of the many cutting operations in vogue for entropium 
were formerly required, for the relief of the condition. I desire to call the attention 
of those interested in eye surgery to the method of electrolysis in the treatment of 
such conditions, and particularly to call attention to its usefulness, not only in the 
removal of the cilia, a most troublesome factor in these cases, but to its resolvent effect 
upon hypertrophied tissue, causing an absorption of the thickened lid edges, and thereby 
often overcoming the tendency of the lid to turn inward. Where there is incurvation 
of the tarsal cartilages, with a marked tendency of the lid to inversion, a cure could 
not, of course, be expected from the use of the electrolysis needle ; but even in this 
condition great assistance may be obtained from using the needle before an operation, 
in the way of removing any greatly displaced eyelashes and reducing the hypertrophied 716 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lid tissue ; recourse may also be had to the process after an operation which would 
otherwise have been successful but for a few straggling hairs, thus simplifying and 
assisting much in the treatment of cases of entropium. 
In the spasmodic or acute form of entropium, where there is simply folding in of 
the lid or lids as the result of spastic contraction of the orbicularis palpebrarum muscle, 
associated with no structural alteration in the tissues of the lid, nor disarrangement of 
the eyelashes, little or no operative interference is required. Removal of a foreign body, 
alleviation of photophobia by the instillation of a few drops of a 4 per cent, solution 
of cocaine or atropia, cure of corneal ulcer or crop of phlyctenulae, or painting 
several coats of collodion on the surface of the lid, is often sufficient to overcome this 
form of entropium. In old age there is often present, owing to a redundancy and lax 
condition of the tissues of the lids, a persistent tendency of the lids, especially the 
lower, to roll in against the eyeball. For the relief of this condition the removal of a 
horizontal fold of skin tissue, of greater or less width as required, will usually be 
sufficient to overcome this malposition of the lid. 
It is not, however, in these acute spasmodic displacements of the lids that entropium 
assumes its troublesome features. In chronic ophthalmia and granular lids of long 
standing, often hastened and aggravated by the inj udicious use of irritating caustic 
substances, such as the commonly used blue stone, nitrate of silver, etc., the structure 
of the conjunctiva becomes almost or entirely destroyed, being replaced by cicatricial 
or scar tissue, which, upon contraction, usually results in incurvation of the tarsal car- 
tilages, and inversion of the lid edges and cilia against the globe of the eye. In a 
number of these cases of entropium, as the result of long-standing irritation, there is 
a notched, ulcerated, thickened and contracted condition of the edges of the lids. 
The eyelashes are scattering, dwarfed, and displaced, often being brought in contact 
with the cornea, producing corneal roughness, with consequent great impairment of 
sight. If data could be obtained, it would, doubtless, show a larger number of cases 
of blindness after childhood, as the result of entropium, than from any other one cause. 
This condition of corneal involvement, while it is almost universally present in granular 
lids of long standing, results not so much from the inflammatory process of the granu- 
lations, as from the irritating effect of the displaced eyelashes. It becomes a point of 
importance, then, in the management and care of these cases, that such an important 
structure as the cornea be protected from injury to as great an extent as possible, and 
while the management and cure of granular ophthalmia is an admitted slow and not 
readily tractable affection, still, with the timely use of the efficient means of the 
electrolysis needle now attainable, for the permanent removal of the offending cilia, 
there need be very few cases of corneal impairment and destruction as the result of 
entropium. In many cases of destruction and absorption of the conjunctival tissue, 
the result of chronic ophthalmia and trachoma, with cicatricial tissue covering the 
inner surface of the lids, and bands of the same tissue extending from the lids to the 
eyeball, there will occasionally be observed not the least impairment of the cornea, 
leaving the individual useful eyesight after passing through the slow and usually 
destructive process of neglected granular ophthalmia. This immunity of the cornea 
from involvement in such cases is due to the fortunate escape of its surface from the 
grating, irritating effect of the cilia which happen, in such cases, not to be displaced 
against the eyeball. If, therefore, in cases of cilia displacement, timely recourse should 
be had to the electrolysis needle in the permanent removal of each displaced eyelash, 
the number of cases of corneal involvement, and consequent impairment of vision, would 
be greatly, if not entirely, prevented in all cases of entropium. 
There are, however, aggravated conditions of entropium in which the displaced 
cilia are associated with a thickened, ulcerated and notched condition of the tarsal cartil- 
ages, which requires for its relief and restoration operative interference. In this condi- SECTION XI-OPHTHALMOLOGY. 
717 
tion of the lids, while the electrolysis needle cannot be depended upon for the cure of 
the entropium, the resolvent effect upon the hypertrophied lid tissue is desirable and 
beneficial in lessening and simplifying the operative procedure. In referring to the 
different entropium operations, usually named after the author suggesting the pro- 
cedure, it is a matter of difficulty to give the preference to any one method except in 
special cases, as the conditions present may determine. 
In an hypertrophied, thickened lid, with incurvation or doubling up of the tarsal 
cartilage, the operative procedure of Von Graefe will be found to afford relief,-the 
removal of a triangular portion of the skin of the eyelid down to the cartilage, the 
base of the triangle being parallel with the margin of the lid, reversing the process in 
the removal of a triangular wedge from the cartilage, cutting entirely through the 
thickness of the cartilage to the conjunctiva ; uniting the edges of the cartilage in 
uniting the edges of the skin. The operation of canthoplasty being usually required 
primarily, in order to avoid too much shortening of the palpebral aperture. A sim- 
pler operation and one that is claimed by the author Von Burrow as affording success 
in over one thousand cases of entropium, consists in everting the lid and dividing the 
tarsal cartilage through its entire length, parallel with and a few lines above the edge 
of the lid, leaving the incision free ; if there is not sufficient gaping and turning out of 
the lid edge, it may be increased by excising a strip of more or less width from the 
upper surface of the lid, uniting the edges of the skin incision by sutures. 
In some conditions of entropium the operation of transplantation gives satisfactory 
results. The operation consists in slitting the lid along the edge for about five or six 
mm. deep, through the entire length, the upper portion containing the skin, hair 
bulbs, orbicularis muscle, etc. An incision is next made through the skin about five 
to six mm. above and parallel to the edge of the lid, reaching down to the first inci- 
sion. Another incision is then made above this last, varying in width according to the 
degree of the effect desired ; this riband of skin may be dissected up and removed-the 
Arlt-Jaesche operation-or it may be brought down and attached to the intermarginal 
edge, the band of integument containing the cilia being carried up and over the bridge 
of loose skin and stitched to the upper border of the highest incision-Deanoux's oper- 
ation. 
Dr. Stephens, in a late edition of the Archives of Ophthalmology, proposes the inser- 
tion, after slitting open the lid edge, of a piece of transplanted lid tissue, which, upon 
union, is claimed to so stiffen the lid tissues and elevate the eyelashes as to overcome 
the entropium ; further experimentation will be necessary to establish its usefulness. 
As to the adoption of the method of transplantation, Von Graefe's operation of removal 
of a portion of the lid tissue or Burrow's operation of dividing the cartilage, will 
depend upon the conditions present. The operation of Von Burrow is simple and has 
given some brilliant results, and is worthy of more universal trial. 
My desire, however, is not so much to call attention to the features of the different 
operations for the relief of entropium, as to the simplifying and ameliorating effect of 
the process of electrolysis in permanently removing any displaced cilia, and in the 
further effect of reducing the thickened, hypertrophied tissue usually present, thus 
relieving the cornea from the presence of the irritation of the displaced eyelashes and 
in reducing the hypertrophied lid tissue, overcoming often the tendency to entropium ; 
such treatment, in a great number of cases, will afford entire relief. 
The process of using the electrolysis needle in destroying the hair bulbs and in 
reducing the hypertrophied tissue, in the treatment of entropium, needs no special refer- 
ence in this connection, further than to call attention to the thoroughness and frequency 
with which the application should be made. 718 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE OPERATION FOR STRABISMUS. 
L'OPÉRATION DU STRABISME. 
ÜBER DIE SCHIELOPERATION. 
BY DR. EDMUND LANDOLT, 
Paris. 
The operation for strabismus has marked peculiarities which distinguish it from all 
other surgical procedures performed upon the eye. All other operations, however much 
they may differ among themselves, have this in common, that they concern one eye 
only. The operation for strabismus, on the other hand, is, so to speak, binocular. It 
always involves both eyes, and this for the simple reason that strabismus is a binocular 
affection, a defect in the relative direction of the two eyes. The cyclope does not 
squint; he who has only one eye has no cause to fear a strabotomy. 
This observation might appear self-evident. It seems to me, however, that we are 
far from taking it sufficiently into account in our daily practice. We may operate for 
cataract upon an eye without paying much attention to the other, the first day we see 
the patient, provided the cataract is mature and uncomplicated. Strabismus, on the con- 
trary, should not be attacked surgically before the relationship of the two eyes, as regards 
direction and mobility, as well as the movements of each eye separately, have been 
thoroughly ascertained. The neglect of this principle is the chief cause of the failures 
and imperfect results of our strabismus operations, while to take it into account will 
increase considerably and confirm their success. 
To make myself clear: In the great majority of cases strabismus occurs in the hori- 
zontal plane, it is either convergent or divergent. Now, there exist most potent func- 
tional concomitants tending to increase the convergence, others which induce the eyes 
to diverge. He who is aware of these factors and knows how to profit by them, makes 
them his most precious auxiliaries in the surgical treatment of strabismus; he who 
neglects them will have them as antagonists. They will often deprive him of the fruits 
of his operation, however well performed. 
We all know the causes which produce convergence : the desire to see distinctly a 
near object, the stimulus to accommodation, the excitement of the ciliary muscle. Con- 
versely, the lack of an object of fixation, the repose of the eyes, absence of light, 
paralysis of accommodation, are conditions which diminish convergence and favor 
divergence. 
But above all these factors, the one which tends to do away with strabismus, of what- 
ever kind, our most powerful aid in the cure of squint, is the, desire to see binocularly. 
If binocular vision is wanting, sometimes in consequence of strabismus come on at an 
age when it was not yet firmly established, its absence becomes more frequently still 
the principal cause of the deviation of an eye and of its persistence in squinting. 
Consequently, everything which tends to the reestablishment of binocular vision 
helps us toward our goal, the cure of strabismus, and, let me add, to its complete, its 
ideal cure. For without binocular vision we gain for our patient only an apparent cure, 
we obtain merely a cosmetic effect. To have attained this is, of course, not to be 
despised ; it is, frequently enough, all we can hope for ; but this cure, in addition to being 
incomplete and existing almost always for one distance of fixation only, is often also 
limited in its duration, because it lacks the principal element which maintains the eyes 
in their normal direction. 
Now, what are the conditions which favor binocular vision ? Equal vision in the 
two eyes and their harmonious working. To correct the optic defects in the weaker 
eye, to equalize the refraction more or less in anisometropia, visual exercises of the SECTION XI-OPHTHALMOLOGY. 
719 
amblyopic eye and orthoptic exercises of both eyes together,* will, therefore, render us 
the greatest service in the surgical cure of strabismus. 
I beg you, gentlemen, to believe that these simple considerations, which have pro- 
bably occurred to all of us, are no mere theory. I would not dare to present myself 
before you so poorly armed. No, I wish to lay facts before you, and what I just said is 
as much the result of experience as of reflection. 
When I have to deal with a squint, I proceed in this manner: After having deter- 
mined its nature (paralytic or concomitant), I measure its degree f and the mobility of the 
eyes (field of fixation) at least in the plane of deviation. I take into consideration the 
duration of the affection, the patient's age, his amplitude of accommodation as well as 
his refraction, and his acuteness of vision. 
I then try how far binocular vision has been lost, if it is possible to produce diplopia 
or binocular vision by means of a prism or of my stereoscope. If the patient is young, 
I set myself, in the first place, to use exhaustively all the means which tend to dimin- 
ish the strabismus before proceeding to an operation. 
In convergent squint I order the cessation of all ocular work, I atropinize both eyes, 
furnish them with convex lenses, correcting the total hyperopia, and institute stereoscopic 
exercises as far as possible. 
Our non-surgical means of removing divergent squint are less numerous and less effi- 
cient, except when the condition is due to a general or local muscular weakness, which 
can be relieved by a tonic treatment. In this case, orthoptic exercises, especially 
stereoscopic, can render us good service, whereas we cannot count upon the most natural 
and most energetic factor which combats this form of strabismus, namely, the excita- 
tion of convergence. The latter is, in fact, nearly constantly invoked, that is to say, 
every time one fixes a near object. If, in spite of this, he has developed a divergent 
strabismus, this would indicate that the equilibrium of his ocular muscles is altered 
(through their insertion, their relative power, the form of the globe, or through some 
other cause), to such an extent that orthoptic exercises have scarcely any chance to 
reproduce the normal conditions. We shall see that they assume an importance so much 
the greater when once the operation shall have given them an opportunity of action. 
Be that as it may, I never operate until I have satisfied myself that the non-surgical 
methods have yielded their full result. It is upon this degree 'of strabismus, often 
considerably less than the one found at the commencement of treatment, that I base 
the selection of the method of operating and the extent to which I will carry it. It 
is evident that this is especially important in a càse of convergent strabismus in a young 
person, because we know that this strabismus is frequently spastic, associated with an 
excessive contraction of the ciliary muscle, that it often disappears spontaneously as 
years advance, and that it nearly always diminishes under an appropriate treatment. 
Now, if a child be brought to us with a convergent strabismus of, say 30°, and we 
at once correct it by operation, it is certain that, sooner or later (perhaps within six 
months), a divergent squint will develop, a squint for which we are to blame, and 
which will become more extensive, more disfiguring, more troublesome and more diffi- 
cult to correct than the original deformity. We, therefore, begin with placing the child 
under a course of treatment such as we have just sketched, and continue it until no 
further improvement can be obtained. A strabismus of 30° may thus easily be reduced 
to 0° or to 10°. Suppose that in this case a squint of 10° remains. This is still a 
very apparent strabismus. The child's parents may say that the treatment has been of 
no use, and the surgeon, unless he employs an accurate method for measuring the 
* Exercises with a colored glass, with a distant flame and prisms, stereoscopical exercises, 
experiments with Hering's test, etc. 
f Its angular amount, of course, the linear measurement being as illogical as imperfect. 720 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
degree, is unable to contradict them. But we would felicitate ourselves upon the ten 
degrees gained and the danger of hyper-correction avoided. 
We now may proceed to the operation without fear. We have to correct 20° of 
convergence. Is it possible to operate with such precision that we can say at once that 
the correction of 20° is assured*? No. Our operative procedures, with whatever skill 
performed, are so coarse in comparison with the delicate action of the ocular muscles, 
that he who relies exclusively upon the operation would incur almost certain failure 
by either exceeding or falling short of the aim before him. He can only say in a gen- 
eral way, " In this case tenotomy is indicated, in that, advancement; in another, the 
combination of both is preferable-here a stronger, there a lesser effect is required." 
If it is necessary to operate upon both eyes, to perform, for instance, the tenotomy 
of two homonymous muscles, we never do both at the same sitting. We, on the con- 
trary, find a great advantage in basing the second operation upon the definitive result 
obtained by the first. But although we cannot count upon obtaining, by the operation 
alone, the precise correction of the error, still we possess in the orthoptic methods the 
means of perfecting the result of our surgical intervention. 
Now, since it is easier, as a rule, to diminish than to increase the immediate effect of 
a strabismus operation, I am not afraid of operating rather freely. Let us return to 
our example. We have 20° of convergence to correct by an operation. I know by 
experience that such a strabismus could not be removed by a simple tenotomy, and if 
I attempt to force the effect, by conj unctival or capsular sutures, beyond a certain 
degree, I diminish the power of the internal rectus (and even, as we shall see, of the 
external rectus also) by the exaggerated setting back. I must, therefore, choose between 
tenotomy of both internal recti and the combination of tenotomy of the internal with 
advancement of the external rectus in the same eye. I prefer the first, if the strabismus 
is alternating, but where it is monocular, I should prefer the second. The latter would 
occur much more frequently. I would perform a moderate tenotomy and advance 
the antagonist to about one millimetre from the cornea, according to the lines laid 
down in a former paper.* I would continue instilling atropine into each lye, and 
protect both eyes with an antiseptic dressing. When the patient has recovered com- 
plete consciousness (if an anaesthetic has been used), I should probably find a certain 
degree of divergence, the amount of which I would measure either with the perimeter 
or by my subjective method of strabometry.f It is, then, simply a question of gradu- 
ally diminishing this excessive result to the desired degree. Nothing easier to the 
skilled observer. 
In the first place, he will, of course, not have committed an error so great as to 
necessitate the advancement of the internal rectus originally set back. But even if 
this should happen, it would not be a great disaster. Otherwise the eye should not be 
touched, except to change the dressing, until the muscles begin to be attached to the 
globe. If the divergence is rather marked, the atropine should be stopped. If it per- 
sist the third day, the stitches of the advanced muscle should be removed, but both 
eyes should still be covered. But if, on the fourth day, the eye still diverges, the good 
eye should be uncovered. The use of this eye invokes convergence which helps to do 
away with the hyper-correction obtained. One can commence even on the fourth or 
fifth day, systematic exercises of convergence, by desiring the patient to fix his finger 
at a distance and gradually bring it nearer. The operated eye, now free from stitches, 
* Landolt. Art. Strabismus in " Dictionnaire encyclopédique des Sciences médicales," Paris, 
p. 279. In higher degrees of squint, I would bring it right to the corneal border. See Lan-, 
dolt, in de Wecker et Landolt's "Traité complet d'ophthalmologie," in, s. 858. 
+ Landolt. "Annales d'Oculistique," Juillet, 1875, and "The Diagnosis of Diseases of the 
Eyes." 721 
SECTION XI-OPHTHALMOLOGY. 
follows this movement under the bandage. Exercises which require the patient to look 
at the side opposite from the operated eye, are useful adjuncts. It is very rare not to 
have, by these means, the excess removed. 
Having obtained this correction we now proceed to the establishment of what I 
have called the amplitude of convergence * that is to say, the faculty of converging and 
diverging. Indeed, in no case should the patient have lost the latter, unless a relapse 
of convergent strabismus could occur. If, therefore, he can fix binocularly a candle 
flame placed at a great distance, he should still be able to see it single even through an 
abducting prism of, say 4°. 
It is, of course, not less important to exercise his power of convergence proper. For 
this purpose we may employ simply a sheet of white paper with a black spot on it, or 
if the vision of one eye is very defective, the luminous slit of my dynamometer, f the 
other eye being provided with a colored glass. The object selected is then gradually 
brought nearer to the patient, who tries to maintain a single and binocular vision. It 
is wonderful to what an extent the amplitude of convergence can be increased by this 
means. It is self-evident that stereoscopic exercises are also of great use in the estab- 
lishment and confirmation of binocular vision. 
Even if binocular vision should not be obtained, these exercises, by exciting accom- 
modation, have an important influence in lessening the divergence. Should, however, 
divergence remain in spite of all our efforts, we must have recourse to the advance- 
ment of the tenotomized muscle. This can be easily done up to eight or ten days after 
the primary operation. A strabismus hook is introduced through the original wound 
in the conjunctiva and passed under the muscle. A stitch is inserted in the tendon, 
which is then separated from the globe by drawing the hook gradually forward. By 
means of the stitch, the insertion of the muscle is drawn to the cornea as far as is 
thought necessary. The pain and hemorrhage produced by this little operation quickly 
subside under the use of an iced compress. 
This is, in outline, our method of procedure in convergent strabismus. Divergent 
STRABISMUS offers, as you are aware, a much greater resistance to all forms of treat- 
ment. Here the danger is rather to fall short of the required correction than to 
pass it. 
With regard to the method of operation, it is not enough to know the degree of diverg- 
ence; it is essential to ascertain, as exactly as in convergent strabismus, the range- 
action of the abducting and adducting muscles. The examination of the field of fixa- 
tion will often show us a marked limitation toward the nasal side, not only of the 
deviated eye, but also of the other. J This should not surprise us. Binocular vision 
quickly disappearing under the influence of divergent strabismus, the internal recti 
are little exercised by lateral movements, and to a still less extent by their simulta- 
neous contraction in convergence, which, in the normal condition, gives their prepond- 
erance over the abductors. 
It is only when divergent strabismus is of slight amount (1. g. 10°) and the field of 
fixation of each eye extends inward to at least 47°, that one tenotomy will suffice to cor- 
rect. When there is no great difference in the vision of the two eyes, and when the 
muscular conditions of the two are good, one can easily correct, by a second tenotomy, 
later, on the other eye, any deviation which may remain from the first. 
If, on the contrary, as is frequently found, the divergent strabismus is of long 
•* Landolt, in de Wecker et Landolt, "Traité complet d'Ophth.," ni, 185, and Landolt, 
"Réfraction and Accommodation," p, 190. 
f Landolt, loc. cit. ht, 279 ; p. 283 : and Proceedings of the Heidelberg ophth. Soc., 1885. 
J A similar fact is observed in convergent squint, where, very frequently, both fields of fixa» 
tion are considerably limited on their temporal side. 
Vol. Ill-46 722 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
standing and high degree, if the squinting eye is very amblyopic and its internal rectus 
acts feebly, then the combination of a free tenotomy with a complete advancement is 
absolutely demanded. It will often even be necessary to operate also on the other eye 
(either by tenotomy alone, or combined with advancement), in order to complete the 
correction. But before doing this, we should have recourse to all means favoring 
convergence. 
We should not instill atropine. We should dress only one eye, in the case of a 
tenotomy, and, where an advancement has been performed, leave off the dressing from 
the good eye as soon as union has taken place. Exercises must be begun immediately, 
w hich have a tendency to turn the eye in the required direction ; those which induce 
convergence being the most important. 
It is scarcely necessary to say that, if we shall have overshot the mark, we must 
employ exactly opposite treatment. (Paralysis of accommodation, prolonged dressing 
of both eyes, exercises with abducting prisms and stereoscope, in extreme cases, even 
advancement of the tenotomized muscle, but, of course, short of its original insertion.) 
A peculiar interest attaches to a form of muscular anomaly which is not yet a diver- 
gent strabismus, but which, notwithstanding, enters into that category, because it often 
forms its initial stage. I refer to insufficiency of the internal recti, or, more correctly, 
insufficiency of convergence. I have treated this subject elsewhere* and, therefore, con- 
tent myself with merely insisting upon the following points : The greatest prudence 
must guide us in the surgical treatment of this affection; we must not undertake it 
until all other treatment, especially general tonic treatment, has failed; our procedure 
must be based upon an intimate study of the muscular conditions, especially the ampli- 
tude of convergence; and frequently simple advancement is tobe preferred to tenotomy. 
It seems to me that we do not thoroughly appreciate the action of these two opera- 
tions. We too often content ourselves in giving the preference to tenotomy because it 
is the easier of the two, and because it can be made to yield very great effects, thanks 
to conjunctival and capsular sutures, and other similar procedures; whereas advance- 
ment seems to us more complicated and even dangerous. More complicated it is, cer- 
tainly, without, however, being very complicated. But, as regards danger, I see none, 
except the production of a vertical relative displacement between the two eyes. This 
should, however, not occur if the operation has been done skillfully and carefully. In 
cases in which it would be especially troublesome, that is to say, where binocular vision 
exists, nature comes all the more powerfully to our aid, tending to restore to the eyes 
their proper direction, provided we know how to follow her suggestions. 
To arrive at a proper appreciation of the influence which an operation exerts upon 
the direction and especially, the mobility of the eyes, we must abandon those erroneous 
conceptions contained in certain standard-we may even say classical-memoirs upon 
this subject. In tracing, for instance, an eye diagrammatically, on paper, giving it a 
centre of motion and applying the parallelogram of forces, we are very liable to fall 
into the gravest errors. The movements of the eyes are far more complicated than this ; 
they are even too complicated to be predicted by the deduction. We must proceed by 
induction. 
Let us first make the experiment and then try to explain it with our anatomical 
knowledge-if possible; if not, we will have to extend it. In the question before us, 
let us measure the excursions of the eye as well as the amplitude of convergence, before 
and after operation. When we have collected a sufficient number of cases, we are then 
in a position to arrive at conclusions about the action of the operation. 
Now, experience has shown us that, ceteris paribus, the advancement of a muscle 
has an action more powerful and more favorable than tenotomy of its antagonist, and 
*.Landolt. Proceedings of the Heidelberg Ophth. Soc., 1885 ; and Ophth. Review, v, 185. SECTION XI-OPHTHALMOLOGY. 
723 
that the combination of advancement with tenotomy in the squinting eye is preferable 
to tenotomy practiced upon both. 
Muscular advancement, far from limiting the field of fixation, increases it, whereas 
a simple tenotomy diminishes it, and tenotomy exaggerated by sutures may limit it in a 
very disastrous manner. This is easily understood. If, by a forcible rotation of the 
eyeball away from the divided tendon, I force the latter to take an insertion far behind 
its original one, I weaken its action so that objects situated at that side are seen double. 
At the same time, the field of fixation is frequently found to be limited on the opposite 
side also. Krenchel's theory* is thus demonstrated to be correct. This muscle has, so 
to speak, also undergone a setting back. It is relaxed, its elasticity and contractility, 
though undiminished, have less effect upon the globe. The eyeball has, as it were, 
partially escaped from the grasp of the two muscles by advancing in front of them. 
The muscles are not wrapped so far around the eyeball, and as it is during their unwrap- 
ping that the muscles act at their full mechanical advantage, their power is consequently 
diminished. 
To enter more into these considerations would lead us too far. Let me finish my 
communication by reviewing it in a few sentences : The operation for strabismus ought 
not to be considered alone a cure, but only as one step in a systematic orthoptic treat- 
ment which oftentimes has to precede, and always to follow, the operation. The 
orthoptic treatment will regulate and render more perfect the effect of the operation; 
it will oftentimes restore binocular vision in cases where this has been considered impos- 
sible, and will thus realize the ideal cure of strabismus. 
As regards the method of operation, I believe that muscular advancement has, in 
general, a great advantage over tenotomy, and should be offener practiced than it is 
generally done. 
SOME IMPORTANT PROBLEMS RESPECTING INSUFFICIENCY 
OF OCULAR MUSCLES. 
PROBLÈMES IMPORTANTS CONCERNANT L'INSUFFISANCE DES MUSCLES 
OCULAIRES. 
ÜBER EINIGE WICHTIGE PROBLEME BEI INSUFFICIENZ DER AUGENMUSKELN. 
BY GEORGE T. STEVENS, M.D., PH.D., 
New York. 
Practical advances in the knowledge of the anomalies of the directing ocular muscles 
have by no means kept pace with those which have been made in the understanding of 
the anomalies of refraction and accommodation. Less crude, indeed, are the prevailing 
methods of dealing with these muscular defects than were the older methods of cor- 
recting near and old sight. Yet much is to be done in this department to bring it 
abreast the science of refraction and accommodation. 
Graefe and his co-workers, as the great pioneers in this branch of ophthalmology, 
taught the important doctrine of muscular asthenopia, locating the trouble in the insuffi- 
* Krenchel. Arch.f. Ophth., xix, 2; 275. 724 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
cient force of the interni to overcome the resistance of the externi when the eyes were 
employed at near range, and principally incases of extreme myopia. 
Certain methods for the discovery of this condition were almost universally adopted, 
chief among which was that of the dot and line, or method No. 3 of Graefe-a method 
which, notwithstanding the introduction of others by distinguished observers more 
recently, holds a preeminent place to the present time in text-books and, in great 
measure, in the special literature of the subject. Even the more recent methods are, 
for the most part, directed to the determination of the ability of the interni to overcome 
the resistance of their direct antagonists. 
The question of muscular irregularities then, excluding strabismus and the results 
of paresis, has been, and still remains, in the great mass of the literature almost exclu- 
sively one of "insufficiency of the interni" at the reading-point. It is true that the 
literature is not destitute of recognition of other so-called "insufficiencies," and I 
believe that it was my own privilege to first call attention to important results following 
the operative correction of "insufficiency of the externi." 
If it were true that difficulty in overcoming the externi in convergence were the 
great, if not the exclusive, difficulty which might arise from the absence of muscular 
equilibrium, not regarding strabismus or effects of paralysis, the methods of Graefe, or 
those more recently introduced for the determination of convergence power, might doubt- 
less be, in a certain proportion of cases, satisfactory. Unfortunately, " insufficiency of the 
interni" is not the exclusive anomaly of its class; it is not even the one of the highest 
importance nor of the most frequent occurrence. Unfortunately, too, for even this single 
anomaly, the methods referred to are inexact and very frequently misleading in their 
results. I have elsewhere called attention to this important fact, but will, in order to 
emphasize the truth of the statement, introduce one or two illustrations. 
Making due allowance for the "muscular mesoroptea," the ocular muscles are, 
when the eyes are directed straight forward at a point about twenty feet in advance of 
them, and in the same horizontal plane, in the state of minimum innervation. It 
must be evident that it is at this point that an actual " insufficiency," or, more prop- 
erly, an anomalous tendency of the ocular muscles must be most truly shown. 
Now, it is not an uncommon circumstance to find conditions not unlike the follow- 
ing, which is taken from an actual record:- 
At a distance of twenty feet, with a prism, its base down before the right eye, there 
is shown esophoria (insufficiency of the externi) of 8°. In other words, there is a 
tendency on the part of the visual axes, when not directed by an effort of the will, to 
deviate inward 8°. At the distance of one-half metre, employing the method of 
Graefe, there is "insufficiency of the interni " of 10°, with a power of adduction of 50°. 
It is apparent that both "insufficiency of the interni" and "insufficiency of the 
externi " do not exist to the extent indicated by these results, for at the distance of one- 
half metre, even if no adducting force were employed, there should be little or no 
"insufficiency of the interni." With this real tendency on the part of the visual lines 
to deviate inward 8° these lines should meet at a little more than one-half metre in front 
of the eyes ; hence, without any unusual innervation of the interni, there should be no 
important insufficiency of these muscles, much less an insufficiency of 10°. Still further, 
even if any exertion of the interni should, in this case, be demanded, the adducting 
force of 50° prism is an assurance of abundant energy on the part of the converging 
muscles. 
There is, then, in this instance, associated with actual insufficiency of the externi, 
an apparent insufficiency of the interni of a high degree, when tested by the method of 
Graefe. Evidently, an operation for relaxation of an extemus in such a case would be 
a grave mistake, and probably the employment of prisms for the near point would 
prove unsatisfactory and of no permanent value. SECTION XI-OPHTHALMOLOGY. 
725 
Lest it might be supposed that the influence of a prism in making the examinations 
in the above case should account for the contradictory results obtained, I will present 
another illustration in which the influence of a prism is entirely eliminated. A gen- 
tleman of thirty years of age, with no important refractive error, when looking at a 
lighted candle on a level with his eyes, and at a distance of twenty feet, has homony- 
mous diplopia of 4°, with the two images approximately in the same horizontal plane. 
If, on the other hand, he directs the eyes to the flame of the candle at a distance of 
only two feet, he has no longer homonymous, but crossed diplopia of 5°. His actual 
convergence power, according to the method of Landolt, is onë-half metre angle. Here, 
then, with no extraneous disturbing influence, we have both slight converging and 
diverging strabismus. 
The above illustrations represent only a single class of anomalous results which are 
frequently encountered by the observer who investigates these deviating tendencies, 
not by a single method, but under a variety of circumstances. 
How can we reconcile these contradictions, and how are we to proceed for the relief 
of the nervous irritations to which they give rise ? The question is too broad to admit 
of a single reply, and the purpose of this paper is more especially to suggest the prob- 
lems rather than to offer a solution of them. It will, however, be proper to consider 
in this relation an important element which is doubtless the main factor in many such 
cases. It is that condition of the ocular muscles in which there is a tendency on the part 
of the visual line of one eye to rise above the direction of that of the other eye. This 
important condition cannot be properly called an "insufficiency " of one or other supe- 
rior or inferior rectus muscle, for it may be the result of a failure of any one of the 
four superior and inferior recti, or it may not be from failure of either of these. Hence, 
the term "insufficiency" is even less appropriate than in the conditions more com- 
monly described as such. To this condition I have applied the term hyperphoria*, and 
shall employ it in this paper. 
This condition, hyperphoria, frequently lateral in part or entirely, is doubtless the 
most important disturbing element in these contradictory conditions of the lateral mus- 
cles, and is, at times, an exceedingly troublesome factor, not only in disguising or com- 
plicating other conditions, but in presenting serious obstacles in the way of treatment. 
If it is asked, why should this peculiar condition give rise to so many unlooked-for 
complications ? a ready answer might be found in the assertion that the oblique mus- 
cles, acting in a somewhat complicated manner, must account for the anomalous results 
found. Science which satisfies itself with such easy answers is usually mistaken 
science. To give a reply to the question which shall be of practical value, we must 
present a reason which will enable us in advance to determine what would be the 
result of certain anomalous tensions of certain specified muscles. Failing of this, the 
oracular announcement that such and such irregular phenomena must result from the 
irregular tension of a certain class of muscles, only because the actions of these muscles 
are less perfectly understood than that of others, is simply evading a reply. 
My own experience leads me to suppose that the irregular results found in hyper- 
phoria are not attributable primarily to undue tension of the oblique muscles more 
frequently than to that of the recti. Nevertheless, much has still to be observed in this 
direction. 
With this suggestion regarding the influence of hyperphoria as a disturbing influ- 
ence, I shall further illustrate the perplexing phases of some of these anomalous tenden- 
cies by citing one or two somewhat remarkable complications of the muscular condi- 
tions. 
These illustrations will be taken from cases in which the deviating tendencies 
* Archives d' Ophthalmologie, Nov.-Dec., 1886. 726 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
amount to slight actual strabismus, because these exaggerated cases of insufficiencies 
can be better studied, or, at least, better described, than those of more moderate 
anomalous tendency. 
A lady, aged about forty years, has in the right eye myopia | D., in left eye, 
hyperopic astigmatism 1.00 D. These refractive conditions are verified by the em- 
ployment of atropine. With or without correcting glasses, the following phenomena 
were observed in respect to the directions of the visual axes, the lady having, after con- 
siderable practice, acquired the ability to direct her attention to the image of one or 
other eye at will. She has habitual diplopia, of which she was unconscious until her 
attention was directed to it in the consultation room. The double images were very 
nearly in the same horizontal plane. If the lady covers the right eye for a moment, 
allowing the left eye to fix an object at twenty feet distance, upon removing the cover 
there is homonymous diplopia of from 10° to 15°, with a tendency of the right visual 
line above the other of from 1° to 2°. If, now, the left eye be covered, permitting the 
right eye to fix the distant object, on removing the cover from the left eye, crossed diplopia 
with slight right hyperphoria, results. This condition continues until, by an effort of 
the will, the lady fixes the object with the opposite eye, a change which she can effect 
at pleasure. After both eyes have been for some time uncovered, the hyperphoria dis- 
appears and a prism of a single degree, with its base up or down, throws one of the 
images out of the horizontal plane. 
In the above illustration the condition of hyperphoria is probably causative of the 
remarkable phenomena of double vision described, a presumption strengthened by 
experience in other similar cases-for this instance is by no means unique. 
It is interesting to note the fact that in this instance the hyperphoria, which is 
usually latent while the two eyes are directed toward the object, becomes manifest, to 
a certain degree, when one of the eyes has been for a short time covered. It is not 
always that hyperphoria becomes so readily manifest, and the greatest patience and 
much skill may be required for its detection. 
This suggests the subject of latent anomalous tendencies of the ocular muscles. 
These latent anomalous tendencies are often of great importance and may be easily 
overlooked. Indeed, latent "insufficiencies" are as frequent as latent refractive 
troubles and are much more difficult to discover. A single example will illustrate this 
principle: A young gentleman had manifest esophoria (insufficiency of the extern!) 4°, 
with abducting power of 4°. Partial tenotomy of one of the interni was made, and 
immediately after the operation the following conditions were found: The power of 
abduction had been increased from 4° to 11°, showing that an important relaxation of 
the tension of the interni had been effected. At the same time the insufficiency of the 
externi, which had before the operation been but 4°, was now 8°. Thus, the manifest 
insufficiency immediately after the operation was double that shown just before it, not- 
withstanding a positive relaxation of 7°. 
This example, which is but a fair representative of conditions which may be fre- 
quently observed both after operations and after the use of prisms for a few days, shows 
us that we are to direct our efforts to reveal the whole of these tendencies, not content- 
ing ourselves with the results of a single examination. Indeed, one of the great 
problems in respect to the anomalies of the ocular muscles is that of revealing latent 
heterophoria, or faulty muscular tendencies. In hyperopia we may, by means of the 
influence of atropine upon the ciliary muscle, render latent hyperopia manifest. It is 
equally desirable that some means be found of determining absolute heterophoria. No 
greater service could be rendered in the science of ophthalmology than in pointing out a 
method of revealing absolute heterophoria as readily and as effectually as we now reveal 
absolute hyperopia. 
It is not my purpose to call attention to all the difficulties which may arise in the SECTION XI-OPHTHALMOLOGY. 
727 
course of a series of examinations of the eye muscles, for that would be a vast subject. 
The few illustrative examples which I have given suggest, however, several important 
problems:- 
1. In what direction are we to look for the complicating causes in such apparently 
inconsistent conditions as those shown in the examples ? 
I have already intimated that the existence of hyperphoria will in many cases 
account for these apparently contradictory results, but it remains to discover in what 
proportion of cases it is thus influential, and it remains for us to inquire, if other causes 
exist, in what direction are we to seek for them. 
2. In case the existence of hyperphoria is ascertained, in what manner are we to 
determine through the influence of what especial muscle or muscles the equilibrium is 
lost? 
This is a question of prime importance, for it may be to little purpose that we are 
able to attribute the tendency on the part of the visual lines to deviate inward or out- 
ward, according to the distance for which the eyes are adjusted to hyperphoria, unless 
we are able to deduce from this conclusion some practical method of dealing with the 
faulty condition. It is, however, a legitimate question whether in case of hyperphoria 
it is always essential, in order to restore the equilibrium, that we abase the higher- 
tending visual line or exalt that which tends below. My own experience leads me to 
think that in a certain proportion of cases it is a matter of comparative indifference 
which course is taken, but that in another proportion of cases the selection of the exact 
method for restoring equilibrium is of essential importance. 
3. Allusion has already been made to the problem of determining the absolute 
anomaly in muscular equilibrium. 
4. The question of the manner of procedure in making examinations for hetero- 
phoria is an important one. In some recent publications I have indicated what, in the 
main, I regard as suitable procedures, and I need now only refer to my present method 
of arriving at a knowledge of absolute heterophoria. 
It is my custom, more especially in cases of hyperphoria, to supply for temporary 
use correcting prisms of a degree rather less than the manifest heterophoria. Thus, if 
heterophoria of 3° should be found, a prism of 1° for each eye would be given. A day 
or two, or longer, after the examination is repeated, and if the heterophoria manifest 
has increased still stronger prisms are given, still avoiding a full correction. When, 
after several examinations at intervals of some days, no further difficulty is revealed, it 
is assumed that the whole, or nearly the whole, of the fault is revealed, and the question 
of operative relief may then be settled; for I do not think that we can hope for much 
permanent relief to heterophoria from the use of prisms in the great majority of cases. 
In order to render this method of rendering latent heterophoria manifest as expedi- 
tious and as little troublesome as possible, I have had made for my own use a consider- 
able number of spectacle frames, all taking glasses of the same dimension. I have then 
a supply of plane and of weak prismatic glasses which can be quickly adjusted in these 
frames. 
The patient is supplied with one of these frames and the proper glasses, and when 
at a subsequent visit it may be necessary to supply a stronger glass, the change can 
be effected in a moment. When the hyperphoria has been revealed to the full extent 
which is practical, the frames are returned and are ready for another case. Thus far I 
find this the most advantageous method that I have employed, but I look forward to a 
quicker and more effectual method. 728 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ADVANTAGE OF OPERATING EARLY FOR STRABISMUS. 
L'AVANTAGE D'UNE OPERATION PREALABLE POUR LE STRABISME. 
DER VORTHEIL EINER FRÜHEN OPERATION BEI STRABISMUS. 
BY J. F. FULTON, M.D., PH.D., 
Of St. Paul, Minnesota. 
There is no operation the ophthalmic surgeon feels more certain of success in, nor 
which his patient usually desires more, than the operation for strabismus. We, as a 
rule, are safe in promising to overcome the deformity of all who come to us for that 
purpose, provided they permit us to operate as often as necessary. But there are some 
other troubles connected with this deformity which are not so easily overcome, namely, 
diplopia and the amblyopia so frequently met with in these cases, and it is to these 
two symptoms that the ophthalmic surgeon should direct his attention chiefly in the 
treatment of this class of cases. 
I agree with Scelberg-Wells that the active suppression of the pseudo-image results 
frequently in amblyopia, and this amblyopia increases rapidly in children shortly after 
the strabismus first shows itself. In this connection he says: " The operation should 
never be unnecessarily deferred. The question is often debated, as to whether a child 
of two or three years of age should be operated upon for squint, or whether it is not 
better to postpone an operation until it is much older. My opinion is very strongly 
opposed to the latter practice, and is urgently in favor of the operation being per- 
formed as soon as possible, while binocular vision still exists and the sight of the 
squinting eye is good. When it is, however, absolutely necessary to postpone the opera- 
tion, the vision of the squinting eye should be frequently practiced, and each eye 
apparently used for reading, etc. 
Stellwag, although strongly opposed to operating before puberty, urges the necessity 
or importance of separate exercise for the squinting eye, in order, he says, to avoid the 
development of a central anaesthesia. For this purpose, he says, it is necessary to 
exclude from the visual act the eye usually employed for fixation, and to exercise the 
defective eye several times daily. I think this whole subject can be made clear by 
recognizing the fact, which clinical and careful investigation seems to distinctly prove, 
that amblyopia met with in cases of squinting is either primary or secondary. What 
I mean by primary amblyopia is that which is due to some defect either in the struc- 
ture of the eye or in its perceptive powers, and is always congenital. For this there 
can be nothing done in the way of operating or treating the strabismus, but I am very 
positive in my opinion that a large proportion, at least, of the cases of amblyopia thus 
met with is secondary to and the result of the strabismus. It is one of the laws of 
nature, to which there are certainly but few exceptions, that suppression of activity 
will result in deterioration of the function of the part. It is so here. The objects not 
being focused on the same place on either retina results in a double image, and finally 
in a suppression of the image in one eye and the disuse of that organ, which gradually, 
in some cases very rapidly, loses its functional activity. As proof of this, how rare it 
is to meet with amblyopia in alternating squint, or in those cases in which the refrac- 
tion and acuteness of vision are alike in the two eyes. In each it is a mere matter of 
accident which eye will be directed toward the object and which toward the nose, 
the reason of this being that both eyes are exercised alike. But in the other class of 
cases, in which the refraction of the eyes is different, the vision of the best eye is used 
by instinct, and the squinting is always done by the defective eye. The squint is then 
said to be fixed, and under such circumstances the vision of the squinting eye will 
usually undergo a steady, progressive deterioration. (Carter.) SECTION XI OPHTHALMOLOGY. 
729 
And I maintain that this progressive deterioration of vision can be prevented in a 
great many cases by curing the squint, either by the use of glasses, or, if necessary, by 
an early operation. In this connection, and in proof of what I have just affirmed, 
permit me to refer to the history of a few cases:- 
A young man, eighteen years of age, came under my treatment some years ago, 
with the following history: He had been examined eight years previous to this by an 
oculist. His books showed the condition of his vision to be as follows : Acuteness of 
vision in right eye the vision in the left eye This eye was hypermetropic to 
about one dioptry. Vision could be raised to normal by a + 0.75 glass. Convergent 
strabismus had already commenced. He was advised to use atropine and glasses, but 
for some reason this had been neglected, and the strabismus developed, and, as the 
future history proved, deterioration of vision in the left eye developed also. Just before 
coming to me he met with an unfortunate accident. A little boy shot a horse-shoe nail 
into his right eye, which entirely destroyed the sight. It was necessary to enucleate it. 
The vision of the left eye was ; even this vision was uncertain, as he had the so- 
called " come-and-go " acuteness of vision. This could be improved but very slightly 
by the correcting glass, but by constant and persevering exercise the acuteness of vision 
gradually improved, and continues to improve up to the present time. He now reads 
This case certainly proves, beyond the possibility of doubt, that amblyopia does 
develop as strabismus develops, and that it can be relieved by proper treatment and 
systematic exercise. Is it not but reasonable to suppose that, had the operation for 
strabismus been performed when it first developed, deterioration of vision in this eye 
would have been prevented. 
I wish here to relate briefly the history of the other case, which has strongly 
impressed me as to the importance of, in some way, relieving strabismus as soon after 
it shows itself as possible. Two members of the same family-a little boy and little 
girl-each had convergent strabismus, apparently the result of a low degree of hyper- 
metropia. Strabismus began to develop in each about the sixth year. The boy was 
eight years of age and the girl nearly seven when they came under my observation. 
The left eye of both children was slightly amblyopic, each reading in the defective eye 
as near as could be made out in children so young. The strabismus was well 
marked, reaching a little over three lines in both. An operation was advised for both, 
but the parents consented only to have the operation performed on the elder child at 
that time. Both, however, had the refraction carefully corrected with glasses. The 
child upon whom the operation was performed had binocular vision perfectly restored, 
and his acuteness of vision remained at with the correcting glass, which he always 
used. The strabismus remained stationary in the younger child, but the amblyopia 
increased, as an examination several years afterward showed distinctly. I think it is 
but fair to conclude that, had this child been properly treated, she would not have 
suffered deterioration of vision in her defective eye. 
Any one who has had much experience in the treatment of squint recognizes how 
difficult it is to restore binocular vision after it has once been lost, yet this is an object 
paramount in importance, and I maintain that it is much easier to do this by operating 
early, soon after strabismus shows itself, than by operating later in life. I have from 
time to time carefully examined young people who had their strabismus cured by a 
timely and proper operation early in life, and in but few such cases have been able to 
demonstrate the absence of binocular vision. All the defects of the operation, the 
deformities resulting from it, such as sinking of the caruncle, are less likely to take 
place after an operation on children, in my experience, than after operating on adults. 
The loss of balance between the ' ' accommodation ' ' and the internal recti muscles, 
together with asthenopia, so frequently metwith after this operation has been performed 
upon adults, is much more easily overcome, or I should say much more easily overcome 730 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by nature herself, when the operation is done on children, than at other periods of life. 
And it so frequently happens that the treatment of asthenopia, after the operation has 
been successfully performed, is much more tedious and much more annoying to both 
patient and surgeon than any other part of the treatment. After strabismus has lasted 
fora number of years it frequently results in most serious loss of proportionate strength 
between the internal and external recti muscles. There is very great thickening and 
contraction of the internal, and corresponding elongation and atrophy of the external, 
rendering the trouble all the more difficult to remove. Such a course is prevented by 
operating early in life. 
These conclusions are arrived at by actual experience and clinical observation. I 
am well aware that they are contrary to our usually accepted theories on the subject. 
But theories and far-fetched attempts at explanation should not be permitted to weigh 
in the balance with experience. There are many obscure points in ophthalmology 
which cannot be explained by any theory. We must learn to look such calmly in the 
face, in order to undertake with courage the task of elucidating them. General medi- 
cine, which has for ages been the object of investigation, together with all branches of 
science, affords many more unfilled gaps than does ophthalmology, which was, so to 
speak, born but yesterday. Hence, let us not despair, but seek diligently to analyze 
the many facts that practical experience presents every day, and light will eventually 
dawn upon us. 
DE CERTAINS TROUBLES DE LA MOTILITÉ OCULAIRE ET DES 
MOYENS D'Y REMÉDIER. 
ON CERTAIN DERANGEMENTS OF OCULAR MOTILITY, AND THE MEANS OF 
REMEDYING THEM. 
ÜBER GEWISSE MOTILITÄTSSTÖRUNGEN DES AUGES UND DIE MITTEL ZU IHRER 
BESEITIGUNG. 
PAR LE DR. ABADIE. 
De Paris. 
Je laisserai de côté à dessein la question du strabisme, affection contre laquelle nous 
possédons aujourd'hui des méthodes opératoires qu'on peut appeler parfaites, pour 
m'occuper exclusivement de certains troubles de la motilité oculaire qui semblent avoir 
échappé jusqu'ici à tous nos moyens d'action et auxquels, néanmoins, on peut remédier 
ainsi que je l'indiquerai par la suite. 
Les troubles de la motilité oculaire que j'ai en vue en ce moment sont :- 
1. Le strabisme intermittent. 
2. La parésie de certains muscles provoquant de la diplopie sans déviation apparente 
de l'œil. 
3. L'insuffisance des muscles droits internes. 
Occupons-nous d'abord des troubles de la première variété. 
Le strabisme intermittent, je le reconnais, est souvent la conséquence d'un vice de 
réfraction et est justiciable de l'emploi des lunettes. C'est même cette variété de stra- 
bisme qu'on guérit le plus communément par l'emploi des moyens optiques ou ortho- 
pédiques, mais nous devons néanmoins reconnaître qu'il est des cas où le strabisme 
intermittent persiste même après que nous avons eu recours à ccs divers moyens. 
Dès lors que faire le plus souvent nous abandonnons les malades à eux-mêmes et 
nous renonçons à guérir leur difformité. SECTION XI-OPHTHALMOLOGY. 
731 
Pourtant ces cas ne sont pas incurables, étudions en effet, leur pathogénie. Le stra- 
bisme intermittent est dû à ce qu'à certains moments sous certaines influences, mise 
en jeu de 1'accomodation ou de la convergence un des muscles le droit interne le plus 
souvent innervé très énergiquement prend une action prépondérante. 
Il est trop fort à un moment donné, bien que son insertion au globe oculaire soit 
normale puisque à l'état de repos le strabisme disparait. 
Que faut-il donc obtenir ? Il faut affaiblir ce muscle sans toucher à son insertion, 
sinon, on risque de transformer un strabisme intermittent en strabisme permanent du 
côté opposé. On atteindra ce but en pratiquant la ténotomie partielle du muscle qui 
se contracture de temps à autre en suivant les règles que j'exposerai tout-à-l'heure. 
2. J'étudierai maintenant un cas rare à la vérité, mais si difficile à guérir dans la 
pratique où à la suite d'une parésie portant sur un muscle oculaire il est resté une diplo- 
pie très gênante sans déviation apparente de l'œil. Ces cas, je le reconnais, sont rares. 
D'habitude les paralysies oculaires guérissent par l'emploi prolongé de l'électricité et 
les médicaments appropriés à la cause pathogénique du mal, d'autrefois la paralysie 
persiste reste plus on moins complète et il reste un strabisme permanent qu'on peut 
guérir par les procédés habituels. 
Mais cette règle souffre quelques exceptions. J'ai rencontré des malades chez les- 
quels une diplopie très gênante persistait, diplopie d'autant plus gênante que les images 
étaient très rapprochées et chez lesquels il n'y avait pas de strabisme pas de déviation 
apparente de l'œil. 
En pareille circonstauce l'emploi des prismes qui rapprochent les images et tendent 
à provoquer leur fusion nous sont d'un grand secours, mais ils ne réussissent pas tou- 
jours. J'ai eu alors l'idée de ramener l'équilibre en affaiblissant par la ténotomie 
partielle le muscle antagoniste du muscle parétique. J'ai obtenu plusieurs fois de 
cette façon des résultats complets. 
Sans modifier l'insertion du muscle je l'affaiblis progressivement de telle sorte que 
séance tenante en dosant, pour ainsi dire, peu à peu l'opération, amincissant le mus- 
cle de plus en plus, je diminue peu à peu l'écartement des images jusqu'à ce qu'elles 
soient entièrement fusionnées. Etaient-elles tout d'abord à 0.30 centimètre l'une de 
l'autre, je coupe quelque fibre tendineuse et aussitôt le malade n'accuse plus qu'un 
écartement de 0 millimètre, 15 centimètres, quelques fibres sont sectionnées encore et 
finalement la fusion est obtenue.* 
3. Enfin, j'aborderai en terminant la question la plus importante, celle de l'applica- 
tion de la ténotomie partielle à la guérison de l'insuffisance musculaire des droits 
internes et des troubles qui en sont la conséquence. 
Personne n'ignore combien est fréquente chez les myopes l'insuffisance des droits 
internes et quels sont les troubles fâcheux qu'en sont la conséquence. En première 
ligne nous signalons l'asthénopie musculaire qui rend tout travail de longue haleine 
impossible. Les lésions si fréquentes de la région maculaire dûes aussi en grande par- 
tie aux compressions exercées par le droit externe sur les éléments vasculaires et ner- 
veux de la région polaire postérieure pendant l'acte da la convergence. 
Pour remédier à cet état de chose on a recommandé l'emploi des prismes dans les 
cas légers, la ténotomie complète des droits externes. Mais les cas les plus nombreux 
sont précisément les cas intermédiaires ceux où les prismes ne réusissent plus, ceux où 
la ténotomie complète risque de provoquer du strabisme et de la diplopie. Il faut alors 
recourir à la ténotomie partielle qui donne des résultats excellents. 
La ténotomie partielle avec excision partielle du muscle se pratique absolument 
* Soit dit en passant ce rapprochement, cette fusion des images prouve que la ténotomie 
partielle combinée à l'excision d'une portion du muscle met a néant les objections de ceux qui 
prétendent que cette opération n'affaiblit pas le muscle. 732 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
comme la ténotomie complète. Le manuel opératoire reste le même jusqu'au moment 
où le tendon est chargé sur le crochet. Alors, au lieu de sectionner toutes les fibres ten- 
dineuses on en laisse quelques-unes médianes plus ou moins, suivant l'effet à produire. 
En outre on enlève obliquement avec les ciseaux les fibres musculaires dont l'insertion 
tendineuse à été détachée de façon à effiler, pour ainsi dire, les muscles le laissant 
intact vers son insertion orbitaire mais l'amincissant autant qu'on le désire vers son 
extrémité oculaire. 
Cette méthode opératoire qui permet de remédier à des troubles de motilité si déli- 
cats de globes oculaires nous parait susceptible d'être généralisée et étendue à la chi- 
rurgie générale. Jusqu'ici pour remédier aux difformités ou au troubles de la motilité 
musculaire, on a presque toujours pratiqué des sections tendineuses ou musculaires 
complètes et il est évident pourtant qu'il y a des degrés dans la difformité à laquelle on 
veut remédier. 
Mais avant la découverte de l'antisepsie on ne pouvait pas aborder à ciel ouvert les 
extrémités tendineuses situés dans le voisinage des articulations. On faisait des sec- 
tions sous cutanées un peu au hasard. Aujourd'hui ou pourra peut-être en procédant 
comme nous l'avons fait pour les muscles de l'œil mieux doser les opérations et obtenir 
de meilleurs résultats. La chirurgie oculaire aura eu ainsi l'heureux privilège de four- 
nir quelques indications utiles à la chirurgie générale. 
INSUFFICIENCY OR INEQUALITY OF POWER OF THE SUPERIOR 
OR INFERIOR RECTI MUSCLES AND A VERY SIMPLE 
AND EFFICIENT REMEDY. 
L'INSUFFISANCE OU L'INEGALITE DE PUISSANCE DES MUSCLES SUPERIEURS 
OU INFÉRIEURS DU RECTI ET UN REMEDE SIMPLE ET EFFICACE. 
INSUFFICIENZ ODER UNGLEICHHEIT DER KRAFT DER RECTI SUPERIORES ODER INFE- 
RIORES, UND EIN EINFACHES UND WIRKSAMES HEILMITTEL. 
BY EDWARD O. SHAKESPEARE, A. M., M. D., 
Of Philadelphia, Pa. 
I have found in my practice as an ophthalmic surgeon, that there is often an 
inequality of power, or want of proper balance, between the recti muscles of the two 
eyes. I have found that in cases of stubborn eye headaches, and other exceedingly 
annoying phenomena more or less closely connected with the eyes as the initial agent 
of the disturbance which have not been removed by attention to the focus of the eye 
and to the state of accommodation and condition of the external and internal recti 
muscles, there is often a want of equality and harmony of action of the superior recti, 
lu directing the patient to look at horizontal lines placed at a distance, and alternately 
covering one eye very quickly, there is in these cases a more or less sensible displacement 
vertically of the projected image of the lines, just as is obtained in a lateral direction by 
applying the same test for insufficiency of the internal or external recti muscles. If a 
weak prism, say of one or two degrees angle, is alternately and very quickly placed in 
front of the eyes, with the base down or up, while the patient is still fixedly regarding the 
horizontal distant lines, there is a displacement of the projected image which is greater SECTION XI-OPHTHALMOLOGY. 
733 
in the one eye than in the other. If, again, an attempt is made to gauge the strength 
of these muscles, by learning the strength of prism through which the displaced images 
can be fused, it is also found in these cases that the one superior rectus is stronger than 
the other, or, which is much the same thing practically, the difference is between the 
inferior opponents. 
Now, when we come to consider the small amount of vertical displacement which 
can be overcome by energetic contraction of even a vigorous superior rectus muscle, as 
compared with the great amount of lateral displacement which can be overcome by 
strong action of the internal recti, and remember what annoying and even serious 
trouble can arise, through the desperate efforts of abnormally weak muscles to prevent 
double vision in the case of insufficiency of the internal or external recti muscles, we 
should have no difficulty in understanding how a want of proper balance between the 
strength of the two superior recti or two inferior recti can cause serious trouble of a 
similar nature. 
I have been successfully remedying the disturbances due to an inequality of the 
strength of the pair of superior or inferior recti muscles, in a very simple manner, for 
the last three and a half years. 
If there is an error of refraction combined with this trouble, and I frequently find 
it so, I simply decentre the glass ordered for the refractive trouble, either up or down, 
as the case may require and as much as the circumstances may indicate, making use 
of the action of the decentred lens as a prism. 
In cases where there is no error of refraction, or any other necessity to use a lens, 
I order a prism, with the base up or down as the case may be. 
I have sometimes met with this trouble combined with insufficiency of the horizontal 
recti muscles, and have combined the remedies for each. 
z 
DISCUSSION. 
Prof. N. Manolescu.-Dans l'état actuel de nos connaissances sur le traite- 
ment des granuleux, tous ce qui aide à ces malheureux, mérite notre attention. 
La ténotomie du muscle droit supérieur, que je crois être le premier qui la pro- 
pose, est une intervention chirurgicale qui rend de grands services dans le plus grand 
nombre des cas de granulations conjonctivales. 
En effet, comme vous le savez très bien, le grand danger, dans cette maladie, est 
le pannus granuleux avec ses conséquences bien diverses, et que ce pannus est causé 
par le frottement de la cornée contre les granulations de la conjonctive du tarse 
supérieur. 
Eviter ce frottement, c'est éviter le pannus. La ténotomie du droit supérieur 
permet d'éviter ce frottement en grande partie par l'abaissement de quelques milli- 
mètres qu'éprouve la cornée à la suite de la ténotomie du droit supérieur. 
J'ai pratiqué cette opération au moins dans 25 cas et toujours j'ai enregistré une 
amélioration au bout de quelques jours seulement. 
J'ai enregistré les malades qui n'ont pas pu échapser à la récidive prochaine du 
pannus, qu'après leur avoir fait cette petite et innocente opération. 
Les résultats les plus éclatants de la ténotomie du droit supérieur se montrent 
surtout dans ces cas de granulations chroniques qui entretiennent un pannus épais 
dans toute la moitié supérieure de la cornée. 
Pour que cette opération donne de bons résultats et sans aucun trouble optique, 
il faut couper le muscle complètement et des deux côtés. 
Alors la diplopie n'apparait pas même dans la moitié supérieure du champ visuel. 734 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
L'examen soigneux des malades qui jouissaient après d'une bonne acuité visuelle 
m'en a donné la conviction. L'abaissement de la cornée ne constitue non plus une 
difformité. 
Mr. H. Power, of London.-I am old enough to remember the operation as it 
was left by Dieffenbach. The first operation for strabismus I ever saw was performed 
by Mr. Guthrie, who used a small curved knife, with which the conjunctiva was 
divided. After the eye had been everted with forceps, a grooved curved director 
was then passed beneath the tendon and a free division made of it. Good success 
often followed this simple proceeding. Of late, thanks to the continuous attention 
that has been directed to the subject by American, French, and German surgeons, 
great advances have been made. We all use atropine, determine the amount of 
hypermetropia, prescribe glasses, if required, find out if there be paralysis-and 
then operate. But I do not think gymnastic exercises of the ocular muscles are 
very generally practiced, in England, before the operation is undertaken, but I may 
be mistaken on this point. There is a certain class of cases in which, after the tendon 
is divided, inversion still remains. The operation is repeated, and still the strabismus 
is not cured. Is this due to the margins of the tendon being thickened ? 
Dr. E. 0. Shakespeare regretted that Dr. Abadie was not now present in the 
Section, for in listening to his most interesting remarks concerning his partial oper- 
ation in cases of insufficiency, or squint, in which the trouble is not greatly marked, 
by removing, little by little, some of the fibres of the over-strong muscle, a thought 
arose. 
It is, perhaps, the aim of all operative procedures for these troubles that the 
result be ultimately permanent. Now, it is a fact acquired by many observations, 
that, in general, or, at least, very frequently, when a small or even a large portion 
of the muscular fibres forming a muscle are excised, there is, sooner or later, a repro- 
duction of the lost fibres and a renewal of the original power of the muscle. 
This leads to the question which I had wished to ask of Dr. Abadie : How long 
do the beneficial results of this operation remain ? Are they permanent ? Perhaps 
Dr. Landolt, whom I see present, may be familiar with the final results of these 
operations, or, at least, with the experience of Dr. Abadie in this regard, and will 
kindly reply. 
Dr. White remarked that Dr. Landolt's paper was of value in especially calling 
attention to the great importance of careful examinations and prior treatment of 
cases of squint before attempting correction by operation-because he is aware that 
among American ophthalmic surgeons there is a great deal of careless tenotomy for 
squint without any close previous attention or investigation. 
He wished also to refer to the methods of muscular advancement and advance- 
ment of Tenon's capsule as means of correcting not only paralytic, but concomitant 
squint as well. 
He was indebted to Dr. Landolt three years ago for a renewal of his faith in 
muscular advancement, which had been sadly shattered by his failures in performing 
the operation. Since his adoption of Landolt's method he has had no bad results. 
He was not prepared to say whether advancement of the capsule or muscular 
advancement was preferable, as he had gotten exactly the same correction by the two 
operations, with perfect movement of the eyeball in every direction, but he does not 
do the advancement of the capsule as De Wecker does. In this way it gives only 
slight correction. Dr. White not only puts in the stitch above and below, through SECTION XI-OPHTHALMOLOGY. 
735 
capsule and conjunctiva, as far as the superior and inferior recti muscles, but also 
adds a third stitch through the overlapped muscle itself, which helps to set up 
adhesive inflammation, and in this way gets a much greater correction than by De 
Wecker's method. 
Dr. B. J. Baldwin, of Alabama.-I am glad that the question of age in the 
operation for squint has been referred to. I am convinced from my experience that 
amblyopia may sometimes be prevented by an early operation. Two years ago I 
believed with those who held that squint was congenital, but I do not think so to- 
day. 
The cases of alternating squint which we all meet with and in which binocular vision 
has been retained, cannnot be accounted for unless we admit it is due to active use. 
I have in my list two cases of alternating squint, one forty-six years of age and the 
other thirty-four. In both binocular vision has been preserved-in one case vision 
amounting to zu and in the other in each eye; of course there was manifest 
hypermetropia in both cases. How do we account for binocular vision in these 
cases if not due to their alternating character. 
Dr. Fulton closed the discussion of his paper thus :-Amblyopia, as met 
with in strabismus, may be either primary or secondary, but the secondary cases 
can all be prevented or cured by a timely operation. As to the proper time to oper- 
ate he said that it could not be settled by the age of the patient, but should be done 
just so soon as it was found that the strabismus could not be relieved by glasses and 
atropine, or by systematic exercise. 
Dr. Dudley S. Reynolds, of Louisville, said he had found the correction of 
squint one of the most responsible and, at the same time, difficult duties he had ever 
been called upon to perform. He had given much study to the subject and had 
written a great deal about it. He is convinced the sources of failure in attempts to cor- 
rect squint are numerous ; that they lie mainly in the difficulty of securing homonymous 
fixation. Certainly no operation can possibly succeed where the optical properties of 
the eyes cannot be made the basis of the correction. He feels satisfied tenotomy is 
often done where a complete optical correction might be had with a decentred lens, or 
by the use of prisms. He thinks Prof. Landolt is entirely correct in the statement, 
the orthopædic exercise of the muscles should, in general, precede any operative inter- 
ference. He thinks, in many cases, great discrimination is required of the surgeon, 
as to whether advancement of a weak muscle or tenotomy of the apparently con- 
tracted muscle shall be done. In persons under twenty years of age he often suc- 
ceeds, where perception of light exists in one eye only, in developing considerable 
increase in the power of perception, often sufficient to enable the person to count 
fingers and, in some instances, to read large type. This, of course, should always 
be tried before any operation on the muscles. If the amblyopia can be reduced or 
overcome by strong concentration of light in the retina, the eye should be exercised 
in this way until fixation is possible. Then the correction of the muscular defect is 
comparatively easy. 
Dr. G. T. Stevens.-It is my purpose to refer to the paper of Prof. Landolt, read 
this morning, and to his remarks this afternoon, mainly because he has gone over very 
important ground in which I am especially interested. With the clearness and direct- 
ness of purpose so characteristic of the distinguished speaker, he called our attention, 
this morning, to two grand principles in the subject of strabismus. The first is that 
the great end to be aimed at in strabismus operations is binocular vision ; and second, 
in order to attain to such a result we are not to sacrifice the usefulness of a muscle 736 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
essential to binocular vision, in order to obtain an apparently satisfactory result. 
So long as the operation for strabismus was performed only with respect to the cos- 
metic effect, when the surgeon cut the tendon sufficiently to satisfy the taste of fond 
parents, it mattered little how the end was attained, so long as the parties to the 
transaction were pleased. Now that we aim at a more perfect and useful result, our 
methods must be proportionately more exact. 
We cannot hope to obtain exact results until we know what we are to do. It will 
no longer answer to place a graduated scale upon the eyelid and measure our devia- 
Fig. 1. 
A, B, Cand C" are respectively the supports for the instrument and the chin rest. D, a connecting bar 
maintaining the requisite distance between the chin rest F, and fixation point T. Band E', binding 
screws to adjust height of instrument. G, the sliding arc moved by a rack and pinion O and I. H, the 
carrier, a little brass box into which white or colored papers or the attachment for the measurement 
of deviations of visual lines may be readily slipped. H', a small tongue of brass connected with the 
carrier, and serving as a stop in measuring the diplopia of strabismus. K, a wooden frame containing 
the chart. This frame is attached to support A by a hinge, allowing the chart to be pricked by the 
stylos L, which receives its motion from the arc through the gearing R. M is a clamp screw, to hold 
the arc in any desired meridian. 
tion in lines. We must know the deviation in degrees, and we must determine the 
power of all the muscles involved in the deviation. This done, we have a reasonable 
basis for our procedure. 
Prof Landolt has done well in calling the attention of the profession to the 
necessity of preserving the function of the tenotomized muscle. If we have a case 
of considerable converging strabismus, there exists not only a contraction of the 
internus, but an elongation and relaxation of the externus. If, now, by a very free 
tenotomy of the internus, we succeed in releasing the eye to the extent of being SECTION XI OPHTHALMOLOGY. 
737 
apparently in its proper relation to the other, we have two weakened muscles ; the 
externus, already weak before the operation, and the internus, weakened by the 
setting back. We cannot hope that an eye with such muscles can adjust itself in 
binocular vision with its fellow. We have, by the operation, destroyed all hope of 
Fig. 2. 
?he double images of a candle. As the tongue, H', approaches in front of the image a, it stops 
out the flame, when the chart is pricked by the stylos, marking the position of the stop when the first 
image is encountered. In the same manner, as the tongue encounters the second image, b, its position 
is recorded. 
equilibrium in the action of the muscles of the two eyes. If, on the other hand, a 
moderate tenotomy of the contracted muscle is made, and if the relaxed muscle is 
moderately advanced, we maintain the physiological action of both, and the balance 
of energy between the eyes is maintained. A distinguished delegate has called our 
Fig. 3. 
The chart of the perimeter, showing the two points, a and b, indicating the degree and direction 
of separation of the two images of the candle; in this instance about 15° and in a horizontal 
direction. 
attention to a class of cases in which he finds difficulty in effecting a cure of strabis- 
mus by strabotomy, and inquires what is to be done. It appears to me that the 
answer is found in the precept that we must, in such cases, advance the externus at 
the time that we set back the internus. 
Vol. Ill-47 738 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Permit me, now, to add a few words in relation to Prof. Landolt's very interesting 
remarks upon his method of determining the degree of diplopia in strabismus. 
Since the first publication of this method, several years since, it has been of interest 
to all of us who have cared to perform our work in this department with precision. 
But if two observers are aiming toward a common object, they may reach the goal 
by somewhat different routes. I have been accustomed to make these determinations 
in a somewhat different manner, and I take the liberty of presenting it to you as 
another, but not necessarily a better, method than that presented by our friend. 
At the International Medical Congress at London, and before that, at a meeting 
of the American Medical Association, I had the honor to exhibit a registering peri- 
meter, an instrument which has been several times invented since that time ; the 
principal modification from the original being in the name of the inventor. 
To the movable arc of the perimeter I affix a stop sufficiently large to cover the 
flame of a candle situated at a distance of twenty feet. (Fig. 1, p. 736.) The 
patient, having his chin in the rest, looks across the arc and at the candle, which he 
sees double. (See Fig. 2, p. 737.) The stop is now moved in such a manner as to 
cover one of the images, and a registration x>f this position is made upon the peri- 
meter chart. The stop is then carried along until it covers the other image, when 
the registration is again made, as shown in Fig. 3. This method is extremely simple 
and easy, and the registration can be transferred at once to the case book. 
Dr. Landolt then demonstrated on the blackboard his method of estimating the 
degree of squint by supposing the patient to occupy the centre of a circle, and the 
surface of the wall to be divided into radiary lines running from a common point 
(the object looked at) at 45°. The patient sees the central point in its proper place, 
and at an angle of so many degrees in any direction within a radius of 45°, according 
to the squint. The method was explained not long since in the Archives d'Ophthal- 
mologie. 
THE VISUAL AXIS. 
L'AXE VISUEL. 
DIE SEHAXE. 
BY ALBERT G. HEYL, M.D., 
Of Philadelphia. 
It is proposed in this paper to define with some precision what the visual axis is. 
This will be done, not after the laboratory method, by measuring angles or locating 
points, etc., but the endeavor will be rather to develop the idea that the visual axis is a 
physiological reality, and not a mathematical fiction. The subject is of great practical 
importance. There can be no doubt but that in the treatment and etiology of cases 
embraced under the term Anomalies of Refraction and Accommodation, attention has 
been directed too exclusively to the eye as a focusing apparatus; this has been well so 
far as it goes, but it does not go far enough. The eye is not a mere mechanical appa- 
ratus, it is a living organ, and the true solution of many difficult and puzzling cases of 
asthenopia will only be found when clearer conceptions as regards vital, in distinction 
from mechanical, functions are evolved. SECTION XI-OPHTHALMOLOGY. 
739 
It will be well to glance at certain definitions which occur in works on physiological 
optics in connection with the visual axis. 
1. The Gesichtslinie, or visual axis proper. This is defined as a line passing through 
the nodal points and striking the macula lutea. A brief explanation may make this 
somewhat clearer. It has been found convenient in studying the properties of lenses 
to establish certain cardinal points, as they are called, which depend for their position 
on the curves, refraction indices, etc., of the lenses. One set of these is known as the 
nodal points, and possess the following property: If a ray of light strike a lens in 
the direction of one nodal point, it will emerge from the lens as if it came from the 
other nodal point, and the emerging ray will be parallel to the incident ray. If a dia- 
gram be made showing this relation, it will be readily seen that if the two points were 
caused to approach each other until they coincided, then there would be one single 
nodal point and the ray of light would pass through it and undergo no deflection. It 
simplifies matters to consider such a fusion to have taken place, and it often can be 
done without making any practical difference. Now the eye possesses a lens apparatus, 
and therefore nodal points. Considering these nodal points to be fused together into 
one, we can say that rays of light striking the cornea so as to pass through the nodal 
point will undergo no deflection, but right on to the retina. The particular ray 
which, passing through the nodal point, strikes the macula, will, according to the above 
definition, coincide with the visual axis. Now, were the eye simply a mechanical 
apparatus, like a camera obscura, the definition would be correct; but the complex 
physiological requirements of the eye are not satisfied by it. 
2. The Blicklinie. The eye being more or less spherical in shape, rotates about 
a point within, named the rotation centre of the eye. If a line be drawn from any 
point in space at which we are looking, to the rotation centre, it will constitute the 
Blicklinie. It is not identical with the Gesichtslinie already described. Now here we 
have another mechanical definition. It would be quite correct to draw or conceive of 
such a line were we studying the movements of a rounded body, destitute of life, 
with reference to points in space, but in so doing we do not rise to the level of 
physiological processes. 
3. The Visirlinie, or collimating axis. This axis is made use of when two points 
in space, one more distant than the other, are brought in the same line with each other 
and the macula, i. e., the two points and the macula lie on the same line, and this line 
is the collimating axis. It seems to me that it is also the same axis which is made use 
of when we look sharply at any object. Now, if we study the mental processes associ- 
ated with the use of this axis it will be found to be a function essentially of monocular 
vision ; even if both eyes be open when this axis is being used, it will be found that 
one eye is essentially sighting the points in space, etc. We have here a physiological 
reality, and the conception of the collimating axis is therefore one which will retain a 
position in physiological optics. Its peculiarities are that it is a function of monocular 
vision, that it is associated with conscious exercise of will. 
4. There is one more conception to be mentioned. When one is walking along the 
street, with the mind absorbed in thought, the macula of each eye is pointing at one 
point in space. In this there is no conscious exercise of will, and yet the maculæ are 
each directed to the given point. A line drawn from this point to the macula will give 
what I conceive to be the initial position of the visual axis. Notice, (a) that we are 
not dealing in this case with a mathematical fiction, but with an innate mental concep- 
tion. The collimating axis is likewise a mental conception; just as surely as I know in 
my own consciousness that I am pointing my finger in a given direction, so do I know 
when I point my macula in a given direction. One great point of distinction between 
the mental processes involved in these conceptions is this: The collimating axis is a 
conception which lies high up in consciousness, while the visual axis lies low down in 740 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
consciousness. The distinction may be thus illustrated. There is in the consciousness 
of every human being a fundamental conception of a median plane which divides the 
body into two lateral halves and extends indefinitely out into space; very likely this 
conception is developed from the symmetrical positions of the double portions of the 
body. This median plane has to do with our ideas of about the relative position of 
things in space, e. g., the ideas of right and left. Now, this innate conception of a 
median plane is one which does not easily suggest itself to the mind ; we have to study, 
and observe somewhat closely the operations of the mind to find it; in other words, it 
lies low down in consciousness. So is it with the mental conception which constitutes 
the visual axis, while the collimating axis is a conception much more easily thought 
about and studied, and therefore lies high up in consciousness. (&) The visual axis is 
a function of binocular single vision. Whenever in the process of vision the impressions 
of each retina are mentally conceived of as single, although each retina receives its own 
individual impression, we have the phenomenon of binocular single vision. This pro- 
cess I believe to be distinct from that of sharply fixing an object, although it is often 
associated with it. In this sharp fixation it is the collimating axis which is made use 
of even when both eyes are open, and there is brought into existence what has been 
described as the prevailing or dominating eye. It is, so far as the sharp fixation goes, 
a monocular process. The visual axis is brought into play in the process of convergence, 
as in writing, reading, etc. It involves the binocular use of the eyes at the same time, 
and always stands, in consciousness, in relation with the median plane. The two visual 
axes are therefore always to be considered as inseparably connected together, just as 
the two eyes may be looked upon as parts of one single organ. 
(c) It will be seen from this that the nodal points do not come into consideration in 
the above conception of the visual axis. The truth seems to be that it is not the nodal 
points which determine the axis, but it is the axis which determines the nodal points. 
The anatomical point which has essentially to do with the position of the visual axis is 
the macula lutea; considered simply as a point, without reference to mental processes, 
it would be insufficient to determine the position of a line or axis. The other deter- 
mining quantity is the angle made by the visual axis with the median plane. This 
may be called the axial angle. I believe that this angle is defined by mental processes 
set in operation as the result of the peculiar position of the macula in the retina, so 
that after all, from the physiological standpoint, the position of the macula does define 
the position of the visual axis. From all this the visual axis then may be defined as a 
mental conception, low down in consciousness, which may be diagram matically repre- 
sented by a line extending from the macula lutea to a point on the median plane and 
forming a certain angle with it termed the axial angle. It is a function of binocular 
single vision, and its initial position is determined when the muscles of the eye are in 
what is ordinarily described as a state of rest, i. e., not being acted on by the will. A 
curious coincidence may be noted here between the initial position of the axis and the 
state of rest of the muscles. How is this brought about ? What is the meaning of the 
muscles being in a state of rest ? These questions bring us face to face with a great 
many obscure problems, e. g., the physiology of muscle, the development of the macula 
lutea, etc. 
The method of formation of the macula lutea is unknown. Von Baer and Huschke 
started the idea that the macula is a remnant of the fœtal cleft, and this, in lieu of a 
better explanation, has been looked upon by embryologists as probable. As Kölliker 
has shown, however, a great difficulty which confronts this explanation is, that while 
the macula lies to the outer side of the disc, the fœtal cleft lies downward and inward. 
Vossius (1883), in some studies on the optic nerve, has arrived at the conclusion that 
the optic nerve undergoes a rotation in position during gestation sufficient to overcome 
this objection. By this rotation the point of entrance of the central muscles of the SECTION XI-OPHTHALMOLOGY. 
741 
retina into the optic nerve sheath comes to lie in the outer lower quadrant instead of 
the inner lower quadrant of the cross section of the optic nerve. Therefore, so reasons 
the author, a rotation of about 90° has taken place in the fœtal cleft toward the macu- 
lar region. Even if this be granted, however, it does not explain or account for the 
wonderful precision with w'hich the macula is located and formed. I believe that there 
is an explanation which can dispense, if need be, with the fœtal cleft, and which 
accounts for the location and also for the coincidence between the state of rest of 
the external ocular muscles and the initial position of the axis as already defined. The 
explanation, then, which I have to offer is that the macula is not formed because of any 
inherent peculiarity in the embryonic retina, but that it is the result of intraocular 
pressure which, in the formation of the eye, after the closure of the fœtal cleft, so 
presses on the tissue which is to constitute the retina that the inner layers split, leav- 
ing the layer of cones exposed ; that this pressure is perpendicular to the tangent at 
the macula; that the position of the macula in relation to the corneal axis is due 
to the antagonisms between the external muscles of the ball. 
The principle underlying this explanation may be thus illustrated : Take a circular 
piece of rubber cloth of given diameter; at every point of the circumference let an equal 
force be applied, the line of force being perpendicular to the tangent of the point at 
which it is applied. The rubber will stretch in all directions, one point alone remain- 
ing stationary and in equilibrium. This will be the centre, and if the tension be suffi- 
cient a rupture will take place at this point. Suppose in place of the rubber we have 
the embryonic tissue of the retina subjected to a similar tension. Then we can under- 
stand how, at the central point, the vitality of the tissue would suffer, the blood supply 
to it diminish and a defect arise. Such, roughly stated, is the theory. Let us examine 
a little more thoroughly the details of the process. It will be necessary to briefly 
allude to several preliminary points:- 
1. The recti oculi muscles may be divided into two sets: (a) Those supplied by the 
third nerve, (b) The rectus externus, supplied by the abducens. These two sets are 
antagonistic, so that not only is the externus opposed by the internus, but also, in a 
measure, by the superior and inferior, by virtue of their power to rotate the eye 
inward. The consequence is that the externus, in order to maintain equilibrium, has 
to exert a greater force than it otherwise would. 
2. Its muscle is not simply to be looked on as a contractile band, but a living 
structure attached to the organ, which it is to move by a tendon which is endowed with 
reflex sensibility. A familiar illustration of this is the knee reflex. Here a blow upon 
a tendon causes the muscle to contract, and I think the conclusion, if the matter be 
studied, will be that there is an unconscious contractility set up in all muscles through 
the agency of their tendons. 
3. Applying this to the eye, we may say that as the recti muscles are formed, a degree 
of unconscious tension is set up in them corresponding to the reflex demand of their 
tendons. Suppose the eye, in its process of formation, is converged, by reason of the 
embryonic state of the externus. As the latter, however, develops through its tendon, 
contractility is set up in it until the antagonism set up by the third nerve muscles 
resists further shortening of the externus. Thus, equilibrium between the recti is 
established, and such are the relations of the parts that the eye assumes the proper 
position in the orbit. This is altogether a reflex and unconscious act. Nor is this all. 
Within the eye is the ciliary muscle, and between it and the recti an antagonism exists. 
As equilibrium is established between the two sets of recti muscles, so, also, is there 
an equilibrium between the total pull of the recti and the ciliary muscle. Precisely 
how this happens need not be elaborated at this time. It may be through the pull of 
the recti tendons on the scleral region anterior to their insertion, or it may be through 
the effect induced on the intraocular tension by the contraction of the recti. 742 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
4. What is the effect of all this ? We have the third nerve recti muscles antagonized 
by the single externus muscle ; this will result in the sclera being pulled on by the 
externus tendon to a greater extent than by the third nerve tendons, and, as a conse- 
quence, the scleral region posterior to the externus tendon will be the most yielding 
part of the sclera to the iutra-ocular tension, and in the processes of growth and 
shaping of the ball there will be special tendency to bulge in this region. More than 
this. The total pull of the recti developed in establishing the position of the ball in 
the socket starts up antagonistic contraction of the ciliary muscle. Through this the 
sclero-corneal foramen would be drawn toward the corneal axis, i. e., its diameter will 
be shortened, the choroid stretched, and the ciliary processes advanced. At the same 
time, the vitreous tension is being developed, the principal element, perhaps, being the 
tension of the anterior chamber. The result of all of this is that while the embryonic 
structure which is to constitute the retina is drawn by the ciliary muscle around the 
vitreous, a pressure within the vitreous is tending to stretch it in every direction. 
It will, perhaps, make this rationale clearer if we glance at the mechanical princi- 
ples involved. The problem is essentially to ascertain the effect of pressure from within 
on the casing of a body. 
Let a c b be a section of a sphere filled with water, having an 
opening at a b of a given area. Suppose at a b pressure is made 
on the water in the sphere, through the opening a b. The effect 
will be that each unit of surface of the sphere will be pressed on by 
the same amount of pressure. Suppose the casing of the sphere to 
be extensible to the same extent in all directions: increase the ten- 
sion to an extent sufficient to enlarge the sphere; the spherical 
shape will be preserved if every point of the spherical case be 
equally free to move outward from the centre. Suppose, however, a and b are fixed 
points. Then, if sufficient force be applied, the spherical form will be lost, a sphenoid 
will take its place, the long axis being transverse and the short axis running antero- 
posteriorly through c. Suppose the point a and b, instead of being rigid, are acted on 
by equal forces tending to bring them closer together. The effect on the point c would 
be essentially the same, i. e., it would still be the point in equilibrium in the line a c b. 
Now, suppose that the casing, a c b, instead of being the same in thickness at every 
point, is thinner in the half a c. If, now, the same forces be again applied, the point 
of equilibrium will no longer be in c, but will be moved toward a. Let h be the 
point. Suppose, in the above cases, the forces be so applied as to cause a slight rup- 
ture in a c b. This rupture will take place at the point of equilibrium. Let us now 
apply this to the formation of the macula. Let us suppose a time in the embryonic 
development of the eye when the vitreous exists, enclosed by the tissue not yet fully 
differentiated into the hyaloid membrane and retina ; the ciliary muscle is developed, 
and also the aqueous humor. We have the anterior tension exerted through the 
anterior scleral foramen ; we have the ciliary muscle contracting and drawing what will 
be later, or what already is, the ciliary processes forward, and thus tightening the 
hyaloid and retina. The effect of this is obvious. The point corresponding to c in the 
diagram is pushed back, and thus the antero-posterior axis is formed. There is an 
important principle in this as regards the relation between the sub-tension, the con- 
traction of the ciliary muscle, and the length of the antero-posterior axis of the ball. 
Let us, however, keep to the subject before us. Were this process of extension to take 
place evenly in a casing with the posterior end of the antero-posterior axis as the point 
of equilibrium, the macula would be on this axis, but the conditions are not so. As has 
already been shown, the ball is more free to spread in the external half, owing to the 
greater force exerted on the sclera by the externus in its antagonism to the third nerve 
recti muscles, and hence the macula is shifted to the external side of the point which 743 
SECTION XI-OPHTHALMOLOGY. 
it would otherwise occupy, and the greater the contraction of the externus, other things 
being equal, the greater the eccentricity of the point of equilibrium, i. e., the further 
to the external side of the point pressed by the antero-posterior axis. 
One or two questions may arise here :- 
1. Granting all this, is there any proof that such a point of equilibrium would lose 
its vitality and become converted into an opening? In answer to this, we have, I 
think, the conus as an illustration of what intra-ocular traction and tension can do. 
Here we have lessened vitality in the choroid adjoining the disc, with gradual disap- 
pearance of the elements. There is another thing to be remembered in this connection, 
and that is, the lower the vitality of the cells in any part of the body, the fewer the 
blood vessels in it ; the reason the cornea is ordinarily destitute of vessels is because 
the vitality of its cells is low. Stimulate these cells, as by hot water, and blood 
vessels begin to form. The process, then, by which the macula is formed is that, by 
virtue of its being the point of equilibrium in the embryonic tissue enclosing the 
vitreous, its cells become less vitalized, the blood vessels belonging to it shrivel and 
disappear, and, finally, a slight rupture takes place, and the macula is formed. 
2. Why is there not an opening through the whole thickness of the retina, and not 
merely through a part of it ? This cannot be answered until the connection between 
the different elements of the retina is better understood. Embryology shows this 
much, that the cones are among the earliest formed retinal elements, and, possibly, at 
the time of formation of the macula, they are already too strongly developed to be 
affected by the tension and pressure. 
We have thus set before us the mechanical processes concerned in the develop- 
ment of the macula and of the visual axis. But this axis is not simply a mechanical 
production. Were it so, the axis would coincide with the line of intra-ocular force 
exerted at the macula, and this would be represented by a line drawn perpendicular 
to the tangent at the macula. The visual axis, although in part depending on mechan- 
ical causes, is essentially a mental conception. A fundamental mental conception in 
every human being, as has already been shown, is that of a median plane dividing the 
body into two lateral halves. Through this conception of a median plane we get cer- 
tain ideas of our relation to things in space. The visual axis is a mental conception, just 
as the median plane is, and stands, doubtless, in some relation to it. This relation, I 
think, is dependent on the degree of eccentricity of the macula as regards the antero- 
posterior axis. Were the macula at the point pierced by the posterior pole the visual 
axis would be perverted to the median plane. As soon as eccentricity of the macula 
begins to the external side we begin to have an angle formed with the median line, and 
the greater the eccentricity the greater the angle, other things being equal. This pro- 
cess is, I believe, associated with the perception, but not the projection of light. 
Now, conceive of an eye at the moment of its exposure for the first time to the influ- 
ence of light. We have before us an organ in which the macula is pointing in a given 
direction corresponding to the equilibrium already established between the two sets of 
recti muscles. Ether undulations stream against the organ from the outer world ; the 
first effect will be that upon the sclero-corneal epithelium, which I look upon as a 
structure intimately associated with the process of sight.* The result of this will be to 
give a set to the ball, or, to express it in another way, the muscles of the ball will grip 
it more firmly ; this is an unconscious reflex process. More than this, ether undula- 
* Vide, "A Form of Epithelial Mycosis," Albert G. Heyl, M.D., Transactions Medical Society, 
State of Pennsylvania, 1884. Also, "Purulent Ophthalmia and its Treatment by Hot Water." 
Archives of Ophthalmology, English edition, Vol. xv, No. 3, 1886. G. P. Putnam's Sons, New 
York. 744 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tions stream into the eye, striking the percipient elements of the retina, and starting in 
the consciousness the sensation which we call light. One spot in the retina will be 
affected to a peculiar degree, viz. : the macula, and the sensation thus developed will be 
located by reference to the median plane, and will constitute the visual axis. The 
train of phenomena will, perhaps, be better followed by reference to what occurs in 
another organ, viz. : the leg. When we are lying down the muscles of the leg and foot 
are said to be at rest. This cannot indicate that they are perfectly flaccid ; there is, 
beyond reasonable doubt, a species of involuntary tension of the tendons. This corre- 
sponds to the equilibrium established between the recti muscles before the eyes are 
exposed to light. Now, let the individual stand on his feet ; instantly a state of 
rigidity is set up in the muscle through the agency of a reflex from the soles of the feet. 
This corresponds to the reflex of the sclero-corneal epithelium, giving a set to the recti 
muscles. The perception of heat through the proper terminal perceptive elements of 
the skin and of light through the retina are to be classified together, but the macula 
seems to have no analogue in the skin, being peculiar to the eye. 
I wish, in conclusion, to direct attention to the phenomenon of fusion, which is inti- 
mately related to the visual axes. Fusion may be defined as an involuntary process by 
virtue of which the axis of each eye tends to intersect at the same point in space at the 
same moment. 
Physiologically it is an involuntary process and takes precedence, in point of time, of 
voluntary binocular vision. That is to say, in a normal condition fusion must take place 
before conscious binocular vision. Hence, in cases of difficult vision (the reference is 
not to defective vision from structural lesions, but to functional disorders) it by no 
means follows that the root of the trouble is a focusing defect-it may be simply a 
defect of fusion. 
Space may be considered as being made of an infinite series of lamellae, curved, con- 
centric, applied closely to one another. Some of these will be more distinct than 
others; and we have presented in connection with this the idea of depth, which does 
not specially concern us at present. Select a given lamella in front of us. It will be 
intersected by the median plane of the body in a vertical line. Conceive of a plane at 
right angles to this median plane and coinciding with the plane passing through the 
origins and insertions of the recti intemi and externi (it is supposed that these recti 
planes are on the same level). The intersection of this plane in the space lamella will 
be a horizontal line. Now, both of these planes, the horizontal and the vertical, are, 
I believe, innate mental conceptions, not diagrammatic fictions. Suppose the lamella 
chosen at a distance at which the initial position of the axis pierces the median plane. 
Then two distinct phenomena are to be noted; one relates to the division of the lamella 
made by the horizontal plane. This has to do with indirect vision, involving the retinal 
surface in its general extension. It probably is not essentially connected with the lens 
apparatus of the eye. The point in connection with it to be specially noted is that the 
plane must be horizontal and include the horizontal recti planes of both eyes. If the 
horizontal plane of one eye lie below the other, or inclined to each other, then difficulty 
in fusion may arise. It is to this category that the cases belong in which the patient 
walks with his head inclined to the shoulder, and some cases of this kind, at least in 
my experience, can be met by oblique prisms, base up before one eye, base down before 
the other, the axes being parallel. This phenomenon of binocular retinal fusion does 
not seem to be connected with voluntary vision, and I suppose exists in creatures below 
man. 
Distinct from this retinal fusion is the axial fusion. Conceive of a plane passing 
through the axis in its initial position. It will intersect the median plane in a vertical 
line, which practically may be considered to be identical with the intersection of the SECTION XI-OPHTHALMOLOGY. 
745 
space lamella already referred to by the median plane. The axial plane must be per- 
pendicular to the horizontal plane, otherwise it would not intersect the median plane 
in a vertical line. The axial plane is diagrammatic, not psychological, as I believe the 
median and horizontal plane to be, and simply is a help in our conception of the axis. 
The angle made by the initial position of the axis is the axial angle, and the abnor- 
malities in the size of this angle lead to the axial anomalies proper. Sometimes the 
angles are too large, and the necessity occurs for the use of adducting prisms. Some- 
times the angles are too small, and then abducting prisms are indicated. The whole 
clinical course of these cases, the relation of abnormalities of the axial angles to the refrac- 
tion, need to be studied and arranged so as to be available for use in the daily routine of 
practice. One thing more can only be added here, and that is with reference to the 
muscles of the ball in reference to these fusion phenomena. Retinal fusion requires that 
the horizontal recti planes coincide, and this coincidence must be preserved. This is done 
through the agency of the superior oblique. To briefly explain this : From the 
physiological standpoint I believe that three sets of voluntary muscles attached to the 
ball exist, one supplied by the motor oculi or third nerve, composed of the recti and the 
inferior oblique. These muscles in their unconscious reflex tendon contraction take the 
initiatory in determining the position of the ball. Opposed to these muscles are two 
others. One, the superior oblique, supplied by the fourth nerve, which is the special 
antagonist of the inferior oblique. The initiatory action of the inferior may be supposed 
to have taken place, disturbing the horizontality of the horizontal plane. Now the 
superior oblique begins to act, involuntarily by its tendon reflex, let it be understood, 
until the horizontality is restored. It will be seen from this that it is the superior, not 
the inferior oblique which is the regulator of the horizontal plane. As this is an 
unconscious process, and not voluntary, it may be asked, How is it that the superior 
performs this function ? It may be because it is relatively the weaker muscle, by reason 
of its line of traction being altered by its tendon bending around its pulley. The ini- 
tiatory would then be made by the stronger muscle. It may be that there are cases of 
abnormality in the horizontal plane due to too great or too little action of the superior 
oblique, and it may be that cases which I have observed in which the image of one eye 
is projected behind the other find their explanation in such an abnormality. 
The other muscle which stands in antagonism to the third nerve muscle set is the 
extemus. This has been alluded to in the earlier part of the paper. It remains only to 
say, that in this case, as in the preceding, it is the stronger set which take on the 
initiatory in determining the position of the ball in the socket, while the weaker 
muscle-the externus-contracts until the equilibrium is established and the macula 
formed. 
DISCUSSION. 
Dr. Ole Bull, of Christiania, Norway.-I should like to know how Dr. Heyl 
would explain the existence of two maculae. As we all know, many birds, which have 
but a restricted field of binocular vision, have two maculae. 
Dr. Heyl said it would be difficult to answer. 
Prof. Keyser, of Philadelphia, remarked that he has been very much interested 
in and instructed by the excellent paper of Dr. Heyl, and, in illustration of one of 
the abnormities of the visual axis and its correction by prisms, related the following 
case: In May last a physician from the interior of the State of Pennsylvania brought 
to him a young man, 28 years of age, for examination in relation to a peculiar 
diplopia. The man said that from a little child he never could see like other persons; 
that he always saw two objects, one diagonally above the other, and he was obliged 746 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to shut one eye to see and distinguish anything near or far. In this way he went 
through school. On careful examination all the muscles of both eyes were found in 
perfect action, but there was persistent diagonal diplopia of 60°. Vision either 
eye f and no specially perceptible astigmatism. The diplopia was completely 
corrected by holding a prism of 10° at an angle of 60°, base downward. He 
was given a pair of prisms of 5°, with the bases in opposite direction, which made 
the corrrection, and with which he reads and works without any difficulty with both 
eyes open. SECTION XI-OPHTHALMOLOGY. 
747 
FOURTH DAY. 
ON THE CURABILITY OF THE DETACHMENT OF THE RETINA 
AND ITS TREATMENT BY ASPIRATION OF THE FLUID 
UNDER THE RETINA. 
SUR LA CURABILITE DU DÉTACHEMENT DE LA RETINE ET SON TRAITEMENT 
PAR L'ASPIRATION DU FLUIDE SOUS LA RETINE. 
ÜBER DIE HEILBARKEIT DER NETZHAUTABHEBUNG UND IHRE BEHANDLUNG DURCH 
ASPIRATION DER FLÜSSIGKEIT UNTER DER RETINA. 
BY DR. GALEZOWSKI. 
Notwithstanding the progress made in the pathological anatomy of the eye, the 
actual acquaintances upon the pathogenia of the detachment of the retina are still very 
few ; we have no certain knowledge of its etiology, nor about the manner it produces 
itself. 
There is a positive fact, that the detachment of the retina, in the greatest majority 
of cases, is with myopia, but it can be found also in hypermetropic and emme- 
tropic eyes, as I have mentioned in the statistics which I published on the subject in 
the year 1883, {Recueil d' Ophthalmologie, 1883, page 701). At that date, on 649 detach- 
ments observed at my dispensary, I found 51 hypermétropies or emmetropics, there- 
fore, I repeat that myopia is not the only piedisposing cause of the illness, but is 
surely one of its principal agents. Sometimes the illness breaks out suddenly, without 
any provocation. Sometimes, also, it is the consequence of traumatism, of a blow 
on the eyeball or on the head, of a contusion in the neck region, of a general com- 
motion of the organism, produced by a fall. 
In regard to the ophthalmoscopic alterations, there are a great many sorts, relatively 
to the atrophie choroidea, or posterior staphyloma, and to the place it occupies, but 
there are also cases in which there are no appreciable alterations of the choroid. 
Leber's opinion was that all the detachments of the retina are sometimes preceded 
by a rupture of the retina, easily perceived with the ophthalmoscope, and he makes 
conclusion that the fluid sub-retinian is just the same as that formed in the fluid corpus 
vitreum, which introduced itself between the retina and the choroid. I am on this 
question of a different opinion, and believe that the laceration of the retina is far from 
being a general fact of the detachment. In my statistics established in 1883, on 649 
cases, I have only observed 31 lacerations of the retina. 
I have seldom regarded this class of diseases among constitutional illnesses. So, I 
have met it once in an albuminuric patient who I examined with Dr. Noël Gueneau de 
Mussy, and a second time in a man who suffered with neuro-retinitis albuminuria, and 
■whom I saw with Professor Peter, but these are exceptional cases. 
Syphilis constitutes also a cause, relatively rare, of these diseases; I have seen it but 
13 times. Sometimes also, there is a sympathetic cause. 
If I complete my statistic with the cases I have observed since that epoch until now, 
I find the following numbers :- NINTH INTERNATIONAL MEDICAL CONGRESS. 
748 
On 124,000 new patients treated at my clinic since 1867, and 28.000 patients I have 
examined in my own house (total 152,000 patients), I have constated : - 
Detachment of the retina 784 (532 men, 252 women. ) 
Both eyes affected 57 
Emmetropia and hypermetropia 63 
Caused by wounds or traumatism 194 
Sequel of cataract extraction 13 
Syphilis 18 
Sympathetic affection 4 
Tumor of the interior of the eye 10 
A most important fact, upon which permit me, Gentlemen, to direct your attention, 
is that myopia is the most frequent cause of the detachment of the retina. But the 
vitreous liquid is liquefied before the detachment ; that iritis and irido-cyclitis invaria- 
bly make their appearance during a well-known period of the illness, and that those 
two last affections cause, at a certain moment, a cataract and the atrophy of the eye- 
ball. 
If now I pursue this idea, and seek to solve the question of the possible curability 
of the disease, I find myself face to face with the opinion shared up to the present by 
the majority of practitioners, that the detached retina cannot resume its functions. I 
had held this opinion for a long while, when I was struck by a very curious fact. I 
have found two patients with the same kind of lesions. In the infero-external region 
of the retina I found, as it were, folds of the detached retina, with scotoma in the cor- 
responding visual field. Both patients had stated that they had lost vision of one eye 
for some time, that vision had afterward returned, to a great extent. There had 
undoubtedly been detachment of the retina cured spontaneously. 
These facts led me to hope for obtaining a cure of detachment of the retina. I 
have resorted to the antiphlogistic treatment, to horizontal position, to iridectomy, to 
posterior sclerotomy with suture, and finally to aspiration of the sub-retinal liquid by 
an operative procedure, which I desire to bring to your notice to day. 
I have by these different methods obtained 15 cures. 
Antiphlogistic treatment in connection with horizontal position, 7. 
Antisyphilitic treatment, 3. 
Treatment by aspiration without suture, 2 in 19. 
Treatment by aspiration with suture, 2 in 6. 
Treatment by posterior sclerotomy, 1 in 4. 
Iridectomy has not afforded me any cures, but it has permitted me to arrest the 
inflammatory accidents on the part of the iris and choroid. 
I aspirated by means of a small aspirating syringe, which I had made by M. Collin, 
surgical instrument maker, 6 rue de l'Êcole, de Médecine. This syringe is constructed 
like that of Prof. Dieulafoy, of Paris, which he employs for pleuritic effusions. I pass 
the small trocar into the sclerotic, beyond the ciliary ring,, and open the stop-cock. 
The liquid then pours into the syringe, its quantity ordinarily being from 1 to 2 grms. 
The effects of this operation are of little consequence. 
I have applied this method 25 times ; 19 of these cases were simple aspirations. 
Out of this latter number I have had two successes ; in the other cases the liquid was 
reproduced. I thought at the time that in making the suture across the sclerotic of the 
detached portion of the retina, one would be able to maintain the retina in position 
and promote its adhesion. In six cases I have obtained two cures, but in the other 
four cases sight was not reestablished. In two operated upon, hemorrhages into the 
vitreous supervened a few days after the operation. SECTION XI OPHTHALMOLOGY. 
749 
For the suture I employ five threads of catgut No. 000, prepared and preserved in 
carbolic acid, hence antiseptic. 
These, gentlemen, are merely the first attempts. I recommend to you an applica- 
tion of this method, and to see whether, by discarding the suture after the aspiration, 
and combining the latter with an injection of an antiseptic astringent liquid, we can- 
not bring about the cicatrization of the detached portion of the retina, and thus save 
the rest of this membrane. 
DISCUSSION. 
Dr. Abadie, of Paris.-In order to treat in a scientific manner a subject so difficult 
and complicated as retinal detachment, first of all it is necessary to classify its causes. 
In some cases it is undoubtedly due to causes either rheumatic or syphilitic in nature, 
and here we may bring about an amelioration by a constitutional treatment. But 
this is by no means the rule. In the immense majority of cases it is due to myopia, 
and generally speaking without a single inflammatory symptom which would act as 
a precursor. And to what is this attributable ? It seems rational to admit the 
mechanism of the sclerotic in progressive myopia. We know that it is gradually 
distended, the antero-posterior diameter of the eyes becoming greater, till finally the 
retina is separated from the other coverings. It explains to us the momentary 
improvement that the puncture of the sclerotic gives. The fluid ebbs out and the 
sclerotic retracts and the retina takes its proper place, but only in a few days to 
resume its first position and give us just the same condition of detachment as we 
had before the operation. The whole subject is remarkable for the insufficiency of 
its treatment. 
Prof. Keyser remarked-There is nothing so interesting to the ophthalmologist, 
and the treatment of which is such an enigma, as detachment of the retina. He was 
with v. Graefe when he first suggested and made incision of the retina to let the fluid 
out into the vitreous ; also with de Wecker when he introduced his trocar through the 
sclerotica ; and with Bowman and Critchett when they opened the sclerotic with the 
knife to let the effusion pass out under the conjunctiva. All of these operations he has 
tried many times, ■without any permanent success. In some cases there seemed to be 
an improvement at first, which soon passed away. The absorption by injections of 
pilocarpine, and the prostrate position with compress bandages, have all failed of 
permanency in his hands. In the operation of opening the sclerotic the vitreous 
does not give pressure enough to force the liquid out, and as the instrument of Dr. 
Galezowski draws it out by gentle action in vacuum, he thinks it deserves a fair test. 
He thinks there maybe some benefit derived in very recent cases, but cannot see how 
there can be any adhesion of the retina again to the choroid in old detachments 
of months and years standing. He agrees entirely with the remark that there is 
always inflammatory action going on in all cases where detachment of the retina 
takes place. He has frequently noticed well marked choroiditis extending through- 
out the eye in such cases ; and has had the separation to take place suddenly in 
cases of choroiditis while under his care. He says that all such patients should be 
treated for choroiditis at once, and any operation proposed be made soon after the 
detachment has taken place and absorption has not occurred under proper treatment. 
It is a well known fact that when detachment of the retina takes place there is 
softening of the vitreous, so in the operation suggested care must be taken not to 
draw the vitreous off instead of the effusion behind the retina. The operation as 
proposed by Dr. Galezowski is one requiring great care and delicacy to prevent more 
serious trouble. Attention must be called to the fact, however, that effusions take 750 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
place in and behind the retina, which are absorbed in a short time under proper 
treatment, so that too great haste in operative influence should be guarded against 
until internal remedies and other methods have been unsuccessfully tried. 
R ichardson Cross, Esq., of Bristol-I have watched one case where imperfection 
of the visual field agreed with a segment of the retina which lay anterior to the rest 
of the fundus. There was no apparent retinal degeneration ; the condition suggested 
sub-retinal inflammation, and I expected detachment to develop. The patient was 
energetically treated by diaphoretics with absolute rest. No change occurred ; and 
even some months afterward no alteration was noticed except that the retina was less 
prominent, as judged by direct examination. Here the exudation seemed to have 
organized, but had it increased detachment would have resulted. 
I have had one successful result by sclerotomy under the detachment. A girl 
aged seventeen came in, August 1886, with well marked gray detachment in the 
lower segment of each eye, which floated up across the visual axis. She said she 
had always been short-sighted, and for some time had noticed a floating film in front 
of the left eye. In May 1886 the right eye became suddenly blind, and soon after a 
marked impairment of vision followed in the left. I found the vision R. not fingers ; 
L. I, J- 10. at 8 inches. I exposed the sclerotic between the external and inferior 
rectus, where I considered the main detachment lay, and carefully dissected through 
with a Graefe knife. A thin tinged fluid escaped. The eye was kept closed six 
days, the patient being recumbent. On the ninth day vision of R. was TV, 
Jaeger 10. 
She left the hospital and returned on January 7th, 1887. The right saw and 
J. 4 close. Fine thin synchysis in vitreous. Disc pale ; no white floating membrane. 
Position of detachment + 1. Fundus - elsewhere. The left eye saw as above. 
At her request I operated by the same method on this eye. The result was even 
more satisfactory than in the former case. I have no record of the vision with me, 
but it markedly improved, and I heard in August of this year that she sees very 
well. 
I admit such cases are fortunate exceptions, but I believe the operation was the 
sole cause of the improvement of sight. 
I am of opinion that, while Professor Galezowski's method is a real addition to 
the rational means at our disposal, incision of the sclerotic under the detachment, as 
practiced by Wolff and others, remains the best surgical procedure. 
Every case, however, must be treated upon a full consideration of its pathological 
details. 
Prof. Landolt, of Paris-A few words, gentlemen, on the subject that now 
occupies our attention. I have divided it into three forms : first, detachment due 
to choroidal exudation ; second, that due to the very high degrees of myopia ; third, 
that due to traumatism. And now as to the first, that due to choroidal exudation, 
a condition frequently disappearing under suitable internal medication and when an 
operation, indeed, would do positive harm. Often, indeed, that which we take for 
a retinal detachment with the ophthalmoscope is nothing more than an exudation 
in the tissue of the retina, without having separated the retina from the adjacent 
membranes. I have seen, very recently, a case in point. As regards the second 
form, I cannot understand how the theory of Graefe per se can hold for an instant. 
It is physically impossible for the sclerotic to so distend itself that the retina resting 
upon it shall become detached. It is necessary to search for a more satisfactory 
explanation, and I am only too sorry that I am unable to give it. Those forms of SECTION XI-OPHTHALMOLOGY. 
751 
detachment of the retina, in all probability due, as Leber says, to changes in the 
choroid or alterations of some sort in the nature of the corpus vitreum, in this form 
of the disease I regard an operation as indicated, that is to say when the detachment 
is of recent date and not complicated, and after I have decided to operate I do it 
with the greatest prudence. 
As regards the operation with the syringe, I look upon it as exceedingly dangerous. 
A detachment which has been produced by an exudation is by no means comparable 
to a pleuritic exudation, in so far as its operative treatment is concerned. In the latter 
case we obtain a pathological liquid ; in a detachment of the retina we run the risk 
of drawing off some of the corpus vitreum and so complicating the difficulty. 
Finally, as regards those cases due to traumatism, it is impossible to speak of them 
in a general manner, the circumstances attending the injury are so different. I wish 
to relate a case in point. A small boy came to me, accompanied by his father. He 
had just received a blow from a sharp stick in one of his eyes. I made out a detach- 
ment of the retina, near the macula lutea. I advised absolute rest, the greatest care 
and gentle pressure. Nevertheless, the father started out on a journey of fourteen 
hours in a railroad coach, with the child. Gentle pressure was, however, kept up, 
and, notwithstanding the father's imprudence, the retina re-attached and sight was 
completely restored. 
Dr. Smith, of Detroit-The operation of Prof. Galezowski strikes me favorably, 
particularly if the needle is not passed through the retina, thereby endangering the 
escape of the usually fluid vitreous. I have made the operation of tapping with a 
paracentesis needle with exceedingly brilliant, immediate results, but, as Prof. Abadie 
remarked, the detachment returns anew and the ultimate result is nil. I have several 
times made the operation of my friend, Prof. Wolff, of Glasgow, who has reported 
a number of successes. As you know, it consists in making a somewhat free incision 
in the sclera and choroid, the idea being that the inflammatory exudate tended to hold 
the retina in place after the escape of the effusion. I have made this operation 
several times, but, I must admit, with only temporary amelioration. 
Dr. Wm. Fred. Holcombe, of New York-The word "cure," used to-day by 
Dr. Galezowski, should be taken with allowance, due to his speaking English, while, 
in using French yesterday he said vision never returned in the part detached, but that 
all future detachment was prevented and present sight saved, and this is what he 
calls a "cure" and claims as most important. It is well to recall that the elder 
Sichel and other oculists always performed tapping of the eye with a long, thin knife, 
similar to von Graefe's cataract knife, and allowing the patient to go about and the 
oozing of any fluid to go on freely. Gradually, benefit became more and more 
apparent, and a so-called cure was effected, as fair sight was preserved. In the use 
of the catgut seton as a means of drainage, I conceive it may be of great benefit. 
The retina undoubtedly is more or less paralyzed, according to the pressure upon it, 
unless rupture has occurred. Any means of removing and relieving the pressure of 
the fluid without more injury than it affords, is very important. But let us not 
forget that sclerotomy proved successful in the hands of ancient surgeons, whose 
patients were thus greatly relieved, before they had any knowledge of the appearance 
of the optic fundus with the ophthalmoscope, and they only judged of results by 
return of fair vision. 
Dr. Calhoun, of Georgia, asked Dr. Galezowski what advantage he expected 
to gain in making the operation upon chronic cases of detachment of the retina ? 
He had made the operation a number of times and had been disappointed in the 752 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
results. In one case of recent detachment the effusion broke through the retina 
into the vitreous and was absorbed. The retina replaced itself with tolerable vision. 
In another case (traumatic) the foreign body was removed and the retina resumed 
its natural position, but there was no improvement of vision. But in chronic cases, 
as long as the eye remained free from secondary inflammation, he was of the opinion 
that no attempt should be made to replace the retina, but that the eye should be 
let alone, unless other complications manifested themselves. 
Mr. H. Power, of London.-In detachment of the retina the situation of the 
fluid has not, so far as I know, been quite accurately ascertained. Is it entirely sub- 
retinal, and what relation does it hold to that pigment layer which probably fulfills 
important functions in regard to vision, and which, in its development, may be said 
properly to belong to, and to form an integral part of, the retina ? I wish to ask 
M. Galezowski whether he is of opinion that that portion of the retina which is 
actually detached ever resumes its functions, whether the removal of the fluid be 
effected naturally or by operation ? I think I can afford a partial explanation of 
improvement in vision after such removal of the fluid in some instances. A case 
occurred to me in out-patient practice, in which a woman in middle life applied for 
relief, in consequence of great impairment, though not total loss, of vision. The case 
was examined ophthalmoscopically, and extensive detachment of the retina was 
found to be present. She was directed to attend again in order that students 
might have an opportunity of seeing the eye. Three days after she reappeared, 
stating that her vision had greatly improved. On examination, the fluid was found 
to have been entirely absorbed and the retina to have become reapplied. Now, I 
presume that the retina here formed a sac which hung over and obscured the 
macula. When the fluid was reabsorbed, the sac disappeared and light once more 
fell on the region of the macula. 
Dr. Galezowski closed the discussion of his paper with the following words:- 
I do not agree with Dr. Abadie that distention of the sclera has any relation to 
retinal detachment. With Dr. Keyser I agree. The operation I propose is a new 
and, perhaps, a more promising method for chronic and bad cases. In some cases 
I find arrest of the morbid action and restoration of sight in other portions of the 
retina. If I succeed in arresting the detachment, I feel that the eye is saved by 
the operation. 
ON THE PREDISPOSITION TO GLAUCOMA. 
DE LA PRÉDISPOSITION AU GLAUCÔME. 
ÜBER DIE PRÄDISPOSITION ZUM GLAUCOM. 
BY DR. BRUGSCH-BEY, 
Ophthalmic Surgeon, Cairo, Egypt. 
Since von Graefe declared glaucoma to be a disease with increase of intra-ocular ten- 
sion and with a certain reaction on the functions of the optic nerve and the retina, 
increased tension is now considered by the greatest number of authors, with only a few 
exceptions, as the most characteristic symptom of this disease. As soon as the intra- 
ocular tension is increased and the sight begins to fail, we are justified in diagnosing SECTION XI-OPHTHALMOLOGY. 
753 
glaucoma, either primary or secondary, according as there is any other disease in the eye 
that may cause it. As the eyeball is formed by a dense membrane enclosing a liquid 
interior, the tension can increase in two ways-either by a larger secretion of fluids, or 
by the retention of liquids which have been used to nourish the eye. The theory of 
retention has already found some anatomical facts proving it. Kines, as it is well 
known, first drew attention to the occlusion of the region of the ligamentum pectinatum 
in a certain number of cases of typical glaucoma, by the growing together of the cornea 
and the ciliary portion of the iris. It is evident that after an occlusion of a part in this 
way a temporary, and in case of a perfect occlusion, a continuous increase of tension, 
i. e., glaucoma can be provoked. According to this consideration, the author of this 
article conceived the idea that not only an occlusion, caused by inflammation or by any 
other pathological process, but even a natural short periphery of the cornea, would be 
able to produce the same effect. Therefore, eyes with a relatively small cornea would 
be more exposed to glaucoma than those with a large one, provided that in both eyes 
the length of the diameter would be the same. 
According to this fact, we see only a very small number of children's eyes attacked 
by glaucoma. It is perfectly exceptional to see this disease in men younger than twenty 
years. Also, it is well known that the smaller an animal is the larger relatively is his 
cornea. I may be allowed to illustrate these statements by some calculations. We 
find in Jaeger's (an eminent late professor of Vienna) " Ueber die Einstellungen des 
dioptrischen Apparates im menschlichen Auge, " pp. 12 and 13, the following data in 
connection with the eyes of children and adults :- 
The diametrical proportion of the diameter of 20 children's eyes younger than 40 
days is 17.4 millimetres. Von Reuss, in Graefe's 11 Archiv für Ophthalmologie," 
vol. XXVII, part i, p. 27-53, gives the middle length of the corneal diameter of young 
children as 9.5 millimetres. In the same author's writings we find for adults, middle 
length of the diameter of the eyeball, 24.3 millimetres ; middle length of corneal 
diameter, about 11.6 millimetres. Hence it follows that during the time of growth the 
diameter of the eyeball increases from 17.4 to 24.3 millimetres. The length of the 
corneal diameter on the other side is only lengthened from 9.5 to 12.5 mms. The 
greater volume of the adult's eye relative to its corneal diameter and to the propor- 
tions, as we find in children's eyes, is very evident. 
By the classical experiences made by Schwalbe, Leber and others, it is stated that 
the way in which the used liquids leave the eyeball is the region of the ligamentum 
pectinatum all around the cornea. A diminution of this way, i. «., a small cornea 
with a short periphery, must throw great obstacles in the way of the affluent liquids. 
The following calculations will serve to illustrate this :- 
As it is not our purpose to state either the exact volume of the eyeball or the 
exact length of the corneal periphery, we may consider the corneal periphery as a circle 
with the radius of half the diameter and the eyeball as a globe with the radius of half 
the diameter. 
By the formulas d7r and fr3«-, we find for children the proportion between corneal 
periphery and volume of the eyeball as about 1 : 100 (more exactly, 1 : 99), and for 
adults the proportion is 1 : 200 (more exactly, 1 : 203). 
By this we see that for children 100 parts of volume have one part of way, and for 
adults, 200 parts of volume have only one part of way at their disposal. The greater 
difficulty on the side of adults is therefore evident. 
A similar predisposition to glaucoma, as between adults and children, we see also 
between large and small animals. For instance, a peculiar ophthalmia of horses is 
presumed to be of a glaucomatous character. On the other hand, rabbits, mice and 
such like are almost never affected by glaucoma. Also by experimenting on them a 
Vol. Ill-48 754 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
transitory increase of tension can be provoked, but never a continuous tension, a glau- 
coma, as we find it in human eyes. 
If these more theoretical considerations should be true, a greater number of men 
suffering from glaucoma would be among a population showing the above-mentioned 
anatomical peculiarity than ordinarily is to be found. So, indeed, I find it in the city 
of Cairo, where also a good many of the patients from all Egypt pass under my notice. 
While in Europe the number of glaucoma patients is about 1 per cent., this number 
in Egypt amounts to about 4 per cent. 1| per cent, are secondary cases. These 
figures are taken from 2000 patients. The predisposition of the Semitic race for glau- 
coma is observed in Egypt, and has also been noticed by other authors Also among 
Algerian Arabs glaucoma seems to be a very common disease. In the beginning of 
my medical practice in Egypt, I was greatly surprised at finding children attacked by 
glaucoma, principally of a secondary form. Very often after a perforating ulcer with 
anterior synechia of the iris, caused by a horrible Egyptian blennorrhœa, began to 
close, and the denser cicatricial tissue not allowing any more the aqueous humor to flow 
out, the tension slowly increased and a typical glaucoma resulted, which necessitated 
the operation of iridectomy. The immediate consequence of increased tension shortly 
after the healing of an anterior synechia is a most surprising fact in Egyptian oph- 
thalmic practice. 
The smallness of the cornea was first observed in finding that all artificial eyes sent 
from Europe w ere furnished with too large corneas. Even eyes with a cornea of 11.5 
mm. are met with but very rarely. Attentive to these facts, I began to measure the 
corneal diameters of men of the pure Egyptian race. I found, by the examination of 
forty-six recruits in the Government Hospital at Kasr il Ainee, the mean proportion of 
the corneal diameter to be 11 millimetres. I am very thankful to Dr. Mohamed Bey 
Off, who gave me the opportunity of measuring a number of these men of high stature. 
Then I measured nineteen adult patients on w hom I operated for glaucoma. I only 
found a diameter of about 10.5 millimetres. These observations are very exact, because 
I made them during the narcosis of the patients. 
The question has still to be studied whether the eyes of pure Egyptians are not 
smaller than the eyes of other races. The number of eyes I examined for this purpose 
is, indeed, not yet sufficient, because it is very difficult in the hot climate of Egypt to 
get eyes fresh enough. Already two hours after death the eye is too putrefied in the 
summer time, and cannot serve any more for measuring purposes. Nevertheless, I found 
in the cases I examined, under favorable circumstances, that the diameters were not 
smaller than 23.5 millimetres. 
If it be true that eyes having small corneas are more disposed to glaucoma than 
eyes with large corneas, then a good many symptoms may be lightly declared, and thus 
overlooked. 
So in many instances the sudden appearance of glaucoma acutum in its form "fou- 
droyant" will lose its mystery. Such eyes have been long ago in danger on account of 
their anatomical construction, and as occasion arises, such as congestion, emotion, etc., 
an attack of glaucoma foudroyant is the result. 
As both eyes generally have the same anatomical construction, it will not be surpris- 
ing to see the other eye attacked by glaucoma after the emotion caused by the operation 
on the first eye. 
Hypermetropic eyes, which are very often attacked by glaucoma, are very short 
eyes ; but the vertical diameter is proportionally longer than in other eyes ; so their 
form resembles more a globe, which possesses a great volume; whether hypermetropic 
eyes have also small corneas is a question still to be studied. 
The healing effect of iridectomy in glaucoma will be easily understood on the basis SECTION XI-OPHTHALMOLOGY. 
755 
of this theory and in the following manner. If a glaucomatous eye remains without 
any help of art, it slowly degenerates and attempts to take the form of a globe. The 
first sign is the known disappearing of the sulcus corneo-scleroticalis. The cornea 
becomes flat. The iris, spread out like a compact membrane with a little hole for a 
pupil, hinders a further expansion of this part. 
After a piece of iris has been cut out, the expansion is freely permitted. Indeed, 
we see colobomas of iridectomy in a good many cases enlarged some time after opera- 
tion. A small, artificial pupil made for an optical purpose appears as a large coloboma 
made for glaucoma. Both sides of this coloboma remain parallel. Such enlargement 
can only be caused by an enlargement of the base of the cornea. If a coloboma is too 
small or too little peripherally done, it does not modify, in the least the glaucoma, 
because the desired expansion cannot take place. 
I am well aware that the data I can give are too restricted to prove everything 
sufficiently, but since I conceived this idea, I see daily facts proving it, and therefore 
I wish to ask the illustrious members of this International Medical Congress whether 
similar facts have happened in their experience. 
Till now I have only found one observation similar to mine, made by Professor 
Rimpoldi, who saw glaucoma more frequently in "small eyes" than in large eyes. 
Perhaps in Italy there may be similar pathological peculiarities producing the same 
effect as in Egypt. 
DU GLAUCÔME DANS LA RACE NOIRE. 
ON GLAUCOMA IN THE NEGRO. 
ÜBER DAS GLAUCOM BEI DEN NEGERN. 
PAR LE DR. MOURA. 
Dans une communication faite à l'Académie de Médecine de Rio de Janeiro au sujet 
de la tension intra-oculaire dans les races noires, mixte et blanche, j'ai démontré au 
moyen de statistiques que cette tension variait beaucoup d'une à l'autre race. J'y ai 
fait remarquer que celle-là était bien plus exagérée chez la plupart des nègres dont 
l'état de la vision était pourtant physiologique, de façon qu'on pourrait considérer un 
grand nombre de ces individus sous l'imminence du glaucôme prodromique si, par 
hasard, quelques autres manifestations fussent constatées. Chez les métis l'accroisse- 
ment de la tension oculaire se montre à un moindre degré ; enfin chez les individus de 
la race blanche elle est encore plus faible. Ainsi s'explique la fréquence considérable 
du glaucôme chez les sujets de la race noire ; ce fait est parfaitement confirmé par 
notre déjà assez longue observation soit en ville soit à mon service à la Policlinique où 
les sujets de cette race se présentent en plus grand nombre. C'est ainsi que sur un 
total de 5458 malades de tous les âges enregistré dans ce service et dont 3466 de la race 
blanche, 1379 métis et 513 noirs, j'ai rencontré le glaucôpie dans les proportions sui- 
vantes: 1.36 pour 100 chez les blancs, 2.39 pour 100 chez métis, 10.72 pour 100 chez 
les nègres. 
Cela montre donc combien varie d'une race à l'autre la fréquence proportionnelle 
du glaucôme ainsi que la prédominance marquée de l'affection chez ces derniers. Ce 
qui du reste semble expliqué par cette augmentation de la tension oculaire dûe proba- 
blement chez eux à des conditions particulières à la race. 756 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
D'abord deux facteurs principaux donnent lieu, chez ces individus, au défaut 
d'équilibre entre la sécrétion et l'excrétion des liquides de l'œil. Les nègres ayant le 
fond de l'œil fort pigmenté, ont-ils besoin de recevoir une plus grande quantité de 
rayons lumineux pour la clarté de l'image, et pour cela sont-il obligés d'avoir la pupille 
plus dilatée, d'où il résulte un embarras considérable au cercle de filtration antérieure 
des adhérences multiples se produisant à l'angle irien. En deuxième lieu l'endurcisse- 
ment de la sclérotique débute plus tôt chez les nègres, de façon qu'il n'est pas rare de 
retrouver chez eux le glaucome entre vingt et vingt cinq ans. 
Il est bien probable que cette même cause agisse également sur la filtration posté- 
rieure, en l'empêchant même dans certains cas. D'ailleurs on observe rarement chez 
les nègres l'anneau sclérotical ; si l'on admet en même temps l'hypothèse très judicieuse 
et très acceptable du savant Prof, de Wecker que cette partie du pôle postérieur du 
globe oculaire joue un rôle marqué pour la filtration des humeurs de l'œil, on aura un 
élément de plus pour expliquer l'accroissement de la tension intra-oculaire dans cette 
race. 
Le glaucôme se présente chez les nègres sous la forme chronique simple ; jamais je 
n'eus l'occasion d'observer aucune autre comme manifestation primitive, mais lorsque 
l'affection est arrivée au degré le plus avancé, il n'est point rare de voir le glaucôme 
prendre la forme irritative. 
La marche du glaucôme des nègres est plus rapide par rapport à celle qu'on observe 
chez les sujets de la race blanche ; l'excavation de la pupille est plus profonde dans un 
délai relativement plus court chez les premiers. 
L'iridectomie ainsi que la sclérotomie réussit parfaitement chez eux, bien qu'il ne 
soit point rare de voir la reproduction du mal de façon à réclamer la répétition de l'opé- 
ration. 
BI LATERAL GLIOMA OF THE RETINA-ENUCLEATION OF THE 
RIGHT EYEBALL-EXTIRPATION OF THE CONTENTS 
OF THE LEFT EYE. 
GLIOME BI-LATERAL DE L'ÊNUCLÊATION RETINALE DU GLOBE DE L'OEIL 
DROIT EXTIRPATION DES MATIERES DE L'OEIL GAUCHE. 
BILATERALES GLIOM DER NETZHAUT-ENUCLEATION DES RECHTEN AUGAPFELS- 
EXSTIRPATION DES INHALTES DES LINKEN AUGES. 
BY A. G. SINCLAIR, M. D., 
Memphis, Tennessee. 
V. B., male, æt. nineteen months, was brought to me in November, 1881, with 
the following history: In July of the same year vision of the right eye began to fail, 
and soon afterward also that of the left, and total blindness in both rapidly supervened. 
Following this, in a short time, a whitish reflection from the pupils attracted attention. 
This soon acquired an appearance which the father of the child described as " ridged " 
or "lumpy," and aptly compared with the convolutions of the brain. Coursing over 
this uneven surface, dark lines (blood vessels) were observed. The pupils were 
apparently somewhat larger than in the normal condition when the disorder was first 
noticed. There was no redness of the eyes, and apparently no pain until about the end of 757 
SECTION XI-OPHTHALMOLOGY. 
September. At that time an attack of indigestion, lasting a day or two and attended 
with more or less fever, was followed by inflammation in the eyeballs, which continued 
up to the time of presentation, accompanied with, apparently, almost constant pain. On 
examination of the right eye, there was found considerable congestion of the conjunctival 
and episcleral blood vessels, haziness of the cornea in its central portion, diminished 
depth of the anterior chamber, the crystalline lens lying nearly in contact with the 
cornea and having on its anterior surface dots and patches of pigment derived from the 
posterior surface of the iris, the lens still transparent, enlargement and immobility of 
the pupil, except that a slight additional enlargement was obtainable by the employ- 
ment of mydriatics, dullness and alteration in color of the iris and extensive posterior 
synechiae. Through peripheral portions of the pupil, where unobstructed by pigmen- 
tary deposit, a yellowish-white reflex appeared, which, on close inspection, was found 
to proceed from the surface of an intra-ocular mass reaching nearly to the posterior surface 
of the crystalline lens. The tension of the ocular globe was somewhat above the normal 
degree. The movements of the eye were unrestricted. Vision had been entirely 
destroyed. 
The foregoing description of the right eye applied also to the left, except that there 
was a space about one line in diameter near the centre of the cornea which was abraded 
and hazy, and that the intra-ocular growth was less advanced and was obscured by 
blood extravasations, both old and recent. 
Diagnosis.-Bilateral glioma of the retina. 
Prognosis.-Very unfavorable; enucleation of both eyes with possibly evisceration 
of the orbits was proposed to the parents as the only means of affording relief from 
pain and prolonging life. They eagerly accepted the proposition, and accordingly, on 
September 7th, I enucleated the right eye and removed with it about half an inch of 
the optic nerve. Entire relief from suffering followed the operation, and extreme debil- 
ity was speedily replaced by strength and vigor. A few weeks later I removed the 
contents of the left orbit as thoroughly as it was possible to do it without the employ- 
ment of cauterization of its walls. From this operation, also, the child made a rapid 
recovery. 
For microscopical examination the first specimen was submitted to Dr. T. Mitchell 
Prudden, Director of the Physiological and Pathological Laboratory of the College of 
Physicians and Surgeons, New York, whose report is as follows :- 
New York, Nov. 23d, 1881. 
My Dear Doctor :-The microscopical examination of the eye sent me confirms your diagnosis. 
I examined individual sections of the whole eye with the following result :- 
The cornea shows few new-formed blood vessels in the limbus. There is a small quantity of 
granular fluid in the anterior chamber. The iris, ciliary body and portions of the choroid are 
sparsely infiltrated with pus. There is a broad, vascular, cyclitic membrane closely enclosing the 
lens behind. There is a partial detachment of choroid from sclera, and nearly complete separa- 
tion of retina from choroid. The retina in the parts examined is almost completely involved in 
larger and smaller nodules of closely aggregated, small, spheroidal and variously shaped cells. 
With a nominal amount of intercellular substance the nodules are moderately vascular, and are, 
in some cases, aggregated into fungiform masses. The largest of these nodules projects forward 
from the optic nerve entrance, while the numerous smaller ones are irregularly scattered over the 
retina. There are also small similar nodules in the choroid, and also at the sides of the cyclitic 
membrane upon the ciliary body. 
The new growth has infiltrated back into the optic nerve about 1.5 mm. beyond the cribriform 
lamella. 
The anatomical diagnosis would, accordingly, be " irido-eyclitis and choroiditis, with glio-sar- 
coma of the retina extending into the optic nerve beyond the cribriform lamella." 
The tumor cells, so far as could be detected with the microscope, extended only to within 7 
mm. of the cut end of the optic nerve. 758 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The microscopic examination of the second specimen was made by Dr. Carl Heitz- 
man, of New York, who reports as follows, under date of September 25th, 1882:- 
Dr. A. G. Sinclair :- 
Dear Doctor :-I have examined the tumor of the eyeball and the extra-ocular mass, with the 
following results :- 
The tumor is a primary glioma of the retina which grew into the vitreous body, almost com- 
pletely replacing it, and reaching the posterior aspect of the lens without having led to an 
increase of the diameters of the eyeball. 
The tumor consists of a large number of globular elements characterized by a large, often 
double, nucleus. Between the groups of the glioma elements there is scanty, fibrous connective 
tissue. The change into glioma tissue pervades a great portion of the choroid, the pigment layer 
between the retina and choroid being, at least in some places, still recognizable. Broad bundles 
of fibrous connective tissue between the groups of glioma elements characterize the former tissue 
of the choroid. Anteriorly, there are remnants of the vitreous body nearly intact, still even here 
a beginning transformation of the vitreous body into glioma tissue can be traced. 
The crystalline lens is, in portions, transformed into homogeneous lumps, replacing the rib- 
bons, which, as such, retained their shape ; scanty plastids, partly lying in vacuoles, are scattered 
throughout the ribbons of the crystalline lens, representing a transformation of the bioplasm of 
the tissue into glioma tissue. The peri-orbital tissues are more or less transformed into glioma. 
The lachrymal gland exhibits glioma elements in its connective tissue portion, while the epithelia 
are not markedly changed, except an augmentation of the nuclei and a coarse granulation. The 
calibers of the acini are not noticeably altered. 
Confirmed by the results of these examinations, the correctness of the diagnosis made 
prior to the operation is, of course, beyond question. 
With the subsequent history of the case I have kept myself familiar, and under 
date of August 6th, 1887, that is to say, nearly six years after the operations were per- 
formed, the child's father reports him in excellent health and with no sign of a return 
of the disease. In the history of the case nothing indicative of a hereditary tendency to 
the disease could be discovered. The parents have one other child, now four years old, 
whose eyes are thus far unaffected. 
I regard the case as interesting, in that it tends to show that the prognosis in 
glioma is, perhaps, somewhat less unfavorable than we have usually considered it. In 
regard to bilateral glioma, Knapp, in his masterly work on intra-ocular tumors, says 
(page 121): "The uncertain result of this remedy can alone influence the physician 
not to request permission for the bilateral operation of extirpation. ' ' 
Dr. D. Tench, in a valuable report on enucleation for various causes, which appears 
in the last (June) number of the Archives of Ophthalmology, says, in regard to some of 
the cases operated on for glioma: "The optic nerve was affected, thus dooming the 
patient, with almost absolute certainty; while in still two more cases the other eye had 
also become affected, making death only a question of time;" while Meyer, in his latest 
edition (Diseases of the Eye) says: "If the optic nerve is invaded by the degeneration, 
and especially if there are traces of it in the peri-orbital tissue, it is certain to return 
after a very brief interval." 
In the subject of this report not only was the disease far advanced in both eyeballs, 
but also the optic nerve, of one side at least, and the peri-orbital tissues of the other, were 
in process of transformation into glioma, conditions all supposed to point to a speedy 
relapse, and yet we have here six years following the operations without a sign of 
recurrence. 
DISCUSSION. 
Prof. Keyser remarked that it has always been taught that the enucleation 
of an eye with retinal glioma in a child is not sure to result in saving life, but only 
in prolonging it, as the disease is sure to attack the brain sooner or later. In most SECTION XI-OPHTHALMOLOGY. 
759 
instances death ensues in from four to eighteen months. It is not every case that 
looks like glioma of the retina which is true glioma. He has seen and operated in 
several cases apparently of undoubted glioma, most of which have succumbed in 
some months after, two of which, however, are still living, in which six and seven 
years have elapsed after the enucleation without relapse. The one of six years had a 
sister who died five months after enucleation for glioma, from its extension to the 
brain, just twelve months previous to the operation on his patient. Yet it may be 
that the diagnosis in these two successful cases was not certainly correct, although 
the microscope showed the characteristic cells etc., found in glioma. He advised 
operation with great caution as to diagnosis. 
Mr. Power, of London, said he doubted exceedingly whether genuine cases of 
glioma were relieved by operation. 
Dr. Dudley S. Reynolds said he thought where the disease originates in the 
brain or at any point in the optic nerve, enucleation could, of course, do no good ; 
but where the disease originates in the retina, the case is different. There are many 
well-authenticated instances of permanently successful results from enucleation. 
Out of a large number of cases-perhaps twenty-he knows of but one instance in 
which the disease appeared in both eyes simultaneously. This was the case of Anna 
Lewis, a girl nine years of age. who, being blind and having a golden reflex from the 
pupil, was said to have cataract. She was sent to the Indiana institution for the 
education of the blind. In June, 1887, her aunt brought her to Louisville. She 
had for two or three weeks suffered severely from headache, and the blindness, which 
was limited to the central part of the field at first, had recently become complete. 
Both eyes were sensitive to pressure, tension very great. She was put under the 
influence of chloroform ; and when I enucleated, it was found the disease did not 
extend-at least, apparently-beyond the globe. A little more chloroform was 
administered, and the other eye enucleated before the patient recovered conscious- 
ness. It was found precisely like the one first removed. Sections through the pro- 
jecting end of the nerve near its point of contact with the sclerotica were made, and 
nothing abnormal observed. The retinae in both eyes had been almost entirely 
incorporated in the morbid growth. Sections of this growth were made ; and I 
still use them as typical examples of glioma. Miss Lewis has never had any return 
of the disease, and has ever since enjoyed excellent health. I take this to be an 
extraordinary case, both in its nature and the result of the operation. It is sufficient 
to decide my mind in favor of enucleation in every case where I have reason to believe 
the disease does not extend beyond the orbital cavity. 
Dr. Galezowski remarked, I have seen perhaps four cases of retinal glioma in 
my practice. In one of these cases I enucleated, and the patient is now living, after 
six years. I have seen one case of glioma in both eyes, but here I did not operate, 
and the child died. 
Dr. Randolph, of Baltimore, Md., said, apropos of Dr. Reynolds' remarks as 
to the origin of glioma, whether in the retina or optic nerve, I had an opportunity 
not long since of examining a glioma which evidently had its origin in the optic 
nerve, the entire structure of the nerve being virtually destroyed, the nerve fibres 
being pressed apart and densely infiltrated with round cells, the characteristic cells 
of this strictly sarcomatous growth. 760 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ERGOT OF RYE IN OPHTHALMIC PRACTICE. 
L'ERGOT DE SEIGLE DANS L'OPHTHALMIE PRATIQUE. 
MUTTERKORN IN DER OPHTHALMOLOGISCHEN PRAXIS. 
BY H. CLAY PADDACK, M.D., 
Of New York City. 
This valuable agent was not used by the ancients. The most complete of all our 
earlier writers on materia medica note none of the medical virtues of ergot of rye. We 
are now all familiar with the use of it in obstetrics, but popular tradition had then 
taught a few empirics its virtues in the practice of Midwifery, but this remedy, destined 
to become one of the most valuable, was not understood by science. It has been thought, 
of all the properties of ergot, the most important and incontestable was certainly that 
of producing contractions in cases of uterine inertia, even at present, in spite of the 
obstinacy of a few physicians who deny to ergot the possession of properties almost as evi- 
dent as those of cinchona. As the value of this remedy is generally admitted in inertia 
of the uterus, it is indeed as certain to play as important a part in the practice of oph- 
thalmology. I shall not take up the physiological action of the drug ; it is too well 
known, as far as it acts on the unstriped muscular fibre of the uterus, but shall add, 
it has lately been proved beyond a doubt that it also acts on the blood vessels in gen- 
eral, and those of the brain and spinal cord, as well as the uterus, in particular. Full 
doses unquestionably diminish the frequency of the pulse slightly ; but even large doses 
fail to reduce it below sixty. The chemistry of ergot is not at present understood. 
Those who have made ophthalmic practice a study will without doubt welcome any 
remedy that will have an influence over some of those diseases due to congestion and 
over-distention of the arteries, capillaries and veins ; a per cent, of those affections we 
know are only slightly if at all controlled by any local or general treatment, in the pre- 
sent state of our knowledge. Dr. Sœlberg Wells says of "episcleritis : " The disease 
"is very protracted and obstinate in its course, also very little influenced either by the 
general or local treatment." All of those diseases of the eye that are due to congestion 
and inflammation are speedily controlled by the use of ergot of rye. Where this remedy 
is most valuable is in diseases of the conjunctiva, cornea, sclerotic and retina, having as 
a prime symptom congestion, of an acute or chronic character. Ergot not only has an 
influence on the maternal and placental circulation, but it has also as positive an in- 
fluence on the blood vessels of the brain and spinal cord. 
Dr. William A. Hammond says :- 
" As is well known, ergot possesses the property of constricting the organic muscular 
fibre. This property has for several years past led to its successful application in the 
treatment of those diseases of the spinal cord in which it is desirable to lessen the 
amount of blood in its vessels. It is only lately, however, that this agent has been 
employed in similar affections of the brain. From my own experience, as well as for 
the consideration of the investigation of others, I am entirely satisfied that ergot does 
contract the cerebral vessels, and hence that it diminishes the quantity of intercranial 
blood; it causes contraction of the arteries of the retina, and loss of capillary tint in the 
disc." 
Now, it must be admitted that the chief difficulty in many of those obstinate dis- 
eases of the eye, especially in promoting resolution, is the congestion and over-disten- 
tion of the blood vessels, that fail in many cases to reduce their calibre, often where 
internal medication is administered, with the local application of the various astrin- 
gents. There are, indeed, many cases that fail to respond even to heroic treatment. 
In ergot we have, we believe, the essential factor to contract the over-distended blood SECTION XI-OPHTHALMOLOGY. 
761 
vessels, giving them tone and also acting as a tonic to the nerve supply of the organ, 
thereby promoting resolution in many cases so speedily as to appear almost magical in its 
effect. From what has been said it will be easily seen that there is nothing empirical 
in the use of this new remedy in those affections of the eye that apparently have so 
little tendency to improve under other methods of treatment. Certainly this must be 
admitted as a rational remedy, and it has been used quite long enough, at least, to have 
its action on certain blood vessels established beyond a doubt, and nothing more is 
claimed than the therapeutic action of the drug, that is well known in obstetrjcal prac- 
tice. Its action on the cranial vessels is just as apparent to an observer. I will give 
you a few cases to show what result I have obtained from its use since I first discovered 
its value in diseases of the eye, seven years ago, this having been the first, as far as I 
know, of its being used in the treatment of the eye troubles. I now offer it as an addi- 
tion to the large list of new remedies. 
Case I.-C. D., age thirty-five, a blacksmith, was struck in the right eye, at the 
margin of the cornea and sclerotic, with a small piece of hot steel from an anvil. The 
effect was not severe at the time, but it produced a slight irritation. Thinking it better 
to consult a physician, he applied to an oculist, who used for two sittings, of one hour 
each, alternate applications of water as hot as could be tolerated, and then immediately 
applying it ice cold. This was used for two consecutive days. At the end of that time 
there was a fully developed attack of episcleritis, with the most severe ciliary neuralgia 
I ever witnessed. The eye was so congested that it was crimson in color, then there 
appeared small, dusky-red and yellowish-red elevations on the sclerotic a short distance 
from the edge of the cornea. The suffering was so intense that powerful anodynes were 
resorted to to quiet the pain. I treated this case for five months according to the latest 
authorities. At the end of that time there was no improvement. I had able counsel 
to see the case, but all we tried was of no avail. The only relief for the time was by 
opiates and leeches to the temple. There was such an intolerance of light that the 
patient was compelled to be confined in a dark room most of the time. After trying 
everything known to the profession I concluded the only way to cure the case, and I, 
indeed, had no faith in its being cured at all, was, by some heroic means yet untried, to 
reduce the enlarged vessels. This, astringents and other remedies, locally, failed to do, 
with tonic and alterative treatment internally. I conceived the idea of using ergot, as 
a last resort, thinking possibly it would do something toward improving the symptoms 
for a time, at least, even if there was no permanent benefit. I gave the patient four 
grammes three times daily, suspending all other treatment. On the second day there 
was marked improvement. Indeed, considering the severity of the case, there was a 
miraculous change for the better. After the fourth day only two grammes were given 
at a dose, three times a day, and then discontinued at the end of ten days, and the 
patient was given an elixir of iron, quinine et strychnia, also cod-liver oil as a tonic. 
The neuralgia abated. No more opiates were now given, and in one week's time the 
patient was able to go about town and see his friends. In six weeks from the first dose 
of ergot the disease was completely arrested and he was able to resume work. 
Case II.-Mrs. Van A., age thirty, was suffering from chronic conjunctivitis, iritis 
with ulcers of the cornea and ciliary neuralgia. She had been treated by several differ- 
ent physicians with the usual treatment, for six months before I saw the case. I gave 
her first alteratives and tonics internally and applied three-grain solution of atropia 
locally, with mild astringents. She was much reduced in flesh and strength. The case 
improved slowly for some weeks and then came to a stand. I tried other lines of treat- 
ment with no better result. I then determined to again try ergot but to continue the 
tonics also. There was an improved condition of the eyes on the following day, and 
with this treatment the congestion was speedily reduced. I stopped the ergot on the 
tenth day, and with the atropia I soon finished successfully this unpromising case. 762 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Case III.-Mrs. B. ; age twenty-five; she had first an attack of conjunctivitis for 
some months, having been treated by her family physician with a solution of sulphate 
of zinc et morphia, also argenti nitrate. When I saw the case there was conjunctivitis, 
iritis with retinitis and ciliary neuralgia. She was also very anæmic. I gave her syr. 
ferri iodidum, fifteen minims, with cod-liver oil and local applications of a three-grain 
solution of atropia, twice daily, and a generous diet. There was marked improvement 
at first, although it was gradual for four or five weeks. Then there was no further 
advancement to be observed ; and the patient feeling somewhat discouraged, I used the 
ergot as before, and the change for the better after its use was daily visible. In a few 
weeks the patient was discharged cured. 
In all those cases there was congestion and over-distention of the blood vessels, which 
we frequently find so difficult to cure. I have since continued daily to use the ergot 
in my ophthalmic practice, with a success in treating many cases that I have been 
unable to receive from any other line of treatment. I will close with a few directions 
regarding its use. 
1. A reliable preparation of the drug must be obtained. We certainly could not 
expect success from an inert article. 
2. It should be given in maximum doses, and in bad cases for several days, and then 
diminish the quantity or stop it for a time. 
3. In cases accompanied with anæmia and general debility also give tonics, with 
cod-liver oil, a generous diet and fresh air. 
4. Atropia must be used when cases are complicated with iritis, 
5. Cases of a syphilitic origin, or complicated with, must have treatment also for 
that disease. 
Mr. H. Power, of London, read a paper by Mr. P. H. Müles, of Manchester, 
England, on- 
USE OF THE ARTIFICIAL VITREOUS AFTER EVISCERATION. 
L'USAGE DES VERRES ARTIFICIELS APRÈS L'EVISCERATION. 
ANWENDUNG DES KÜNSTLICHEN GLASKÖRPERS NACH DER EVISCERATION. 
The battle between Evisceration, Enucleation and Neurectomy yet remains to be 
ought out, and a large mass of facts must be accumulated before either the one or the 
other can defy deposition. 
My object in this paper is-so far as we have at present accumulated these facts- 
to lay before you the result of present experience of the permanent impaction of the 
glass globe into the denuded sclera. 
We may take for granted, that if no ill effects follow the use of this globe, and if 
the pain and discomfort after the operation are no greater than after enucleation, the 
result obtained is immeasurably superior. To quote from an article in the British 
Medical Journal :* " No one who has performed this operation or seen its results, can 
fail to appreciate the immense advantage it gives from a cosmetic point of view." 
Apart from this, the cavity remains clean and free from muco-pus, with numerous other 
advantages already treated of in papers on the subject, f 
* June 4th, 1887, p. 1230. 
f British Medical Journal, Dec. 19th, 1885. SECTION XI-OPHTHALMOLOGY. 
763 
Do we gain these advantages from evisceration alone, without the use of the glass 
globe ? 
Partly, yes. 
The cavity is clean and free from discharge. No cicatricial bands form, but as time 
progresses the orbital fat shrinks and a cavity is formed, not one whit less deep than 
after enucleation, projecting from the centre of which is a button of sclera the size of a 
large pea. I have taken careful measurement of the orbital cavity of a man whose sclera, 
eleven years ago, was apparently perfectly eviscerated, how I do not know, and I find 
it as above stated; it is very easy to understand this; first the optic nerve shrinks; 
secondly, there is obliteration of vascular and lymph channels; thirdly, there is, the 
most important part of all, ' ' absorption of orbital fat from the alteration of muscle 
insertions" and secondary contractions depending on scleral shrinkage. With the 
insertion of the glass globe you avoid all this; instead of changes of shape progressing 
in the cavity for an indefinite time, necessitating constant alteration of artificial eyes, 
you have in the course of three months the form as it intends permanently to remain, 
and a beautifully rounded stump, two-thirds the size of the normal, is presented for the 
adaptation of the artificial eye. 
There remains the degree of pain and distress of evisceration as contrasted with 
enucleation. 
This was undoubtedly a formidable fact; we have records of some eighty cases of all 
ages, and here I include the simple éviscérations of which we have done few, but as 
far as pain is concerned, it makes no difference whether the globe is introduced or 
not, the pain and constitutional distress being severe for three or four days. In none 
have we had suspicion of meningitis, or indeed any cause for uneasiness, yet it is this 
that has militated against the universal adoption of the operation. But having lately 
established the "raison d'etre " of the pain, as a pressure, not an inflammatory one, 
the remedy was not far to seek, and I found it by deeply draining the sub-scleral space 
with antisepticized horse-hair loops introduced through the conjunctiva to the outer 
side of the globe, and allowed to discharge through a divided canthus, and the appli- 
cation of an ice bag. Vide British Medical Journal, June 4th, 1887, p. 1213. By this 
means all pain and constitutional disturbance is avoided and, if necessary, the patient 
can be discharged on the third day. 
We have, as before stated, performed evisceration in some 100 cases, of all ages, 
and have modified the operation in a few points. 
Silk sutures should be used instead of catgut; even then a small percentage will fail 
to unite primarily; in these I remove the glass globes, treating them as simple éviscéra- 
tions. 
One sclera only reopened after four months completion of union: this was in a woman 
of drunken and immoral habits. Twice I have seen sloughing scleræ from want of 
care in antiseptics. 
My first case, operated upon two years and seven months ago, is still happy in a 
perfectly fitting glass eye. 
I do not know one instance of sympathetic irritation after the removal of the globe 
contents which could be fairly attributed to it, and I still hold by the view that I have 
published elsewhere*, that in evisceration we have an absolute prophylactic against 
sympathetic disease. 
It only remains for me to urge those who have not adopted this treatment to a trial 
thereof, and an insistance that the artificial eye makers shall properly second their 
efforts by a well fitting shell. 
In July of the present year, Cross, of Bristol, brought before the Ophthalmological 
J British Medical Journal, Feb. 6th, 1886. 764 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Society of Great Britain two cases-the only ones on record-entitled ' ' Sympathetic 
Ophthalmitis occurring after Evisceration." He classified them with those where 
sympathetic ophthalmitis commenced after enucleation. Holding the opinions expressed 
above, I agreed, that if sympathetic in their character they would come under the 
class named, but I dissent most strongly from the view that they were necessarily 
sympathetic, solely because a simple, easily cured iritis followed an accident to the 
fellow eye; holding it to be illogical that an accident to one eye shall alone determine 
whether or no simple inflammation of its fellow be sympathetic; both the recorded 
cases recovered rapidly and perfectly, one within ten days. Cross also expressed an 
opinion, in which I fully concur, that the worst eyes for evisceration are those lost 
from slow irido-choroiditis with tendency to flushes and recurrent inflammatory 
attacks; these always give trouble, more or less pain and chemosis; in these the drain 
must be allowed to remain at least a week, as we find early withdrawal followed by 
rapid swelling and pain. 
I need say nothing to those who have given their patients the advantage of this 
operation, for I believe they will be loth to return to the less satisfactory methods of 
enucleation or of neurectomy: and lastly, we have opened a road for interesting physi- 
ological research by establishing the tolerance of foreign bodies, when judiciously 
used, in the cavities of the human body. 
DISCUSSION. 
Mr. Cross, of Bristol, Eng.-The operation devised by Mr. Mules must be 
admitted to possess many of the advantages claimed for it ; it retains a large and 
prominent stump which is controlled by the muscles in a natural way. The muscles, 
therefore, with their nerves, are kept in a state of functional activity, and the general 
atrophy of the contents of the orbit that follows any other operation of this class is 
prevented. The movements of the glass eye upon the stump, however, are not com- 
mensurate with those of the stump alone, and some shrinking of the orbital fat and 
tissues occurs. 
The operation is admirable in conception and will, I believe, be increasingly useful 
in suitable cases. I protest, however, against the view that it is a prophylactic 
measure against sympathetic ophthalmitis, or that it can be compared with enuclea- 
tion of the globe as a safe procedure where the reason for operating is to save the sight 
of the fellow eye. Admitting that septic uveitis is the prime factor in the occur- 
rence of sympathetic ophthalmitis, yet the researches of Brailey, Snellen and Leber 
show that the septic elements soon pass into the sclerotic and the lymph spaces 
outside it. The cases of sympathetic ophthalmitis that have occurred some time 
after the eye has been enucleated indicate that at the time of the operation the 
morbid process had already passed beyond the piece of optic nerve removed with the 
eye. In the question of the prevention of sympathetic ophthalmitis, the character 
of the stump left by the operation goes for nothing. The sole consideration is for 
the remaining eye. 
Enucleation gives the most complete removal of the irritating tract, with imme- 
diate physiological rest, and thus tends, without delay, to resolution of the morbid 
process, where this might have advanced beyond the part removed. 
Evisceration is likely to leave behind particles of the uveal tract at the vena 
vorticosæ or around the disc, and leaves danger behind with the sclerotic. The 
introduction of the artificial vitreous is usually followed for a few days by considerable 
inflammatory reaction, which, by reducing the vitality of the sclera favors the progress 
of the special morbid conditions which may have been left behind, or it may be a SECTION XI OPHTHALMOLOGY. 
765 
direct danger in itself. The report of Mr. Mules' operations, however, shows that 
unfavorable results rarely occur. In my two cases* the healing had resulted in a 
small sinus, and there followed, seventeen days after the operation in one case, and 
twënty-one days after it in the other, a condition of the remaining eye that was 
considered by my colleagues in the Society to be sympathetic ophthalmitis. The 
removal of the artificial vitreous was at once followed by improvement, and both 
cases recovered after several weeks of what I feel sure was definite (though not malig- 
nant) sympathetic ophthalmitis. I did not directly attribute this to the operation, 
but consider that had enucleation been performed instead, no such circumstance would 
have occurred. The possibility of a sinus becoming established later in the thin 
covering that lies between the artificial vitreous and the glass eye, ought to be recog- 
nized, and cannot be entirely devoid of danger. In such cases as progressive buph- 
thalmos, and in recent wounds that require removal of the eye, where no inflam- 
mation is present that threatens its fellow, the operation may be performed, but 
where the damaged eye is threatening to affect its fellow it should be looked upon 
as a morbid centre that requires thorough and radical removal. 
Professor G-alezowski, of Paris, said-I think evisceration is not the best pro- 
ceeding. The artificial vitreous should never be introduced except in successful 
enucleation. The presence of an artificial eye upon the wounded structures lying 
about it must be a cause of irritation. I think enucleation is far more simple and 
advisable. I recall two cases. One operated upon several years ago by Prof. Richet. 
A violent inflammation ensued but the patient recovered. The stump, however, 
remained always red and injected, and finally, the patient, being the entire time a 
sufferer, came to my clinic. I cut out the stump and the patient never had any 
uncomfortable sensations afterward. A few months ago another patient presented 
himself in my clinic. He had undergone an evisceration some time previous. The 
stump was intensely sensitive and contained a fistula. I was not many moments 
in deciding to get rid of the stump, which I took out. Immediate and permanent 
recovery followed. In short, with this operation we have very much the effect of a 
foreign body introduced into the cavity of the eyeball. I advise and practice 
enucleation in every instance. 
Dr. Baker mentioned a case where he introduced a glass button with the most 
satisfactory result. The button, after remaining in for some time, fell out, from an 
accident, and the eye was lost. 
Dr. Keyser mentioned a case of sympathetic ophthalmia following an enucleation 
which left a small piece of the sclerotic attached to the optic nerve. He thinks that 
evisceration should never be done in eyes lost, from inflammation. 
Dr. Eugene Smith said that he had seen the happiest results from Mr. Mules' 
operations. Whenever evisceration had been done he always favored the introduc- 
tion of the artificial vitreous. 
Mr. Power, of London, said-I have performed or have seen the operation 
performed about twelve times. I eviscerate, wash the cavity of the sclerotic with 
strong boracic acid, and wait till all bleeding has ceased. Then introduce the glass 
ball, over which the sclerotic is brought and the edges of the cut sclerotic carefully 
sutured with carbolized gut. There should be no tension. The edges of the sclerotic 
should fit accurately. The ball should be replaced by a smaller one if there is the 
least strain on the sclerotic in bringing the edges together. The conjunctiva, which 
* Opthalmological Society Transactions, London, 1887. 766 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
has been first separated a little way from the sclerotic, is then brought together over 
the sclerotic wound, so that this wound is rendered subconjunctival ; before closing 
the lids the whole conjunctival sac should be carefully washed out with boracic acid. 
I have seen one case of suppuration of the globe, one of separation of the lips of 
the conjunctival and scleral wounds and consequent exposure and necessary subsequent 
removal of the glass globe ; and two or three attended with severe inflammation, but I 
think in my latest cases, performed with more care, these results have been much 
less frequent. 
FURTHER CONTRIBUTIONS TO THE STUDY OF SYMPATHETIC 
OPHTHALMIA. 
NOUVELLES CONTRIBUTIONS À L'ÉTUDE DE L'OPHTIIALMIE SYMPATHIQUE. 
WEITERE BEITRÄGE ZUM STUDIUM DER SYMPATHISCHEN OPHTHALMIE. 
BY HAROLD GIFFORD, M.D., 
Of Omaha, Nebraska. 
That the bearing of this paper may be better understood, I take the liberty, at the 
outset, of recapitulating the main points which I have previously advanced in this 
connection. These are- 
1. That in several of the lower animals a lymph current passes out from the vitreous 
chamber along the sheaths of the retinal vessels, leaving the optic nerve, for the greater 
part, with these vessels, and passing with them to the posterior end of the orbit, there, 
presumably, enters the cranial cavity through the sphenoidal fissure. This current I 
have called the posterior vitreous stream. 
2. That in rabbits, anthrax bacilli, when introduced into the vitreous of one eye, 
take the paths just described in passing to the cranial cavity, and from there are washed 
down between the optic nerve sheaths to the peri-choroidal space of the second eye, by 
the current which flows from the cranial cavity into the sub-vaginal space of the optic 
nerve. 
3. That leaving the disputed phagocytosis out of consideration, the choking up of 
the lymph channels, which, in rabbits, frustrated my attempts to confirm the results 
which Deutschmann* obtained with ordinary pus cocci, probably explains the non-occur- 
rence of sympathetic trouble in many cases where one eye is injected, especially where 
the primary inflammation is violent, as in panophthalmitis. 
4. That in many, if not all, normal eyes the conjunctival sac contains pathogenic 
bacteria, capable of producing severe inflammation when introduced into the cornea, 
anterior chamber and vitreous of rabbits, and that the ordinary antiseptic precautions, 
such as washing out the sac with sublimate solutions, even in the strength of 1 to 2000, 
by no means suffice to eradicate these bacteria from the sac. 
I. THE EFFECT OF OPTIC NEUROTOMY AND NEURECTOMY ON THE POSTERIOR 
LYMPH STREAM. 
That a posterior lymph stream exists in man, as in the lower animals, is altogether 
probable; whether, however, the bacteria which cause sympathetic ophthalmia leave 
the optic nerve with it, as do the anthrax bacilli in rabbits, is by no means so certain, 
but until the question is decided in the negative it will be necessary to take account of 
it in estimating the value of some of the substitutes for enucleation. To estimate the 
« Arch, of Ophthal., 1886, 2 and 3. SECTION XI OPHTHALMOLOGY. 
767 
value of optic-ciliary neurectomy on this basis, therefore, the following experiments 
were performed :- 
On five rabbits, after cutting the superior rectus, the optic nerve of the right eye 
was cut, about 4 mm. back of the eye, and a piece about 1 mm. long was then cut off 
from the peripheral stump, the wound in the conjunctiva being closed in the usual 
way. On one rabbit simple optic nenrotomy was performed on one eye; on another on 
both eyes. After from nine days to three weeks a drop of sterilized suspension of India 
ink was injected into the vitreous of three of the neurectomized eyes, through a scleral 
incision; in the vitreous of the other two a fine glass rod, carrying a small clump of 
anthrax spores covered with several dried layers of flour paste, was broken off. Of the 
neurotomized eyes two received a drop of India-ink emulsion ; the other an anthrax 
rod. The anthrax rabbits died, five, six and seven days respectively after the inocula- 
tion; the India-ink animals were chloroformed from twenty-one to forty-one days after 
the injection into the vitreous. 
The results of these experiments were so uniform that it would have been simply a 
waste of time and material to increase the number. In the India-ink rabbits the pig- 
ment grains were observed during life collecting on the papilla, just as occurs in normal 
eyes. Microscopically, the cut ends of the nerve were found one to two mm. apart, 
with no indication of any attempt at reunion, even in those eyes where the nerve was 
simply cut. The India ink was found to have passed out from the vitreous through 
the central canal into the orbit, precisely as in normal eyes. In the anthrax rabbits, 
also, the bacilli took the same course through the nerve into the orbital tissue, and in 
the case of one neurectomized rabbit they had passed over into the sub-vaginal space of 
the second optic nerve; the only difference between this and the other cases of transmi- 
gration, which I have previously reported being that in the latter the bacilli were 
carried down from the cranial cavity into the sub-vaginal space of the infected eye, as 
■well as into that of the second eye; whereas, in the neurectomized rabbit the central 
end of the cut nerve was free from bacilli. Whether this was an accident or a reliable 
indication that the current from the brain to the eye does not continue after a section 
of the nerve, future investigation must determine. The point demonstrated by these 
experiments, therefore, is that in neurectomized rabbits the posterior vitreous stream 
still persists; and whether we eventually accept the sheaths of the optic nerve, or the 
sheaths of the orbital vessels as the path taken by the microbes from the eye to the 
cranial cavity of man, the fact that in rabbits optic neurectomy is no bar to the passage 
of bacilli from one eye to the other should, until we have some positive evidence that 
this cannot occur in man, restrict the field of the operation to those eyes where there 
is no active infection. 
II. THE ANTERIOR LYMPH OUTLETS AS CHANNELS FOR THE TRANSMISSION OF 
SYMPATHETIC TROUBLE. 
The experiments of Deutschmann and my own have hitherto considered only the 
passage of microbes backward from the vitreous; but in a large proportion of cases 
sympathetic ophthalmia results from wounds which do not infect the vitreous at all. 
With this in mind, the writer has made a number of experiments on the anterior lymph 
outlets, of which I reserve for another paper such details as are of no immediate interest 
for our subject. 
The experiments of Knies,* Weiss,f and Ulrich | have gone furthest in following 
the anterior outflows, but they are open to certain theoretical objections on account of 
their having used diffusible solutions. Those of Brugsch,$ on the other hand, were 
made with suspensions of India ink, but they were carried out under the discouraging 
* Arch.f. Augen- und Ohrenheilk. 
f Arch.f. Ophthal., xxv, 2. 
J Arch.f. Ophthal., xxvi, 3. 
$ Arch.f. Ophthal., xxiii, 3. 768 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
influence of Leber's idea that there were no important outlets for the aqueous beyond 
that into Schlemm's canal, and they led only to the conclusions that there might be an 
outlet to the sub-conjunctival tissue along the anterior scleral vessels, and that leucocytes 
take up the pigment granules and carry them into the tissues of the iris, and, to a 
slight extent, far into the choroid. 
My experiments were made on white rabbits, and consisted in the injection into the 
anterior chamber of suspensions of India ink, of cinnabar, and of anthrax spores. The 
injections of pigment, instead of being made directly through the cornea, as in Brugsch's 
experiments, were made by passing a fine glass tube into the anterior chamber through 
an incision entering the posterior chamber through the ciliary body, the advantages of 
this incision being that but little aqueous is lost and that whatever is put into the ante- 
rior chamber stays there, the iris preventing any outflow through the wound. 
The results of the pigment experiments were invariably as follows : The mass of 
pigment passed quickly into the spaces of Fontana, from here passing out (1) into the 
tissues of the iris; (2) in a fine line just posterior to the membrane of Descemet, into 
the cornea; (3) in large quantities along the anterior scleral vessels to the sub-conjunc- 
tival tissue; (4) in very considerable quantities into the loose tissues of the ciliary 
processes, and from here passing back into the choroid ; in some cases showing a tendency 
to collect along the layer next the sclera, but in others occurring all through the thick- 
ness of the choroid. In the anthrax experiments the courses taken by the bacilli were 
essentially the same as those just indicated, with the exception that in the case where 
they had penetrated furthest back they were not scattered through the whole thickness 
of the choroid, but lay almost entirely in the peri-choroidal space. The tissues of the 
iris, moreover, were entirely free from bacilli, except such as lay within the vessels. 
The loose tissues of the ciliary processes and of the sub-conjunctiva seem to offer the 
bacteria an especially favorable breeding-ground, for here they were crowded together 
in immense bunches. Whether the pigment and bacilli were carried into these chan- 
nels by any decided stream I cannot positively decide. My impression is that from 
Fontana's spaces to the choroid, and along the vessels leading to the sub-conjunctival 
tissue, there are streams, while the non-occurrence of the bacilli in the tissues of the 
iris indicates that the pigment occurs there simply through the agency of wandering 
leucocytes. Be this as it may, the important point for the present subject is that a 
comparatively free path for the microbes exists between the anterior chamber and the 
ciliary processes and choroid on the one hand, and the sub-conjunctival tissue on the 
other. From the choroid the microbes can, of course, pass into the pial sheath, and 
reaching from this the sub-vaginal space, they fall under the influence of the posterior 
vitreous stream, which, it should be remembered, sucks out the contents of the sub- 
vaginal space as it passes out of the nerve with the retinal vessels. With regard to the 
communication between the anterior chamber and the sub-conjunctival tissue, it might 
at first thought seem hardly worth considering in the present connection. Yet it is 
worth noting that the current in Tenon's space is sharply toward the cranial cavity, as 
the experiments of Knies with diffusible solutions indicated, and as I have proved in a 
number of experiments on rabbits, dogs, guinea pigs and rats. In all of these animals 
I have brought semi-solid India ink under the conjunctiva, with the invariable result that 
the granules that did not remain fixed at the point of introduction were swept back to 
the posterior part of the orbit, where they were joined, in cases where the vitreous had 
been injected as well, by the particles brought through the nerve by the posterior 
stream. There remains to be considered the possibility of the anterior lymph channels 
being infected by microbes passing forward from the vitreous chamber. A current for- 
ward around the lens undoubtedly exists, and, as Ulrich* has shown in one case ot a 
« Arch.f. Ojyhthal., xxx, 4. SECTION XI-OPHTHALMOLOGY. 
769 
rabbit with an adherent leucoma, and as my own experiments have shown me in normal 
eyes, this current will carry pigment particles through between the meshes of the zonula 
into the posterior chamber. The results which I have obtained by injecting bacteria 
into the vitreous indicate, however, that except when the zonula is broken down, either 
by violence or the intensity of the inflammation, no passage of microbes occurs from 
the vitreous anteriorly. 
In some forty cases in which I have injected anthrax spores into the vitreous of rab- 
bits the bacilli were frequently found crowded against the posterior surface of the 
zonula, but the only case in which they passed forward around the lens was one in 
which the lens had been dislocated at the time of the injection. The pus cocci also 
seem to be held back by the zonula as long as the latter remains intact. 
Turning now to more theoretical considerations, I appreciate fully that in sympa- 
thetic ophthalmia the passage of microbes to the cranial cavity along the orbital ves- 
sels is nothing more than a possibility which the facts observed in rabbits make not 
altogether improbable. The main difficulty in the way of this, as of the other modi- 
fications of the germ theory, is the non-occurrence of brain symptoms, and it is rather 
less difficult to understand why bacteria entering the cranial cavity through the sphe- 
noidal fissure should be kept from spreading over the base of the brain by the strong 
current flowing down between the optic sheaths than why they should not keep right 
on into the tractus, and over the whole pia mater, if they pass up through the substance 
of the nerve and in the pial sheath, as is held by Knies and Deutschmann,* for in these 
tissues the current, if any of importance really exists, seems to be toward the brain. 
The other important objection to accepting the passage of microbes along the sheaths 
of the orbital vessels, namely, the non-occurrence of orbital symptoms, I have answered 
elsewhere. One swallow does not make a summer, nor does one coccus make an abscess, 
nor do many hundreds, unless the conditions are favorable. The well-known work of 
Wyssokowitsch f shows that large quantities of pus cocci can circulate in the blood and 
be stowed away in the liver, spleen, and bone marrow, without causing any disturbance, 
unless some trauma or derangement of the circulation give them a starting-point; and 
Grawitz has shown that relatively immense quantities of these microbes can be absorbed 
safely by the subcutaneous tissue of the lower animals, unless some favoring condition, 
such as a trifling bit of necrosis in the injection wound, give an impulse to their develop- 
ment. We need not wonder, therefore, if microbes, in small installments, wander 
harmlessly through the orbit, although the same organisms, when collected in the 
uveal tract, may cause serious inflammation. 
In conclusion, let me urge that in our haste to get rid of the old ciliary theory we 
should not lose sight of the probability that while genuine sympathetic inflammation 
is only caused by germs, its progress may be hastened or favored by reflex irritation 
from the other eye. The germ theory alone can hardly account for the numerous cases 
of immediate improvement of a genuine inflammation, far advanced, which have fol- 
lowed enucleation of the first affected eye. Just as the vasomotor disturbance caused 
by a chill may give the bacteria in the nose a chance to cause an acute coryza, or the 
pus cocci in bone marrow an opportunity for an osteo-myelitis, so, in all probability, 
can the reflex influence of an irritated eye favor the starting up or the progress of sym- 
pathetic disease in the fellow eye. 
Finally, it seems worth while to correct a prevalent misconception of the position 
of Mackenzie to the current theories of sympathetic disease. He is commonly referred 
to as the author of the optic nerve theory, and this theory, as at present held, seems to 
be regarded as simply a revival of his, with the addition of germs. How far, however, 
Mackenzie's idea was from the theory of Kniess, who, so far as I know, was the first 
* Zeitschr. f. Hygiene, I, 1. 
Vol. Ill-49 
f Virchow's Arch., 108, 1. 770 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
to advocate the spread of the inflammation by the continuity of tissue, is best shown 
by his own words. In his "Diseases of the Eye" (Am. Ed., p. 597), he says: "It is 
extremely probable that the retina of the injured eye is in a state of inflammation 
which is propagated along the corresponding optic nerve to the chiasma, and that there 
the irritation which gives rise to inflammation is reflected to the retina of the opposite 
eye, along its optic nerve." It is thus evident that Mackenzie's was but an unscien- 
tific substitute for the later theory of Arlt and von Graefe. 
RETINOSCOPY. 
RÉTINOSCOPIE. 
ÜBER RETINOSCOPIE. 
BY F. RICHARDSON CROSS, M.B., F.R.C.S., 
London, England. 
A large majority of the patients who apply to the ophthalmic surgeon are suffering 
from errors of refraction, and there is no more important subject in the whole range of 
ocular therapeutics than the proper application of spectacles. 
My apology for venturing to make any remarks upon so well worn a theme is, that 
one of the subjects suggested for consideration in the scheme framed for the work of this 
Section was, " The relative value of Retinoscopy in the diagnosis of refraction cases." 
Accuracy is the main point required, but saving of time is important, especially in 
hospital work. 
In order to make a scientific diagnosis of refraction, an objective method of testing is 
essential; but the correcting lens which is suggested by a mathematical deduction from 
the conditions of the eye as an optical instrument is not always the one that produces 
the best acuity of vision, nor that gives the greatest comfort to the wearer. Allowance 
must be made for the individuality of the eye, and subjective testing with types and 
lenses must control the results of the objective method; the patient's judgment must be 
exercised also, as to which is the best glass for his purpose; so that the surgeon may have 
a variety of evidence upon which to base his conclusion in prescribing spectacles. 
In very young children we are entirely dependent on the objective method, and with 
stupid or illiterate persons, or with very amblyopic eyes, its advantages are self-evident. 
For estimating astigmatism (which is nearly always dependent on an error of the 
cornea) Javal's optometer is an excellent instrument. 
Direct examination of the eye by the ophthalmoscope and retinoscopy are much more 
general in their application, and require no special apparatus. The first of these two is 
a most valuable test for estimating refraction, but I think it is difficult to apply in the 
lesser degrees of ametropia and in astigmatism. 
The shadow test is based upon the fact that under ophthalmoscopic examination the 
appearance of the illuminated pupil alters in a certain and definite way, according to the 
position and movements of the mirror. (Bowman, Cuignet). 
The eye which is being examined must look well into distance, so as to relax accom- 
modation; this condition is not fulfilled if the pupil varies in size; tonic or clonic spasm 
requires the use of atropine; if the pupil is merely small, cocaine is sufficient. 
On rotating the mirror the light shifts, and it is seen to be edged by a shadow, SECTION XI-OPHTHALMOLOGY. 
771 
which crosses the pupil in a direction that is constant, either with or against the 
mirror. 
Whatever be the refraction of the eye, there is always produced at its fundus an 
inverted image of the light in the focus of the mirror; the image is brighter as the retina 
is more nearly in the conjugate of the light, and it must move in an opposite direction 
to the light and to the focal point of the mirror. The illuminated image at the fundus 
of the eye is directly seen on the retina of an eye which is either emmetropic, hyperme- 
tropic, or slightly myopic; it moves as the mirror is rotated, and is followed by its 
shadow, which goes in the same direction as a plane mirror, in the opposite direction to 
a concave mirror. 
In its turn the illuminated retina reflects the rays of light which pass through the 
pupil and emerge at the surface of the cornea in a direction which depends upon the 
refraction of the eye. 
The rays are parallel in emmetropia ; in hypennetropia they diverge, more so as the 
refractive error is greater. But in myopia they converge, and thus form in the air at 
the far point of the eye a real inserted image of the illuminated retina. The produc- 
tion of this image at the far point of a myopic eye is the essential unit in retinoscopy. 
It gives rise to definite phenomena which must be briefly considered. 
When the patient's myopia is of low degree, and his far point lies behind the observer's 
eye, the illumination of the retina itself is seen at the fundus of the eye ; just as is the case 
in emmetropia and in hypermetropia, and it passes with its shadow in a converse direc- 
tion to the focal light from the rotating mirror. If, however, the far point of the 
patient's eye lies in front of the observer a shadow is seen passing over the pupil just 
in the opposite direction to the former case. The shadow now seen is no longer within 
the observed eye but lies at its far point, around the real inverted image of the illumi- 
nated retina which is formed here in the air. The shadow obscures the illumination at 
the fundus by which it has been produced, and it necessarily moves in the opposite 
direction. (If the mirror used be concave the shadow goes with it, but it goes against 
the direction of rotation of a plane mirror. ) 
When, therefore, in myopia the examination by retinoscopy is made at a greater 
distance from the patient than the far point of his eye, the shadow around this far 
point is seen to cross over the pupil in the same direction as the focal light of the mir- 
ror. Under all other circumstances the shadow is seen at the fundus of the eye, moving 
contrary to the focal light. 
Under one condition no appreciable shadow can be detected, but the retinal 
illumination seems very bright and stationary. This is when the surgeon's eye is close 
upon his myopic patient's far point and the one retina is at the conjugate focus of the 
other. 
By the aid of a suitable lens any eye may be rendered short-sighted to any required 
extent, the distance of the far point or the degree of convergence of the rays being the 
resultant of the reparative index of the eye together with that of its modifying lens. 
A method thus based upon sound optical principles-for the elucidation of which 
we are indebted to Landolt, Parent and Charnley-cannot but be of great practical value, 
and it has proved itself an easy, rapid and precise test in the hands of a large number of 
oculists. 
Various methods, by measuring from the eye under examination, have been suggested 
by Chibret, Loiseau, Schmidt Rimpier, but retinoscopy is usually practiced at some 
constant far point to which the eye can be focused by trial lenses. 
A distance frequently chosen is a little over a metre, giving a standard myopia of 
ID; this is not convenient if the ordinary box of trial sights is used ; because every 
fresh adjustment requires the observer to leave his place. The use of Doyne's optometer 
meets this difficulty, and by means of Couper's new instrument, recently shown at 772 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dublin, the oculist can work at a distance of two metres and shift the lenses himself, 
thus reducing the standard ametropia to half a diopter. In reducing it further to - .25 
D., at a distance of four metres, both illumination and trial lenses present difficulties. 
At or beyond a metre a plane mirror has advantages. I find it quite convenient to work 
at 80 cm., so as to hold the trial lens in front of the eye (13 mm.) and to be able to 
alter it from the box without shifting my seat. At this distance the ordinary ophthal- 
moscope mirror is the best; and the trial lens, which is neither too convex to turn the 
shadow with the mirror, nor too concave to give it an opposite direction, leaves a myo- 
pia of 1.25 D. (which is, of course, calculated in prescribing the spectacles). 
The macula is the proper spot for estimation evidently, but this is found impossible 
without atropine. 
The easiest is the disc, but it is unreliable, mainly because of the uncertain depth 
of the physiological cup ; Morton has shown it to be approximately correct. I find the 
space between the disc and the macula practicable and accurate. 
Like many others, I have employed retinoscopy very largely. I have no confidence 
in ordering spectacles without it. In private practice I always use it. At hospital every 
patient is tested by an assistant, with types and trial lenses, and he brings me the result 
written down. Presbyopia and the simpler cases are at once prescribed for, but any 
that are at all complicated I estimate by retinoscopy without atropine. 
In hypermetropia a good deal that was " latent " is at once made manifest. Astig- 
matism and the direction of its meridians is detected. 
The lenses suggested in myopia are frequently found to be too strong, etc. 
As a rule, now, with the subjective test balanced by the objective, lenses can be 
safely ordered. But when it is thought necessary atropine is also used, and under its 
influence both retinoscopy and trial-sighting are again applied. 
I find as a result that the lens, whether spherical or cylinder, which is based upon 
retinoscopy (an allowance of about -1.50 D. being made in each meridian) is quite 
satisfactory to the large majority of patients, so far as can be judged through those who 
remain under observation or who report themselves from time to time. 
Out of a very large number I have kept short notes of 462 cases of retinoscopy from 
which some deductions may be fairly drawn. 
In ten per cent, the result of the test was not quite satisfactory; i. e., the lens decided 
on for spectacles did not completely or fairly coincide with the deduction from retino- 
scopy. 
This seems a large number, but the notes were made for no special purpose; nearly 
400 were examined without atropine; in some the observation may have been inaccurate; 
others can scarcely rank as errors; moreover, many of the notes were kept because the 
cases were unusual. 
In the remaining 413 the lens ordered for spectacles was the one that most nearly 
neutralized the shadow c - 1.25 D. (or C? - 1.50 D., or occasionally - 2D. ) This lens 
often differed materially from that which seemed to give best sight at the earlier sub- 
jective testing. The patient's tendency is to choose a lens too - or not enough -)-. 
In these days of "short-sighted education" it is important to separate excess of 
ciliary tone from myopia, and to give full help in ciliary strain. I believe retinoscopy 
may be fully relied on, and without atropine, even for the detection of slight errors of 
ametropia, where subjective testing alone may be very misleading. It is, however, 
especially valuable in the detection of astigmatism, together with the meridian of 
greatest error. A cylinder will usually be found of benefit in any case where retino- 
scopy indicates that astigmatism is present, and yet my notes show that out of the 
whole number-49-of unsatisfactory cases, 29 had reference to the use of cylinders. 
With few exceptions, however, the errors were very slight in extent. 
In 101 cases of hypermetropic astigmatism, as judged by retinoscopy, a cylinder lens SECTION XI-OPHTHALMOLOGY. 
773 
was of no help in 12 (in one of them the cylinder suggested was + 2 D.). In eight 
the cylinder required to be slightly stronger or weaker than had been judged. In one 
a cylinder + 1 was of value though not estimated by the shadow test, - T2+-. 
The cylinder was also slightly misjudged in eight cases out of 90 patients with myopic 
astigmatism, - fa. 
No rule can, I think, be drawn as to the value of using the weakest cylinders. Very 
frequently they may be disregarded, but they should always be ordered if they aid 
acuity of vision, or when the eye is hyperæsthetic. A colleague of mine is quite uncom- 
fortable in far sight without -.50 D. cylinder. A cylinder -.25 makes all the differ- 
ence to a lady, combined with sphericals, one spherical being only +.50. Slight hyper- 
metropic astigmatism in children gives rise to the symptoms of short sight, and as con- 
cave lenses are found to improve distant vision, they are sometimes ordered instead of 
what is really needed-a convex cylinder. Retinoscopy prevents any such mistake. As 
to the use of atropine in retinoscopy, it can usually be dispensed with. It is of little 
help in aiding in the detection of astigmatism. No doubt it shows a certain amount of 
hyperopia beyond what is manifest to retinoscopy, but the latent defect is spherical and 
common to all meridians; there is no change in the estimation of the cylinder required. 
This fact is legible enough, for atropine affects the muscle of the lens, while astigma- 
tism is an error of the cornea. 
Atropine was used in 12 of the cases noted, usually in hypermetropia, and in some 
for a week or more. 
In eight cases a modification of the strength of the cylinder resulted ; in two a slight 
difference was shown in the meridians which before were similar, and in one astigmatism 
that had been noted disappeared. All these differences from the results of retinoscopy 
without atropine were slight in degree. 
Astigmatism after atropine 
As may be expected, a latent defect was shown by retinoscopy under atropine com- 
pared with retinoscopy without the drug. The latent hypermetropia thus exposed, how- 
ever, was not marked in extent; it was spherical in increase, whether the eye was 
astigmatic or no. 
In 23 cases the increase was 1 D. ; in five cases it amounted to 3 D., and in 12 cases to 
2 D. The difference was barely a diopter in 14 cases, and in three it amounted to 1.5 D. 
In one pair of eyes dissimilar in refraction atropine showed an increase of hyper- 
metropia alike in both eyes, of 3 D. in the horizontal meridians and of 2 D. in the 
vertical. 
Atropine would seem, therefore, to be of little value in retinoscopy as compared with 
the importance it possesses in estimating refraction by subjective testing only; for 
without its use retinoscopy exposes a much higher degree of hypermetropia than is 
manifest to testing with trial lenses, and moreover, after its application no marked 
latent hypermetropia is, as a rule, found-no more, indeed, frequently, than represents 
the normal tone of the ciliary muscles. 
The highest degrees of hypermetropia in my list were a pair of eyes estimated at 
12 D. which required lenses + 10 D., and a pair of eyes 7 D. X 13 D., requiring a 
+ 5 cylinder combined with + 5 spherical. 
In twenty of the cases quoted a lens of at least + 5 D. spherical or cylinder was 
required. 
In myopia I have estimated several cases over - 20 D. and have patients wearing 
- 20 lenses. 
In one case estimated - 17 D. O - 21 D. lenses -14 O - 4 cylinder are constantly 
worn, and pincenez lenses - 4.50 D. over these for improving distant vision, the com- 
bination being 22.50 X 18-50. 
There were 243 myopes, of whom 90 had astigmatism. 774 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Allowing for correction, retinoscopy may understate the concave lens which is 
required in order to produce perfect acuity of vision. A glass slightly too weak is, 
perhaps, an advantage. In four of my cases, however, I found that I had over-estimated 
the lens which gave the best sight. 
In four cases of astigmatism a slight error occurred in the value of the cylinder. 
In four other cases the test did not seem satisfactory; the concave lens required for dis- 
tance, through which also the patient read small type, was much in excess of that sug- 
gested by retinoscopy, but by this means considerable ciliary spasm was detected, and 
the value of the test still further shown. 
Thus, scarcely two per cent, of failures occurred in testing myopia by this method. 
It is well known that after iridectomy flattening of the cornea occurs, requiring the aid 
of a convex cylinder whose axis is at right angles to the direction of the coloboma. 
In my records of several such cases the estimation of the astigmatism by retinoscopy 
is quite in accordance with the lens required for best acuity of vision. 
RETINOSCOPY. 
RETINOSCOPIE. 
ÜBER RETINOSCOPIE. 
BY A. R. BAKER, M.D., 
Of Cleveland, Ohio. 
It would be an interesting study to determine some of the causes which lead the 
Medical profession to accept a new drug upon the most meagre testimony, when origi- 
nating from the most obscure sources, while a new surgical procedure or instrument of 
precision in diagnosis is summarily rejected, and if ever brought into general use it is 
only after a long and persistent fight against the prejudices of the profession. This may 
be illustrated by the many long years which abdominal surgery took to gain the sanc- 
tion of the Medical profession, compared with the almost universal acceptance and use 
of cocaine as a local anaesthetic within a few weeks. Or even with Jequirity, an agent 
quite as potent, and liable to do very great harm when used improperly, which the 
merest tyro in medicine does not hesitate to employ, and is used even by those who 
never dream of using the ophthalmoscope, of which it has been remarked, that with 
this instrument it is "like walking into nature's laboratory and seeing the Infinite in 
action," since by its means we are enabled to look upon the only nerve in the whole 
body which can ever lie open to our inspection under physiological conditions, and to 
follow in a transparent membrane an isolated circulation from its entrance into the eye 
through the arteries to its exit in the veins. We are further enabled to watch and 
study daily, or even hourly, morbid processes in each and every phase, from simple 
hyperæmia to absolute stasis, and from passive œdema to the most violent inflammation; 
while ofttimes through its agency also we get the first intimation of disease in remote 
and seemingly unconnected organs, so as to read, as if in a book, the written trouble of 
the brain, the heart, the spleen, the kidneys, and the spine.* 
Although Retinoscopy has been used very extensively by general practitioners and 
specialists in England and France, it has been almost entirely ignored by German and 
* Virchow. Transactions International Medical Congress, London, 1881. SECTION XI-OPHTHALMOLOGY. 
775 
American practitioners. While Cuignet, Parent, Chibret, Forbes, Morton, Hartridge, 
Juler, Landolt and a host of others, have written articles upon this subject, extolling its 
value and urging its superiority and adoption over other methods of determining errors 
of refraction, no less an authority than Dr. Hirschberg, of Berlin, remarked in a laugh- 
ing manner, when the writer asked his opinion of the value of retinoscopy, "Oh, that 
is a lazy English method, and don't amount to much." 
Dr. Loring, in his excellent text-book says, ' ' that it is, in his opinion, the most 
difficult and least satisfactory of any of the methods of determining the refraction of the 
eye, and contributes nothing which cannot be more easily and more expeditiously per- 
formed by the upright image." 
It is unfortunate for any profession to permit national or race prejudice to bias the 
discussion as to the merits of any scientific discovery, but the manner in which retino- 
scopy has been received shows that the medical profession have not risen entirely above 
these considerations. Retinoscopy was first brought to the notice of the profession by 
the French, and received by the English and used extensively by them. It was sum- 
marily rejected by the Germans and Americans without investigation. 
It was a favorite theory of Bayard Taylor that the Americans were growing more 
like the Germans in their literary and scientific work and methods of thinking, if not 
in physical appearance. 
This has been particularly true of the medical profession in this country, who have, 
in a manner at least, seemingly followed the profession in Germany, accepting what the 
German professor accepts and rejecting what he rejects. He rejected retinoscopy, and, 
true to the prevailing fashion, the American rejected it, without examining the subject 
ffir himself. 
But this is not the only element which decided the question in the minds of such 
acute observers as Prof. Hirschberg and Dr. Loring. Prof. Hirschberg (if he will par- 
don the personal allusion) is one of the most accurate men in the use of the ophthalmo- 
scope I have ever met. I remember, while in his clinic, in Berlin, in 1882, his 
examining a number of patients in the dark room and sending them out for me to 
prove his ophthalmoscopic findings with trial lenses and test type. The accuracy of his 
ophthalmoscopic readings, especially in astigmatic cases, was a revelation to me; especially 
as I had always been rather skeptical as to the ability of any one to determine accurately 
the amount of error in cases of astigmatism by means of the ophthalmoscope alone. 
But granting that Professor Hirschherg can determine the amount of error of refraction 
accurately by means of the upright image, it is not accomplished by every one; in fact, 
very few can do so. The same remarks will apply, to a certain extent, to Dr. Loring, 
together with the fact that his name is associated with one of the best refraction ophthal- 
moscopes made. This method of determining refractive errors has become somewhat 
of a hobby with him, and he could not easily be persuaded that there was a better 
and easier method. 
I believe one of the great objections to the introduction of retinoscopy has been the 
belief that the present methods are good enough. It has been the aim of nearly every 
oculist in this country and Germany to learn to determine errors of refraction by means 
of the upright image. Theoretically, this would seem to be the most rational method, 
but practically, it has been found that few, if any, under forty years can practice it 
successfully, and that no one can do so unless he has a large amount of clinical mate- 
rial to keep him in constant practice. Another reason why retinoscopy has not been 
better received by the profession in America has been the unfortunate manner in which 
the subject has been presented to American readers. The only articles which have been 
published in this country (Dr. Swan M. Burnett's work on astigmatism has appeared 
since this was written) were that by Dr. Jackson, in the American Journal of Medical 
Sciences, June, 1880, and a brief paper in the American Journal of Ophthalmology, July, 776 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
1884, by the writer. Dr. Jackson commits the grave error of recommending a plane 
mirror, and instead of neutralizing the shadow by means of lenses, he judges of the 
amount of error by the distance he is obliged to go from the patient in order to neutral- 
ize the shadow. The method recommended by him is not retinoscopy as taught and 
practiced by the French and English, but merely a modification of the old method 
known as the " fundus image " test. It has always been recognized, and utilized to a 
certain extent, that in emmetropia, at a distance of several feet, when a light was directed 
into the eye from an ophthalmoscopic mirror, nothing but a red reflex could be distin- 
guished. If the eye was myopic or hypermetropic in a high degree, the disc and 
blood vessels could be seen. When a plane mirror is used, these vessels will move in 
direction against that of the mirror in myopia, and with it in hypermetropia, and by 
gradually approaching the patient the vessels will become invisible, and as you come 
closer will be reversed. This point of reversal corresponds to the far point of vision, 
and by measuring the distance from the eye, the amount of myopia or hypermetropia, 
by first making the eye highly myopic with a concave lens, may be approximately 
determined. It is to be regretted that Dr. Jackson has presented this somewhat diffi- 
cult and, at best, uncertain method of determining errors of refraction in place of the 
simple, uncomplicated and definite method of retinoscopy as taught in the English 
ophthalmic hospitals. I like the term retinoscopy, and believe it will be retained as the 
proper one. At one time I was greatly in favor of substituting the name of " shadow 
test," as I thought that would convey the proper meaning of the method of examina- 
tion a little more definitely and prevent confounding of it with other mirror tests, as 
Dr. Jackson has done; but I see he uses, as the title of his article, the very term that I 
thought would prevent this mistake. 
The examination by this method is so simple that I sometimes think much valuable 
time has been wasted in explaining the method of its performance. I fear that the 
descriptions have often served to render the subject more obscure. With a few trials I 
have been able to teach students with no special skill in the use of the ophthalmoscope 
to use it satisfactorily and with benefit to patients. I know one spectacle peddler who, 
making no pretensions to a knowledge of refraction and accommodation, uses it suc- 
cessfully in his business. 
In teaching the use of retinoscopy, if possible, I select for examination a person 
with emmetropic eyes-usually a fellow student. 
For beginners, it is better to dilate the pupil with cocaine. My ophthalmoscope is 
furnished with two mirrors attached by means of a screw; one large mirror of about 
twenty-four inches focus for making examinations by the indirect method and for per- 
forming retinoscopy, and one mirror (small) placed at an angle of the usual focus for 
direct examinations. This is known as the Johnsons' ophthalmoscope, and is made by 
Crouch, of London. 
I seat the patient with his back to the light, and the student opposite at the distance 
of about three or four feet. I then direct him to reflect the light into the eye of the 
patient, who is requested to look past the opposite ear of the one making the examina- 
tion. If the observer has had a little experience in using the ophthalmoscope he catches 
the red reflex from the fundus directly. With beginners, I find this the most difficult 
part to teach. I then direct the examiner to rotate his mirror from side to side slowly 
and watch the red reflex carefully, and ask him whether he sees a slight shadow mov- 
ing across the red disc. Most observers see it easily, others require some little time. 
Beginners often make the mistake of moving their heads instead of rotating the mirror, 
I then direct them to rotate the mirror in the vertical meridian until they see the shadow 
again. I am careful to see that they rotate it, not move it up and down. I then place 
a J- 1 D. in a spectacle frame, in front of the eye under examination. The examiner 
will soon tell you he can see no shadow. I then put in a -f- lens (having the -j- 1 D. in SECTION NI-OPHTHALMOLOGY. 
777 
place, which I do not change during the entire examination) and he again sees the 
shadow. I direct him to observe closely the direction in which it moves. I alternate 
plus with minus lenses, and the examiner will soon tell you that with the plus lenses 
the shadow moves opposite to the direction in which the mirror is moved, and with the 
minus lenses it moves with the mirror. 
By leaving the + 1 D. in the frames we are not obliged to make the additions and 
subtractions which are necessary if it is removed, and we go on with the examination 
just as if it were not there, making the calculations as simple as with a plane mirror. 
One of the first questions asked by the student is, why do we have this shadow 
moving in the same direction as the mirror, in low degrees of myop a ? And why is it 
necessary to use this + 1 D. to neutralize the shadow in emmetropia ? This is because 
with a mirror of twenty-four inches focal distance the rays of light do not cross before 
reaching the observer, and an erect image of the illuminated and shaded portion of the 
retina is obtained, the same as when a plane mirror is used. 
The following rules are of great practical importance in making these examinations.* 
1. If the image of the shadow appear to move in the same direction in which the 
mirror is moved, and if the rapidity of movement and curvature of the shadow are the 
same in all meridians, we have to do with a simple myopia. 
2. If the shadow appear to move in the opposite direction to that in which the 
mirror is moved (remember in all of these examinations the + 1 D. is to be left in 
situ), and if the rapidity of movement and curvature of the shadow are the same in all 
meridians, we have a simple hypermetropia. 
3. The slower the movements of the image the feebler the illumination ; and the 
more crescentic and narrower the shadow, the higher the hypermetropia or myopia. 
4. A difference in two opposite meridians, either of direction or rapidity of move- 
ment, or of the curvature of the shadow, indicates astigmatism. These two dissimilar 
shadows, moving at right angles with each other, either one vertically and the other 
horizontally, or both obliquely, indicates the meridian of greatest and least refraction. 
5. If the shadow moves with the mirror in one meridian and against it in another, 
we have a case of mixed astigmatism. 
By means of ordinary trial lenses it is easy to measure the amount of error of 
refraction. If the shadow move with the mirror, we place concave lenses in the spec- 
tacle frame until the shadow is neutralized, and the number of lenses required will 
indicate the amount of myopia. 
If the shadow moves opposite to the direction in which the mirror is moved, convex 
lenses are used until the shadow is neutralized and the lens required to neutralize the 
shadow will indicate the amount of hypermetropia. In cases of simple astigmatism 
no shadow will be seen in one meridian, and a shadow moving with or against the 
mirror in the opposite. By neutralizing this shadow with the appropriate lens it will 
indicate the number of the cylindrical glass required to correct the astigmatism. In 
cases of compound astigmatism, it will be necessary, first, to correct the meridian with 
the least error of refraction. This will indicate the spherical lens required; and then 
by correcting the meridian with the greater error, and deducting the lesser from the 
greater the cylindrical lens required will be found. Suppose we have a case in which 
it requires a + 1 D. to neutralize the shadow in the horizontal meridian, and a 4- 3 D. 
to neutralize it in the vertical. To correct the error would require a spherical 1 D. 
3 + 2 D. Cylindrical. Axis 90. 
+3 D 
O+id- 
* Morton. " Refraction of the Eye." 778 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Cases of myopic compound astigmatism may be corrected in a similar manner, 
using concave lenses. Cases of mixed astigmatism can be corrected in the same way. 
Supposing a given case requires a + 2 D. to neutralize the shadow in the vertical 
meridian and a minus 1 D. in the horizontal 
+ 2D 
Q_'D. 
The following formula would indicate the lens required to correct the error of 
refraction : Spherical + 2 D. 3 - ID. Cylindrical. Axis 180. 
I think one reason why retinoscopy has not come into more general use is the fact 
that, in order to determine the amount of error of refraction, it is necessary to resort 
to the use of trial lenses. 
One of the great objects to be attained by the numerous optometers presented to 
the profession, and this has been almost as fruitful a field for the inventive genius of 
the oculists as the pessary has to the gynaecologist, has been to do away with trial 
lenses. This has also been one of the great advantages claimed for the direct method 
of examination with the ophthalmoscope. 
But, whatever other means are made use of to determine the amount of error of 
refraction, I do not believe we will ever be able to discard the practical test w ith trial 
lenses. Often the lenses which are theoretically correct are not the ones practically 
best adapted to the needs of the patient. I presume my experience has been similar 
to that of most ophthalmologists, when I say that I frequently find patients wearing 
simple spherical lenses selected by themselves, or some traveling spectacle peddler, 
who have discarded the use of compound lenses which have been fitted with great 
labor and skill by the oculist. 
There is in all these cases an unknown quantity, the accommodation, and the ophthal- 
mologist who keeps this fact in mind, and proves his readings either with the ophthal- 
moscope, or by means of retinoscopy, or any of the optometers, by an actual test with 
trial lenses, will often save his reputation as an oculist, and render the best service to 
his patients. 
But as it is often necessary to prescribe spectacles when we cannot have the aid of 
trial lenses, I have made use of the following simple device which occurred to me in an 
emergency some years since. As already stated, I make use of an ophthalmoscope with 
two mirrors attached by means of a screw. Simply by detaching these mirrors I have 
two instruments. First, a retinoscope with a good handle, and second, a series of 
lenses conveniently arranged for determining the amount of error of refraction, which 
answers every purpose of a trial case. This latter I give to the patient, directing him 
to look past my ear through the small hole. I then proceed to make the examination 
in the usual manner, directing him to turn up the proper lens, as required. 
I have made use of this simple procedure for a number of years and have found it 
to serve me admirably when away from my office, where I could not have access to trial 
lenses. 
I have found the concave mirror much superior to the plane one. It concentrates 
the light so that we secure better illumination, and makes it possible to sit at such a 
distance from the patient that it is convenient to change the lenses without moving. It 
has been urged that the exercise necessary in walking backward and forward each time 
a lens has to be changed was of benefit to a physician of sedentary habits. This has not 
impressed me of very great advantage. I would still prefer to have retinoscopy charac- 
terized as a "lazy English method," and keep my seat. 
The advantages of retinoscopy are many. It does not require any expensive appa- 
ratus or paraphernalia. It is easy of execution; any one capable of making an ophthal- 
moscopic examination can learn to use it in a few hours. It saves valuable time. SECTION XI-OPHTHALMOLOGY. 
779 
Cases which formerly took from one to a dozen sittings, as long as the patience of my 
patient and myself would permit, are now disposed of usually in one sitting of short 
duration. 
Although it is necessary to use atropia occasionally to paralyze the accommodation, 
especially when there is spasm of the ciliary muscle, I find that since I have become 
accustomed to using retinoscopy it is not necessary to use atropia once where I formerly 
used it ten times. There is one point on which many observers are at fault. That is 
in directing the patient to look at the mirror. If, instead, the patient is directed to look 
at the dark wall beyond, the accommodation is relaxed, the pupil dilated, and the 
examination made comparatively easy, and the use of a mydriatic seldom necessary. 
With a little practice the physician soon learns to distinguish when the accommodation 
is relaxed, by the condition of the pupil. 
A retinoscopic examination is more easily performed than an ophthalmoscopic one by 
the indirect method. It is more accurate as a means of correcting errors of refraction 
than by the upright image, and the examination is made as quickly as with the opto- 
meter. 
We are enabled to examine cases and correct the error of refraction without the 
assistance of the patient, a very important matter with children, ignorant people, and 
those of feeble intellect. We are enabled by means of retinoscopy to fit spectacles 
accurately in cases of amblyopia as the result of the excessive use of tobacco, alcohol, 
etc., and especially as the result of squint. In cases of nystagmus, in which it is 
impossible to fix the eye, its use is invaluable. 
I have purposely omitted all allusion to the optical principles involved, as they have 
been fully discussed in the many papers written on this subject. I have endeavored 
to present this subject in a plain, practical manner, and if this incomplete paper should 
be the means of creating enough interest in retinoscopy to lead you to give it a fair 
trial, I am sure you will be surprised with what ease difficult cases of error of refrac- 
tion can be corrected. 
DISCUSSION. 
Dr. Galezowski, of Paris, said : The work of Mr. Cross is very interesting and his 
method worthy of your serious attention. It is probably the most mathematical of 
the methods of estimating errors of refraction. But a word as regards the history 
of this method of examination. Mr. Cross has not made mention of the fact that 
Monsieur Cuignet discovered and practiced this method fifteen years ago, and one of 
my assistants later on wrote several descriptions of the same method of examination. 
And to these two gentlemen is due the credit of retinoscopy. Thanks to Mr. Cross, 
it is now known in America. And another point, allow me to say that I am com- 
pletely against the name Retinoscopy. One, on giving this name, would think imme- 
diately that it was a method for diagnosing the condition of the retina. Other 
authors wish to give it the name of pupilloscopy, but this, on the same principle, 
would not hold, for it would seem to indicate the condition of the pupil. In the last 
edition of my ' ' Atlas of Ophthalmoscopy ' ' I have suggested the name Dioptro- 
scopy, as coming nearer the idea of the discoverer of the method, inasmuch as the 
degrees of the refraction are expressed in dioptres. 
Dr. Swan M. Burnett.-Though a rose by any other name perhaps would 
smell as sweet, an indiscriminate use of a number of names for the same thing should 
not be permitted in a science whose nomenclature is supposed to assist in definition 
and to convey to the learner, by the word used, some precise idea of what the thing 
is or is supposed to be. Prof. Galezowski has shown that neither "retinoscopy" 
nor ' ' pupilloscopy ' ' at all describe the method, which takes its name from the NINTH INTERNATIONAL MEDICAL CONGRESS. 
780 
object seen by the observer, and I am forced to reject his own term, " keratoscopy," 
on the same ground. Both Mr. Cross and Dr. Baker have constantly used the word 
" shadow " in their papers when they wished to indicate the thing seen, and whose 
changes of form and position characterize the procedures. That being the case, 
" skioscopy," it seems to me, is the only term that we can accept as descriptive of 
this method of examining the refraction of the eye. If we wish to use an English 
word we can say ' ' shadow test. ' ' I have shown my belief in the method by giving 
it a chapter in my work on astigmatism. I use myself a plane mirror, but the 
choice of the plane or concave form will depend upon the one with which the 
operator has been most accustomed to work. 
Mr. Cross incidentally, in his remarks, states that astigmatism is corneal, and that 
the action of the ciliary muscle only affects the general ametropia and but rarely the 
astigmatism. 
A considerable experience with the keratometer of Javal has shown me that in 
a number of cases the astigmatism of the eye is not accurately represented by the 
corneæ, but that there exists a lenticular form, due to partial contraction of the 
ciliary muscle, and generally such as to neutralize the corneæ in whole or in part. 
Dr. Fannie Dickinson, Chicago, would like to ask Mr. Cross if, in all cases, 
where, after the use of atropine, he found the latent amount of refractive error after 
retinoscopy to be a spherical correction of 0.50 D. to 1.50 D., did he find points of 
similarity in these cases, as age, occupation, general muscular tone, or other points 
which modify and vary the proportion to be corrected of the entire error of refrac- 
tion found after the use of atropine ? She desired to make a comparison between the 
amount of error left uncorrected by retinoscopy, which Mr. Cross suggests may be 
considered as the "tone of the ciliary muscle, ''and the tone of the ciliary muscle which 
is taken into consideration and allowed for after the use of atropine in many cases. 
Mr. Cross.-Besides our deductions from examination by retinoscopy (as several 
speakers have suggested), varying accommodation of the eye, age, occupation, 
individuality, in fact, must be fully considered in prescribing spectacles. As regards 
the various names that have been suggested for the method, it is not only the shadow 
that is watched but the light of which the shadow is the edge ; its movements are seen 
not only in the pupil but through it upon the retina. The term retinoscopy is too 
inclusive ; it might also be applied to other forms of retinal examination, but for the 
present I think it is the best we can use. Keratoscopy is wrong and misleading, for the 
cornea certainly is not the observed part. I agree with Dr. Burnett that asymmet- 
rical action of the ciliary muscle may occasionally produce a lenticular astigmatism. SECTION XI-OPHTHALMOLOGY. 
781 
FIFTH DAY. 
TREATMENT OF ABSCESS AND ULCERATION OF THE CORNEA 
WITH JEQUIRITY. 
TRAITEMENT D'ABCES ET D'ULCÉRATION DE LA CORNÉE AVEC LA 
JÉQUIR1TÊ. 
ÜBER DIE BEHANDLUNG DER ABSCESSE UND ULCERATIONEN DER HORNHAUT DURCH 
JEQUIRITY. 
BY EUGENE SMITH, M. D., 
Of Detroit. 
We have been taught by experience that, in extensive infiltrations of pus in the 
cornea, there is small hope of its absorption ; and we are all aware of the tendency of 
the pus to diffuse itself widely. This tendency to spread in all directions is found in 
closed abscesses-not infrequently in abscesses which have opened internally or exter- 
nally-and occasionally in open ulcers. 
The progressive destruction in and around the original point of disturbance is due 
to the proliferation, to the solvent property of the infiltration, and to the pressure on 
the infiltrated tissue. Possibly, or probably the presence of microbes play a not unim- 
portant part in the progress of the disease. 
How best to check and suppress the suppuration and arrest the progressive destruc- 
tion of the cornea, are questions which have long agitated the minds of ophthalmolo- 
gists, as has also the best means of getting rid of the more or less extensive opacity so 
invariably left if the patient recovers. 
These somewhat general remarks bring me to the subject under consideration, the 
treatment of abscess and ulceration of the cornea with Jequirity. 
In September, 1883, in an article published in the Journal of the American Medical 
Association, I called attention to its action in a case of asthenic ulcer of the cornea in a 
decrepid man of seventy-three years of age, where the eye was rapidly going to destruc- 
tion in spite of all treatment. As I was using jequirity in several cases of trachoma, its 
peculiar effects upon the circulation led me to test it, by way of experiment, in this case. 
A 3 per cent, solution was applied to the conjunctival sac three times in twenty-four 
hours, and much to my surprise, the progressive necrosis was checkèd, and in two 
weeks the patient was discharged well, and the resulting cicatrix was surprisingly 
slight. 
In October, 1883, I again called attention to the use of this remedy, in an article 
published in the Medical Age, citing several cases of obstinate herpetic trouble, vascular 
ulceration, etc., which were speedily relieved by its use when prolonged treatment by 
the usual methods had failed. 
Since that time I have frequently resorted to its use in cases of ulcus cornea serpens, 
chronic vascular ulcer, asthenic ulcers and abscesses, and in one case of herpes zoster 
seu ophthalmicus. In several cases the extent of the purulent collection and the char- 
acter of the case seemed to forbid all hope of saving the eye, or even a sufficiently large 782 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
portion of the cornea for an artificial pupil, yet, in each case recovery has taken place, 
with the resulting opacity so thin as not to call for operative interference. 
To what is this very remarkable absence of scar tissue due ? 
I have not sought to study the physiological action of the drug, but have occupied 
myself with noting its clinical effect, though I have wondered if the jequiritic bacillus 
had anything to do with the demise of the microbes said to be present in ulceration of the 
cornea. I incline, however, to the belief that the proliferation of the corneal corpuscles 
and their segmentation is checked, while nutrition is increased by the numerous blood 
vessels, a fine network of which, more or less abundant, and apparently quite thin, 
develops on, or in the cornea, for, coincidently with their development is seen a 
marked change in the character of the abscess or ulcer; we soon observe the opacity to 
be disappearing and the transparency of the diseased portion of the cornea returning, 
most positive evidence of improved nutrition. 
I do not practice, nor would I advise pushing the remedy to the point of getting the 
degree of jequiritic inflammation necessary in the treatment of trachoma, but find that 
a 3 per cent, solution applied two or three times in twenty-four or forty-eight hours- 
or one application of a very small amount of the powdered seed, keeping the eye cleansed 
with a 2 per cent, solution of boric acid after the jequiritic effect is established, answers 
the purpose. The inflammation of the conjunctiva is seemingly catarrhal in character, 
with, in some cases, but a slight degree of the membranous characteristic. 
DISCUSSION. 
Dr. Galezowski, of Paris, said-Allow me to make a few remarks on the sub- 
ject of Dr. Smith's paper. In the several years that it has been used, I have seen 
jequirity produce such grave results, that I question the advisability of using such a 
substance in ulcers of the cornea. Certainly much depends upon the strength of the 
solution employed, and, as I have never used the solution in the same strength as 
that employed by Dr. Smith, naturally I can say nothing of its results. Apropos of 
ulcers of the cornea, allow me to make some remarks, the result of my own experi- 
ence during the pagt few years. I have met many cases where corneal ulcers have 
resisted every kind of treatment, and I have searched for the reason in vain. Finally 
I came to the conclusion that in a great number of cases the ulcers were only herpetic 
in nature and were provoked by an intermittent fever. In another case I observed 
a carious tooth had given rise to persistent neuralgia, and again, as a cause, spontane- 
ous neuralgia of the fifth pair of nerves. Of course, in such cases the cause must be 
treated. 
Locally I prescribe iodoform powder, or the steam douche is allowed to play upon 
the eye, and for the pain I generally instill cocaine. The older Desmarres was 
accustomed to use atropine in corneal ulcers, while at the same period Velpeau 
employed nitrate of silver, and indeed recommends it highly in his treatise on "Eye 
Diseases. ' ' This latter remedy I have tried, and I am happy to say in a number of 
cases with great success. I always immediately neutralize with a solution of chloride 
of sodium. To sum up. It is important to get at the cause of the trouble and 
treat that. Locally I use iodoform powder, steam douche and the cauterization of 
the ulcers with a two per cent, solution of nitrate of silver applied with a camel's 
hair brush and immediately neutralized with a solution of sodium chloride, and 
through such treatment I have had the happiest results. 
Dr. Smith closed the discussion by saying that he always tried first a three per 
cent, solution, and if that did not act favorably he stopped its use immediately. SECTION XI-OPHTHALMOLOGY. 
783 
NECESSITY FOR REFORM IN THE MANNER OF DESIGNATING 
LENSES. 
NÉCESSITÉ DE RÉFORME DANS LA MANIÈRE DE DÉSIGNER LES LENTILLES. 
NOTHWENDIGKEIT EINER VERBESSERUNG IN DER METHODE ZUR BESTIMMUNG 
DER AUGENGLÄSER. 
BY DUDLEY S. REYNOLDS, A. M., M.D., 
Of Louisville, Ky. 
The greatest difficulty iu determining errors of refraction in the eye lies in the 
faulty manner of constructing the instruments used in testing. The lenses in our 
trial-cases are graded according to what is known as " the metrical system," or by the 
radius of curvature, according to the plan of determining astronomical refractions. The 
lenses sold in the shops are graded roughly by the approximate length of the refracted 
rays from the nodal point in the lens to the focal point of the light. Now, the attempt 
to grade a system of refracting lenses by the measurement of the focal lengths only, is, 
of itself, unfortunate. It induces the optician to attempt the impossible; and it is just 
here that the metrical system is especially faulty. In this system, the glass which 
focuses light at the distance of one metre, from its nodal point is called " a Dioptre," 
and this is the unit of refraction. According to this system, the lenses are graded by 
0.25 D., 0.50 D., 0.75 D. ; and below the unit, in whole numbers, halves and quarters. 
Now, since the focal length of the unit is a metre, and since it is necessary in any at- 
tempt to establish the focal point of a lens at half this distance the radius of curvature 
shall be considered, it seems unreasonable to go near this point in the choice of the 
unit, and, besides, it is not easy to establish focal lengths of a series of lenses by the 
means ordinarily employed in measuring. In addition to all this, 1.50 D. should have 
a focal length of about thirty inches; 2 D. about twenty inches; while 1.75 D. would 
fall at about twenty-five inches. So that no intermediate focal point may be 
reached by this system between twenty and twenty-five inches, or between twenty-five 
and thirty inches. To every experienced ophthalmic practitioner, this, at times, proves 
unsatisfactory. Now, according to the old system of astronomical refractions, the unit 
is obtained by the maximum angle of refraction in a spherical body. Thus, a trans- 
parent sphere, highly polished, and made of what is known as optical crown glass, 
will interrupt the passage of light to the full extent of its own diameter, while 
light falling upon the surface of the sphere would be refracted toward the centre from 
a portion of the circumference equal to 90°. As the whole circumference represents 
360°, 90° is, of course, equivalent to a quadrant of the sphere. If the sphere be about 
two inches in diameter, the quadrant focuses light near the centre of the sphere, or, by 
actual linear measurement, at f of an inch from the nodal point of the segment repre- 
senting the quadrant. Now, the quadrant, being the unit, represents a definite radius 
of curvature, no matter what the size of the sphere; and the series of refracting lenses 
derived from the division of this quadrant is what Dr. Robert Smith employed to 
designate the varying degrees of refraction in his "Compleat System of Opticks," 
published at London, 1738. It was employed by Dr. Wm. Porterfield in his treatise 
on " The Manner and Phenomena of Vision," published at Edinburgh, 1759. In fact, 
it was the only system of grading lenses recognized by scientific writers and experi- 
menters down to the time of the publication by the new Sydenham Society, of Lon- 
don, of Donders' great work on the " Anomalies of Accommodation and Refraction," 
in 1864. Donders has been the text-book since that time for most of us. In recent 
years, however, the metrical system has been brought forth and made popular by the 
labors of Landolt, Snellen, and the German writers on accommodation and refraction. 784 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
What is commonly called ' ' the inch system ' ' of measuring lenses has never had any 
place in science. It was simply the method used by the common peddlers of spec- 
tacles, and by those engaged in producing the cheap manufactures intended for the 
common people, whose defects being for the most part symmetrical, permitted them to 
employ such lenses as afforded apparent relief by increasing the angle of vision, often 
at the expense of the sharpness of the image. 
In 1878, Prof. Snellen devised an instrument for measuring lenses by determining 
the character of refraction of the points of light thrown upon an opaque screen. Care- 
fully constructed, this instrument, known as ''Snellen's Phakometer," is of great 
value. The want of precision in its measurements has been almost entirely met by the 
placing of a dark, bellows-shaped tube between the clasp which holds the lens to be 
measured and the registering disc upon which the refracted points of light are collected. 
This excludes all interference of either diffuse or artificial light in the line of the 
refracted rays between the lens to be measured and the focal point. With a series of 
minute points of light passing through a lens, in vertical and horizontal lines, inter- 
secting at the centre, the central point may be employed for centring the lens in the 
phakometer. If asymmetry of grinding exist, the points will not be perfectly round, 
or there may be noted at one side of the point a blue margin, and when this is 
removed by sliding the disk, it may be noted that the opposite side of the same point 
is red or blue, according to the direction in which the disk is moved. I esteem this 
instrument, with the improvements I have added, and which are known to the profes- 
sion, of great value. It affords the most accurate method known of testing the refract- 
ing powers of lenses. Employing this instrument for the purpose of testing lenses in 
trial cases, made by the best manufacturers, I have been astonished to find that many 
lenses are not designated properly according to their refracting power. These, graded 
by what may be known as the old scientific system of dividing the quadrant of a 
sphere, do not represent the exact fractional parts of this quadrant that the figures 
etched on the margin would indicate. In 20 cases, graded by the metrical system, I 
found but little difference in those lenses marked 1 D. ; while all those of greater focal 
length, and correspondingly less refracting power, were quite defective. It happened 
in several that the lens marked 0.25 D. was a perfectly plain piece of glass. Of the 
negative lenses graded by this system, scarcely ten per cent, of the whole number were 
even approximately accurate. Those of American manufacture are superior iu the 
accuracy with which they are graded, especially the lower powers. Now, in order to 
do away with some of this class of defects in graded lenses, I propose that no 
attempt shall be made to designate them by focal lengths, and that we shall either 
return to the old system of astronomical refractions, taking the quadrant of a sphere 
for the unit, and dividing it into any desirable number of fractions having a common 
multiple, according to the radius desired to represent a stated angle, which is the 
method I use, or that we shall have our lenses graded by the angle of refraction only. 
This seems to me in evejy way more desirable, as we should then be able to designate 
the lenses we desire with greater precision. We should recognize 90° as the maximum 
angle, not for purposes of division, but for thepurposeof establishing the highest angle 
of refraction which any spectacle lens might possess. We might begin with an angle 
of 1° or 5°, and proceed in this way to construct a series of lenses for ordinary use; 
and for very nice testing of sensitive eyes, we might employ lenses with an angle of 
5ZZ, 15zz or 30zz. We might even grade lenses with any refracting angle desired, pro- 
vided we could secure a uniform quality of crown glass, and this substance has been 
determined to be best adapted for spectacle lenses. Its index of refraction having been 
established, a skilled optician should have little difficulty in constructing such lenses 
as might represent precisely the amount of refracting power desired. I have consulted 
two practical opticians, who inform me this scheme could easily be carried out. I SECTION XI-OPHTHALMOLOGY. 
785 
submit it for the consideration of this Section of the Congress, believing, were it 
adopted, we should have a more scientific grading of the lenses than could be secured 
by considering the angle of the radius. 
Being asked by Prof. Landolt to give an example in writing for a compound cylinder 
after the manner stated, Dr. Reynolds said : "I use the old system of gradation by 
the radius, ' ' and wrote on the blackboard the following :- 
O. D. O. S. Bis. C. 
ioc 90° O ios || + ioc 75° O + ioc | 2|z/. 
DISCUSSION. 
Dr. Landolt requested Dr. Reynolds to explain in detail. 
Dr. Burnett, of Washington, said-I think that the system proposed by Dr. 
Reynolds, which does great credit to his erudition, can never come into general use, 
from the fact that in dealing with the eye we have to do always with the focal point. 
In fact, the chief and important property of any optical system is its focal length, 
negative or positive. What we have needed is some uniform distance of focal length 
as a unit or standard, and this is furnished us in the metre, which is now adopted by 
all civilized nations, either by statute or permission. 
Dr. Allyn, of Pittsburgh, opposed return to inches and advocated the metre 
system. 
Dr. Thompson, of Indianapolis, regarded the method of Dr. Reynolds as scien- 
tific, but he himself uses both methods. 
Mr. Cross, of Bristol, England-Dr. Reynolds' scientific communication is 
worthy of full consideration, as an attempt to improve our method of grinding and 
of designating lenses. In considering refraction we are constantly making reference 
to distance, "far point," "range of accommodation," etc. Our standard lens must 
also bear a similar designation. It must have a standard focal length. If we adopt 
Dr. Reynold's suggestions, we are at once in the difficulty of requiring a constant 
material for making the lenses ; this is impossible. Moreover, our calculations must 
be made in vulgar fractions. I consider the metrical system, as now universally 
used, to be as near perfection as possible. 
THE DESIGNATION OF PRISMS BY THE ANGULAR DEVIATION 
THEY CAUSE, INSTEAD OF BY THE REFRACTING ANGLE. 
LA DESIGNATION DES PRISMES PAR LA DÉVIATION ARTICULAIRE QU'ELLES 
CAUSENT AU LIEU DE L'ANGLE DE RÉFRACTION. 
DIE BESTIMMUNG DER PRISMEN DURCH DIE DURCH SIE VERURSACHTE ANGULARE 
ABWEICHUNG, ANSTATT DURCH DEN REFRACTIONSWINKEL. 
BY EDWARD JACKSON, A. M., M. D., 
Of Philadelphia, Pa. 
The angle included between the refracting surfaces of a prism is called its refracting 
angle. The angle between the direction of a ray as it enters a prism and its direction 
on leaving it is the angular deviation, a direct measure of its refractive power. The 
refractive power of the prism depends on its refracting angle, and the indices of refrac- 
vol. in-50 786 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tion of the substance composing it and the substance surrounding it. For our purposes 
the substance surrounding the prism is always air, with a practically constant refractive 
index. But the index of refraction for optical glass, the substance composing the prism, 
may vary from 1.51 to 1.72, and is liable to change in the future with changes in its 
composition or processes of manufacture. When I order a prism of three degrees by 
the present system of numbering prisms, just so the shape is right, it may deflect the 
light rays 1.53° or 2.14°, and still be exactly the prism ordered. It is no just ground 
of complaint that the prism furnished happens to have 40 per cent, more refractive 
power than the prism in the trial case. That such an extreme case is unlikely to occur 
may be freely admitted. But the fact remains that quite appreciable variations in the 
strength of prisms designated by the same number do constantly occur from this varia- 
bility in the index of refraction of the glass used. And this inexact, unscientific method 
of designating prisms constantly covers inaccuracies of carelessness quite as serious as 
the case supposed. Some of these are revealed in the results obtained by testing the 
prisms in seven trial cases representing four well-known makers, two American and 
two European. These are given below in tabular form, the first column giving the 
number of the prism; the second the deviation it would cause if properly made of glass 
having a refractive index of 1.54; the third the weakest of that number tested; and the 
fourth the strongest. 
Number. 
Proper Strength. 
Weakest. 
Strongest. 
1 
0.54 
0.40 
0.60 
2 
1.08 
0.65 
1.38 
3 
1.62 
1.45 
1.65 
4 
2.16 
1.95 
2.20 
5 
2.70 
2.22 
2.82 
6 
3.24 
2.78 
3.10 
7 
3.78 
3.35 
3.85 
8 
4.33 
3.85 
4.45 
9 
4.88 
4.65 
5. 
10 
5.43 
5.05 
5.45 
12 
6.52 
6.15 
6.60 
15 
8.18 
7.70 
8.10 
20 
11.01 
10.18 
10.50 
Every set examined showed at least one prism varying a whole number from its 
proper standard of refractive power. And in but one set did they all come within 16 
per cent, of the proper standard. 
Now prisms are used solely for their power of refracting light. If we order a certain 
prism, we want, not one made from the same lot of glass as the prism in our trial set, 
not one having the same shape or thickness, but one having the same power of refract- 
ing light. Identity of refractive power is the only identity we must always demand in 
the prism furnished. Would it not be better to designate in the prescription exactly 
the refractive power desired, instead of prescribing one of a certain shape or refracting 
angle which may or may not possess that refractive power ? 
Again, we are often compelled to speak of the deviation of the visual axes as meas- 
ured in degrees; and the introduction of another kind of degrees (degrees of refracting 
angle), not necessarily corresponding with degrees of deviation, is a very frequent cause 
of confusion and obscurity in discussions concerning prisms and the conditionsand pur- 
poses for which they are used. Take this sentence from a recent paper,* in which the 
writer is alluding to ' ' hyperphoria, " as he calls the tendency to vertical deviation of 
the visual axes. "An actual deviation of a single degree w'ould result in a separation 
of images at a distance of one-half metre, approximately of 6.4 mm." Possibly the 
*" Anomalies of the Ocular Muscles," G. T. Stevens, Archives of Ophthalmology, 1887, p. 161. SECTION XI-OPHTHALMOLOGY. 
787 
author could tell whether he meant what he said, an actual deviation of one degree, or 
a deviation such as would be produced or corrected by a prism having a refracting angle 
of one degree. But no one else can feel certain about it. Would it not be best to give 
up a system of notation which requires us to deal with two different kinds of degrees 
where one would better answer every purpose ? 
Then, as we measure convergence in metre-angles its comparison with deviations 
estimated with prisms entails an extra labor of reduction to common terms so long as 
we designate prisms by their width of refracting angle; and the calculation of the 
prismatic, effect of a certain decentring of lenses is complicated in the same way. So 
that it seems to the writer entirely worth while to encounter the inconveniences attend- 
ant upon a change of the system of numbering prisms to one based directly and solely 
ou their refracting power: Lenses were formerly numbered according to their radius 
of curvature, but the change to the basis of refractive power has been readily effected, 
and with prisms such a change would be in some respects even easier. 
My proposition is, a prism shall be designated by the number of degrees light rays are 
deflected from their course by passing through it in such a way that within the prism their 
direction is perpendicular to the plane bisecting its refracting angle; that is, the minimum 
deviation the prism can produce. 
To avoid confusion between the old and new systems, the number of a prism accord- 
ing to the new might always be written or printed with a circle surrounding it. Thus 
prism would indicate a prism whose refractive power, minimum angular deviation, 
is just two degrees, whatever may be its refracting angle. 
DISCUSSION. 
Dr. Landolt said-The work of Dr. Jackson seems to me exceedingly merito- 
rious ; his conclusions in every way logical, reasonable and tending to supply 
a genuine want; I make the motion, then, that the proposition of Dr. Jackson 
concerning the designation of prisms be submitted to the consideration of ophthal- 
mologists throughout the world, that it be supported by this Section, and that it be 
discussed and eventually adopted at the next International Congress. 
Mr. Power proposed that a committee be appointed to bring this matter formally 
before the Ophthalmological Section of the next Congress. 
The President appointed Drs. E. Landolt, S. M. Burnett and E. Jackson. 
AMETROPIA IN OUR SCHOOLS. 
L'AMÉTROPIE DANS NOS ECOLES. 
ÜBER DIE AMETROPIE IN UNSEREN SCHULEN. 
BY F. B. TIFFANY, M. D., 
Of Kansas City, Mo. 
What I have to say to-day on the subject of ametropia is based entirely upon data 
collected from examinations made a few months ago in the public schools of Kansas 
City and vicinity. These examinations included the white, red, black and mixed races, 
embracing several distinct nationalities. Before beginning the examinations I arranged 
a record, with spaces for name, nationality, age, sex, color of eyes, if the pupil himself 788 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
or his brothers or sisters or parents wore glasses ; space for vision of either eye-emme- 
tropia, myopia, hypermetropia, manifest or latent astigmatism, spasm of accommo- 
dation, strabismus, convergent or divergent, and a space for remarks-all of which 
facilitated me in obtaining complete and practically accurate statistics. I not only 
examined for myopia, but for hypermetropia, astigmatism, spasm of accommodation 
and strabismus. When I began the examinations I had in mind ten thousand, but I 
stopped with two thousand and forty. The examinations were quite carefully made, 
examining most of the pupils separately, many with the ophthalmoscope and some 
by the aid of mydriatics, so that I think, in the main, the true diagnosis was made ; 
in some cases I may have mistaken spasm of accommodation for myopia, and vice versa. 
As a result of the examinations I have the accompanying formulated table, showing 
the whole number examined, the average age of each school, the number and per cent, 
of atfected in each school, number of males examined and the number and per cent, of 
those affected, the number of females examined and the number and per cent, of those 
affected. Then the number of different nationalities examined, with the number and 
per cent, of those affected ; a per cent, of each sex. Then comes the colors of the eyes 
-blue, gray, brown, hazel and black, with the whole number of each, and the number 
and per cent, of those affected of each. Under the next head we have the affections- 
strabismus, myopia, hypermetropia, astigmatism, spasm of accommodation ; and fol- 
lowing this comes hypermetropia and myopia, compared one with the other ; and, 
finally, the per cent, the school is to the whole number, per cent, of the affected in the 
same school ; and, lastly, latent hypermetropia, and at the foot a general summation of 
the columns severally. 
That perfect vision, perfect eyesight, be enjoyed by our progeny depends largely 
upon the recognition of any defect (slight though it may be) in early life, timely cor- 
rection of the same (if possible), and care and proper use of the organ while in the 
school-room. That many a boy or girl with some anomaly of refraction or accommo- 
dation has been allowed to suffer day after day in order to keep pace with his class, 
and eventually develop more serious conditions, or even blindness, is too evident;, 
whereas if the trouble had been recognized in time and proper steps taken, much 
suffering as well as serious consequences could have been averted. The object of these 
investigations is to ascertain, if possible, the condition of the eyes of the youth, the 
effect of use of the organ for near and small objects, and the final consequences; and if 
possible to correct the evils arising before irremediable damage has been done. In Dr. 
Cohn's report only one anomaly of refraction (myopia) is considered. Dr. Cohn thinks 
that near-sightedness increases in the higher grades, finding more myopes in the second 
year than in the primary department-more in the third than in the second, and so on 
through the grammar school to the high school, where there is more among the last 
year students than among those just entering the high school, and still more in the 
normal schools and universities. He attributes the increase of myopia to improper use 
of the eye in the school room, as well as bad light and improper heights and structure , 
of seats and desks. This, to a certain extent, is evidently true. In my friend Dr. 
Ernest Fuch's report, which has been translated and appears in the " Chicago School 
Board Report," 1886, the whole attention is directed to myopia alone. Now, in our 
investigations, not only myopia but hypermetropia, astigmatism, spasm of accommodation 
and strabismus were looked for. Every eye that was not up to the standard of vision, 
(that of fg) was not dubbed myopic. A careful examination was made with the trial 
glasses, or optometer, and a more accurate diagnosis made. Our results show a much 
larger per cent, of hypermetropia, and astigmatism, and spasm of accommodation than 
myopia; there being nearly four times as many hypermetropic pupils as myopic. Of 
the whole number examined, 2040, in the different grades and schools, 99 or 4.8 per 
cent, had spasm of accommodation. Now spasm of accommodation (or simple hyper- SECTION XI-OPHTHALMOLOGY. 
789 
metropia, even) if not corrected by glasses or relieved by rest from near and small 
objects, is likely to develop into myopia, or possibly intra-ocular disease; hence the 
importance of these examinations. In our examinations the increase of anomaly of 
refraction as we ascend in the grades is not marked-in fact, in some schools it seems 
to diminish, but this would not be a definite proof one way or the other, from one 
examination, as a different set of pupils are examined in each grade and in each school, 
and from the one examination there is no means of knowing but what those of the 
higher grades started with the same degree of anomaly in the primary departments as 
they are found to have in the sixth year of the grammar school or the high school, as 
the case may be; in fact, it seems to be true that pupils with anomalies of refraction, 
both myopes and hypermétropes, are closer students and fonder of books and study 
than the emmetropes or those of perfect vision, and hence these students remain in 
school while many of those with perfect vision drop out before they reach the higher 
departments. In our examinations we find a greater percentage of anomaly among the 
normal schools of Kirksville and Warrensburg than any other, but it does not neces- 
sarily follow that this is the result of a longer course of study and close application 
with the eyes, although it is conjecturally true. The only way to gain a positive knowl- 
edge that study is the cause, or otherwise, is to watch the same set of pupils from the 
primary department up through the different grades, and see if John, Mary and James, 
starting out at six or seven years of age in the primary department with perfect emme- 
tropic eyes, finally, later on, develope myopia. In our examinations this can be done, 
as we have the name in full, color of each eye, present amount of vision, whether there 
is any hereditary defect or not; and now should the examinations be continued and 
the same pupils be called for as they enter the higher grades, year after year, a very 
definite and satisfactory idea can be gained. 
As to the lighting and ventilation of our school rooms very little need be said, as 
so much attention has been given to this subject by our efficient Board that the Kansas 
City school room is almost perfection in those particulars. In the Washington school, 
where we find the largest per cent, of defective eyes in the lower grades, I noticed first 
and second year pupils (for want of room) were crowded into a room calculated for 
older pupils, and hence the distance between the desk and the seat was too great, as 
well as that from the seat to the floor, compelling the little pupil to hang, as it were, 
upon the desk, his feet not touching the floor; this position of necessity brought his 
face too near his book or slate, and hence taxed the power of accommodation of the eyes 
to a great degree ; and besides, this school, from its location (on the north side of the hill), 
is notas well lighted and ventilated as others. In the Nevada school (adjoining town) 
I found a less degree of anomalies among the same grade of students than in the 
Kansas City schools. This I attributed to the fact that the school is in a small country 
town, where the children have more freedom of the field, where they are not crowded 
as much as our city children are, and! perhaps have better ventilated school rooms. 
Pages 790, 791, 792 and 793 show a tabulated form of statistics, as gathered during the 
months of April and May, 1887, of the schools of Kansas City, Nevada, Mo., Warrens- 
burg, Kirksville, State Normal School and the State Universities of Missouri and 
Kansas. TABLE SHOWING THE RECORD OF TWO THOUSAND AND FORTY PUPILS, OF 
EYES AS TO ERRORS OF REFRACTION AND SPASM OF 
AND DARK EYES, AND IN 
Average Age in Years and Months. 
Whole Number Examined. 
No. having affected vision. J rer vent- 
[aving Affected 
Vision. 
NATIONALITY. 
Per cent, of Females Examined. 
Per cent, of Males Examined. 
COLOR OF EYES. 
Upper numbers indicate how 
many of each nationality. Mid- 
dle numbers show number 
affected. Lowest row of num- 
bers show the per cent, of each 
nationality affected in each 
school. 
First row of figures 
in each square repre- 
sents total number 
of eyes of that color 
examined. 
Middle row of num- 
bers indicates num- 
FemaleS- I No. I 
cZ 
'S 
American. 
d 
C« 
a 
s 
'S 
a 
g 
fa 
1 
5 
£ 
ao 
'E 
4= 
GQ 
Tc 
a 
fa 
'S 
co 
T5 
a? 
.2 
eye 
resT 
per 
□ 
s 
s of 
secti 
bird 
cents 
r.' 
5 
tha 
rely. 
row 
ge. 
d 
k 
o 
» 
t co 
sh 
'ÖJ 
N 
0 
fa 
or, 
JWS 
e« 
s 
s 
Lawrence Uni- J 
VERSITY | 
19.8 
69 
15 
21.7 
22 
5 
22.7 
47 
10 
21.2 
59 
13 
22.0 
2 
0 
00.0 
2 
0 
00.0 
0 
0 
00.0 
4 
2 
50.0 
0 
0 
oo.o 
0 
0 
00.0 
2 
0 
00.0 
31.8 
68.2 
33 
7 
21.2 
10 
3 
30.0 
15 
3 
20.0 
7 
1 
14.2 
4 
1 
25.0 
Columbia Uni- J 
VERSITY | 
17.2 
138 
34 
17.1 
40 
12 
30.0 
98 
22 
22.4 
99 
27 
27.2 
6 
2 
33.3 
6 
2 
33.3 
2 
1 
50.0 
2 
0 
00.0 
21 
2 
9.5 
0 
0 
00.0 
1 
0 
00.0 
28.9 
71.1 
60 
11 
18.3 
29 
8 
27 5 
22 
4 
18.1 
20 
8 
40.0 
7 
3 
42.8 
Kirksville Nor-J 
mal School ] 
20.1 
172 
30 
17.4 
106 
21 
19.8 
66 
9 
13.6 
141 
25 
17.7 
8 
2 
25.0 
2 
0 
00.0 
2 
0 
00.0 
5 
0 
00.0 
2 
0 
00.0 
1 
0 
00.0 
11 
3 
27.2 
61.6 
38.4 
53 
7 
18.2 
45 
9 
20.0 
45 
5 
11.2 
17 
4 
23 5 
12 
5 
41.6 
Warrensburg J 
Normal School. | 
16.9 
170 
44 
25.8 
106 
24 
25.6 
64 
20 
31.2 
157 
37 
23.5 
4 
3 
75.0 
2 
2 
100. 
2 
0 
00.0 
0 
0 
00.0 
0 
0 
00.0 
IS's 
0 
oo.o 
4 
2 
50.0 
62.3 
37.7 
45 
15 
33.3 
1444 
35 
24.2 
38 
12 
31.3 
104 
314 
30 4 
63 
9 
14.2 
20 
8 
40.0 
4 
0 
00.0 
Kansas City High J 
School ] 
16ys 
10m 
395 
104 
26.3 
264 
74 
28.0 
131 
30 
22.9 
291 
72 
24.7 
24 
9 
37.5 
8 
1 
33.3 
2 
1 
50.0 
25 
10 
40.0 
4 
1 
25.0 
8 
2 
66.6 
43 
8 
18.6 
66.8 
33.2 
1294 
324 
25.9 
14 
3 
21.2 
3 
1 
33 3 
Fourth Year J 
17.8 
58 
17 
21.2 
34 
11 
32.3 
24 
6 
25.0 
50 
15 
30.0 
1 
0 
00.0 
1 
1 
100. 
0 
0 
00.0 
2 
1 
50.0 
0 
0 
00.0 
0 
0 
00.0 
4 
0 
00.0 
58.6 
41.4 
22 
3 
13.6 
18 
6 
33.3 
14 
8 
57.1 
3 
0 
00.0 
1 
0 
oo.o 
Third Year 
17.3 
64 
18 
28.1 
53 
15 
28.3 
11 
3 
27.2 
42 
8 
19.0 
4 
1 
25.0 
0 
0 
00.0 
0 
0 
00.0 
7 
3 
42.8 
1 
0 
00.0 
0 
0 
00.0 
10 
6 
60.0 
82.8 
17.2 
18 
6 
33.3 
164 
2| 
66.0 
244 
94 
38.7 
5 
0 
00.0 
0 
0 
00.0 
Second Year 
16.6 
156 
25 
16.0 
87 
16 
18.3 
69 
9 
13.0 
113 
20 
17.7 
6 
1 
16.2 
1 
0 
00.0 
1 
0 
00.0 
7 
2 
28.5 
2 
0 
00.0 
2 
1 
50.0 
24 
1 
4.1 
55.7 
44.3 
66J 
10 
15.3 
414 
9 
21.6 
47 
6 
12.7 
0 
0 
00.0 
1 
0 
00.0 
First Year 
16. 
117 
44 
37.6 
90 
32 
35.3 
27 
12 
44.4 
86 
29 
33.7 
13 
7 
53.8 
1 
0 
00.0 
1 
1 
100. 
9 
4 
44.4 
1 
1 
100. 
1 
1 
100. 
5 
1 
20.0 
76.9 
23.1 
38 
16 
42.1 
28 
14 
50 0 
44 
10 
22.7 
6 
3 
50.0 
1 
1 
100. 
Lincoln School...-j 
13.6 
220 
57 
25.9 
169 
47 
27.8 
51 
10 
19.6 
African or Negro. 
76.8 
23.2 
High, 1, 2, 3 and J 
4 Years "1 
14.10 
57 
21 
36.8 
46 
21 
45.6 
11 
0 
0.0 
80.7 
19.3 
0 
0 
00.0 
8 
4 
50.0 
37 
14 
37 8 
0 
0 
oo.o 
12 
3 
25.0 
Seventh Grade.... 
13.10 
56 
16 
28.5 
46 
14 
30.4 
10 
2 
20.0 
82.1 
17.9 
29.0 
Î 
33 3 
0 
0 
00.0 
37 
9 
24.3 
0 
0 
00.0 
16 
6 
37.5 
Fifth Grade 
13.1 
38 
11 
28.9 
27 
9 
33.3 
11 
2 
18.2 
71.0 
6 
0 
00.0 
2 
1 
50.0 
29 
10 
34.4 
0 
0 
00.0 
1 
0 
00.0 
Fourth Grade 
13.8 
32 
4 
12.5 
19 
2 
10.5 
13 
2 
15.3 
59.3 
40.7 
1 
0 
000 
1 
0 
00.0 
20 
4 
20.0 
0 
0 
00.0 
10 
0 
oo.o 
Third Grade -I 
11.4 
37 
5 
13.5 
31 
1 
3.2 
6 
4 
66.6 
9 
3 
33.3 
80.7 
16.3 
5 
00.0 
0 
0 
00.0 
25 
4 
16.0 
0 
0 
00.0 
12 
1 
8.3 
11 
1 
9.0 
Morse School 
12.6 
207 
34 
16.5 
108 
18 
16.6 
99 
16 
16.1 
138 
24 
17.3 
32 
3 
9.3 
3 
0 
00.0 
2 
0 
00.0 
6 
1 
16.6 
2 
0 
00.0 
15 
3 
20.0 
52.1 
47.9 
95 
18 
18.9 
38 
4 
10.5 
57 
9 
15 7 
6 
2 
33.3 
Fifth Grade 
13. 
178 
28 
15.7 
90 
14 
15.5 
88 
14 
15.9 
120 
19 
15.8 
25 
3 
12.0 
3 
0 
00.0 
o 
0 
00.0 
8 
3 
87.5 
6 
1 
16.6 
2 
0 
00.0 
12 
2 
16.6 
50.5 
49.5 
82 
15 
18.2 
30 
4 
13.3 
49 
6 
12.2 
6 
2 
33 3 
11 
1 
9.0 
Fourth Grade 
12. 
29 
6 
20.6 
18 
4 
22.2 
11 
2 
18.1 
18 
5 
27.7 
7 
0 
0.00 
0 
0 
00.0 
0 
0 
00.0 
1 
0 
00.0 
0 
0 
00.0 
0 
0 
00.0 
3 
1 
33.3 
62.0 
38.0 
13 
3 
23.0 
8 
0 
00.0 
8 
3 
137.5 
0 
0 
00.0 
0 
0 
00.0 
790 WHITE, BLACK AND RED RACES, GIVING THE PERCENTAGE OF AFFECTED 
ACCOMMODATION, IN BOTH MALE AND FEMALE, IN LIGHT 
DIFFERENT NATIONALITIES. 
2: 
: 8O 
: Sc 
: 
O 
: oe 
• © © 
: = = 
© 
: °® 
© 
: c© 
© 
: co K, 
© 
: °o 
en 
© 
: °© 
.8. 
: Sc 
© 
: °© 
Females. 
Strabismus. 
Middle row of ea 
the under figures 
males and of the fe 
AFFECTIONS. 
0 
00.0 
en 
: 
000 
0 
■" 
0'00 
1 0 
0'00 
1 0 
000 
0 
0 
00.0 
0 
00.0 
000 
0 
0 
00.0 
: «te 
HA 
000 
0 
: . te 
en 
en 
0 
00.0 
i 0 
00.0 
No. of each Affection. 
O 
: ©© 
: 
: *-w 
0 
00.0 
000 
0 
0 
00.0 
0 
00.0 
000 
o 
000 
0 
0 
00 0 
0 
00.0 
000 
0 
000 
0 
0 
00.0 
j en - 
© 
: ©o 
: 
0 
00. 
Males. 
• «, 
: K* 
: to 
' 4- °* 
: go 
: © 
: o © 
• ôo« 
: 
: co 
• tow 
: " 1 
•: s» 
= U*» 
■■ s* 
5 
2.9 
= g» 
: g»» 
: g oo 
Females. 
Myopia. 
: co 
• 
7 
3.9 
1 8'£ 
8 
oo 
1 0 
0 
00 
: cn 
5 m1"* 
3 
5.2 
12 
10.2 
- 
5 
3.2 
■= g* 
1G- 
: en te 
• ente 
9 
5.3 
: 
ce ** 
• ce05 
9 
13.0 
No. of each Affection. 
£- 
ST 
Ö 
.ch indica 
LÙ 
• C05 
; £ OS 
-° 
0 
00 
* e* 
© 
: °© 
: So 
: fc» 
; © ce 
■ to ce 
: So 
© 
: o© 
6 
1.5 
4 
2.3 
2 
1.15 
: 
• <D 
a. 
Males. 
: to 
' to 
• O 
: © 
• to to 
: to 
' en 
5 
8.9 
: 
12 
5.4 
igx 
9 
5.7 
... 
6 
9.3 
4 
6.8 
: oo ce 
• ce® 
12 
8.2 
• e- 
6 
4.3 
2 
3.8 
Females. 
Hyperopia. 
tes full number of each affection, while 
juare show the percentage of all of the 
3 
10.3 
10 
5.6 
13 
6.2 
3 
8.1 
: œ 
: co~ 
: Eh 
5 
8.9 
■ U. 
16 
7.2 
22 
18.3 
13 
8.3 
: 5° 
• ce 05 
7 
12.0 
: Es 
22 
12.9 
10 
5.8 
: gX 
: ;<,cs> 
No. of each Affection. 
3 
10.3 
: 
: 00 
: ;. co 
: ço 
: Ö O 
>8. 
• ÔO 
; gx 
3 
5.2 
15 
3.8 
»C» 
• ôo" 
8 
5.8 
• CO 05 
Males. 
O 
:®o 
2 
1.1 
1 te« 
â8- 
: §e 
*8' 
© 
: °© 
'S- 
5 ÔO1- 
5 «" 
• ce 
m 
i5- 
; oo 
• î"1 te 
: "°4 
3 
2.3 
:So 
Females. 
Astigma- 
tism. 
: to 
' ǣ> tO 
>*• 
|8o 
: S® 
: 8® 
>>- 
4 
2.'5 
: 2*- 
: ce 
• te 
: S» 
9 
5.2 
9 
6.5 
1 
1.4 
No. of each Affection. 
:go 
:K 
,8O 
<s> 
© 
: ° © 
■:K 
.8. 
*g- 
'■ g** 
: L,ce 
,8. 
3 
1.8 
■ !*"a> 
• en 
ter 
Males. 
: £- 
4 
2.2 
... 
•: £• 
= 
5 
13.1 
: Ê« 
13 
22 8 
: gS 
: © 
• ôo00 
• U» 
;8e 
: o° 
• © °1 
: ce 
• oo 
: P 
• Jo 
6 
3.4 
: U** 
© 
s 8© 
Females. 
Spasm of 
Acc. 
2 
6.8 
: £ 00 
: 4- I-* 
• GO ° 
: oi 
• 
■ E- 
• co 
: en 
: ôo ° 
13 
22.8 
: 4- co 
= S« 
: «ce 
2 
3.1 
: te 
• 
21 
5.3 
: en g» 
• ôo® 
: P 
• «o 
© 
: © 
• ©® 
No. of each Affection. 
: w 
4 
2.2 
: to 
' îr °1 
: 
: 
o 
: © 
• o 
: 05 
• © to 
: §® 
' ôo 
: ôo 1-1 
• © ** 
: gto 
: ce 
• 
• en 05 
5 
2.9 
: . 
• © 
: Pce 
• te 
o 
: °© 
Males. 
S 
Cn 
i-1 
62.5 
§ 
S 
S 
© 
g 
*- 
en 
o 
S 
© 
te 
8 
en 
50.0 
33.3 
33.3 
Females, per cent. 
Myopia. 
Hypermetropia 
Compared with 
Myopia. 
42.8 
37.5 
O 
O 
g 
© 
© 
© 
g 
ôo 
K) 
Cn 
© 
© 
s 
© 
© 
te 
te 
54.5 
70.0 
© 
© 
© 
66.6 
Males, per cent. 
o 
30.7 
O 
66.6 
© 
© 
© 
© 
© 
77.7 
63.6 
69 2 
© 
© 
en 
h-1 
68.7 
S 
50.0 
te 
00 
40.0 
Females, per cent. 
Hyperopia. 
O 
69.2 
O 
O 
33.3 
© 
o 
© 
© 
22.3 
36.3 
30.7 
© 
© 
fe 
31.2 
s 
30.0 
57.2 
60.0 
Males, per cent. 
CO 
s» 
© 
H-t 
00 
en 
ôo 
JtO 
P 
ôo 
10.8 
en 
© 
w 
ÔO 
P 
9° 
ce 
9° 
© 
P 
ce 
Per cent, that the school is of the whole No. 
CO 
6.2 1 
Cn 
1-1 
>-*■ 
ôo 
P 
po 
en 
© 
12.6 0 
P 
h-1 
Cn 
Cn 
.« 
23.1 2 
9.7 13 
6.6 11 
© 
0. 
i 
3.3 10 
Per cent, of the Affected in same school. 
Latent Hypermetropia. 
791 TABLE SHOWING THE RECORD OF TWO THOUSAND AND FORTY PUPILS, OF 
EYES AS TO ERRORS OF REFRACTION AND SPASM OF 
AND DARK EYES, AND IN DIFFER- 
Average Age in Years and Months. 
Whole Number Examined. 1 p c . 
No. having affected vision.) 
No. Having Affected 
Vision. 
NATIONALITY. 
Per cent, of Females Examined. 
Per cent, of Males Examined. 
COLOR OF EYES. 
Upper numbers indicate how 
many of each nationality Mid- 
dle numbers show number 
affected. Lowest row of num- 
bers show the per cent, of each 
First row of figures 
in each square repre- 
sents total number 
of eyes of that color 
examined. 
Middle row of num- 
bers indicates num- 
ber having defective 
eyes of that color, 
respectively. 
Third row shows 
percentage. 
nationality 
school. 
affected in each 
American. 
German. 
French. 
Scotch. 
co 
►-< 
English. 
a> 
8 
b 
co 
T3 
O> 
M 
3 
Females. 
Males. 
5 
S5 
0 
Brown. 
Hazel. 
'ü 
- 
s 
150 
59 
91 
127 
10 
3 
0 
6 
2 
1 
1 
51 
21 
32 
0 
8 
Woodland School 
8.6 
16 
9 
7 
13 
1 
0 
0 
2 
0 
0 
0 
39. 
61. 
4 
1 
7 
0 
0 
10.6 
15.3 
7.6 
10.2 
10. 
33.3 
... 
... 
... 
7.8 
4.7 
21.8 
... 
38 
13 
25 
36 
2 
0 
0 
0 
0 
0 
0 
Second Grade 
9.7 
4 
2 
2 
3 
1 
0 
0 
0 
0 
0 
0 
34.2 
65.8 
Color not Taken. 
10.5 
15.3 
8. 
8.3 
50. 
... 
... 
... 
... 
... 
... 
112 
46 
66 
91 
8 
3 
0 
6 
2 
1 
1 
.51 
21 
32 
0 
8 
First Grade 
7.6 
12 
7 
5 
10 
0 
0 
0 
2 
0 
0 
0 
11. 
59. 
4 
1 
7 
0 
0 
10.7 
15.2 
7.5 
10.9 
• •• 
... 
33.3 
... 
... 
7.S 
4.7 
21.8 
... 
... 
312 
183 
129 
221 
40 
4 
4 
15 
9 
8 
16 
62 
36 
50 
5 
14 
Washington 
11.2 
88 
57 
31 
61 
12 
0 
1 
3 
4 
1 
6 
58.6 
41.4 
13 
8 
11 
2 
4 
School .......... 
28.2 
31.1 
24. 
27.5 
30. 
25. 
20. 
44.4 
33.3 
37.5 
20 9 
22.2 
22. 
40. 
28 5 
83 
58 
25 
70 
8 
1 
0 
0 
1 
0 
3 
25 
23 
27 
5 
5 
Seventh Grade 
14 7 
24 
16 
8 
19 
3 
0 
0 
0 
0 
0 
2 
69.8 
30.2 
6 
7 
7 
2 
2 
28.9 
27.5 
32. 
27.1 
37.5 
... 
... 
66.6 
24. 
30.4 
25.9 
40. 
40. 
43 
28 
15 
36 
4 
1 
1 
0 
0 
0 
1 
22 
6 
14 
0 
1 
Sixth Grade 
14.7 
6 
5 
1 
6 
0 
0 
0 
0 
0 
0 
0 
65.1 
34.9 
4 
0 
2 
0 
0 
13.9 
17.8 
6.6 
16.6 
... 
... 
... 
... 
18.2 
14.2 
39 
16 
23 
29 
8 
0 
0 
1 
1 
0 
0 
15 
7 
9 
0 
8 
Third Grade 
10.3 
8 
3 
5 
4 
3 
0 
0 
1 
0 
0 
0 
59. 
41. 
3 
1 
2 
0 
2 
20.5 
18.7 
21.5 
13.9 
37.5 
... 
100 
... 
20. 
14.2 
22.2 
... 
25. 
112 
63 
49 
64 
15 
1 
1W1 
10 
7 
2 
12 
Second Grade 
10.3 
41 
26 
15 
26 
3 
0 
1 
2 
4 
1 
4 
61.6 
38.4 
Color not Taken. 
36.6 
41 2 
36.6 
40.6 
20. 
... 
100. 
20. 
57.1 
50. 
31.3 
35 
18 
17 
12 
5 
1 
2 
4 
0 
1 
0 
First Grade 
8.4 
9 
7 
2 
6 
3 
0 
0 
0 
0 
0 
0 
51.4 
48.6 
Color not Taken. 
25.7 
38.8 
11.7 
27.2 
60. 
10. 
... 
... 
... 
197 
100 
97 
189 
3 
0 
1 
1 
3 
0 
0 
86 
43 
30 
10 
28 
Nevada 
10.2 
28 
19 
9 
28 
0 
0 
0 
0 
0 
0 
0 
50.7 
49.3 
12 
4 
5 
4 
3 
14 2 
19. 
9. 
14.8 
... 
... 
... 
... 
... 
13.8 
9. 
16.6 
40. 
10.7 
44 
18 
26 
42 
2 
0 
0 
0 
0 
0 
0 
13 
12 
9 
7 
3 
Central 
7 yrs. 
5 
3 
2 
5 
0 
0 
0 
0 
0 
0 
0 
10.9 
59.1 
0 
0 
1 
4 
0 
11.3 
16.6 
7.6 
11.8 
... 
... 
... 
11.1 
57.1 
37 
21 
16 
35 
1 
0 
0 
0 
1 
0 
0 
10 
8 
6 
3 
10 
Seventh Grade... 
13.7 
4 
3 
1 
4 
0 
0 
0 
0 
0 
0 
0 
56.7 
43.3 
2 
1 
0 
0 
1 
10.8 
14.2 
6.2 
11.4 
... 
... 
... 
20. 
12.5 
00 
00 
10. 
39 
22 
17 
39 
0 
0 
0 
0 
0 
0 
0 
24 
10 
3 
0 
2 
Fourth Grade 
13.3 
4 
2 
2 
4 
0 
0 
0 
0 
0 
0 
0 
56.4 
43.6 
2 
2 
0 
0 
0 
10.2 
9. 
11.7 
10.2 
... 
... 
... 
... 
8.3 
20. 
... 
38 
20 
18 
36 
0 
0 
1 
0 
1 
0 
0 
17 
5 
5 
0 
11 
Third Grade 
9.9 
6 
5 
1 
6 
0 
0 
0 
0 
0 
0 
0 
52.6 
47.4 
2 
1 
1 
0 
2 
15 7 
25. 
5.5 
16.6 
... 
... 
11.7 
20. 
20. 
18.2 
39 
19 
20 
37 
0 
0 
0 
1 
1 
0 
0 
22 
8 
7 
0 
2 
Second Grade 
8.4 
9 
6 
3 
9 
0 
0 
0 
0 
0 
0 
0 
48.7 
51.3 
6 
0 
3 
0 
0 
23 0 
31.5 
15. 
24.3 
... 
... 
... 
27.2 
42.8 
... 
... 
( 
10 
5 
5 
Lawrence 
8 
4 
4 
American oi 
Red Race. 
50. 
50. 
Total Examined 
2040 
1162 
878 
1422 
129 
26 
15 
67 
47 
11 
93 
6291 364 
4431 
99 
91 
458 
290 
168 
300 
32 
5 
3 
20 
8 
3 
22 
56.8 
13.2 
122 
80) 
861 
32 
19 
Percentage 
22.4 
24.9 
19.1 
21.1 
24.8 
19.2 
20. 
29.8 
u. 
27.2 
23.6 
19.3 
22.1 
19.5 
32.3 
19.7 
Twelve Schools Examined with the different grades. 
792 WHITE, BLACK AND RED RACES, GIVING THE PERCENTAGE OF AFFECTED 
ACCOMMODATION, IN BOTH MALE AND FEMALE, IN LIGHT 
ENT NATIONALITIES.-{Continued). 
AFFECTIONS. 
Hypermetropia 
Compared with 
Myopia. 
>ol is of the whole No. 
cted in same School. 
cé 
K 
g 
Q 
a 
Middle row of each indicates full number of each affection, while the 
under figures in each square show the percentage of all of the males 
and of the females. 
Myopia. 
Hyperopia. 
Strabismus. 
Myopia. 
Hyperopia. 
Astigma- 
tism. 
Spasm of 
Acc. 
Females. 
No. of each Affection. 
Males. 
Females. 
No. of each Affection. 
œ 
''S 
Females. 
No. of each Affection. 
Males. 
Females. 
No. of each Affection. 
tn 
Q> 
72 
s 
Females. 
No. of each Affection. 
tn 
<X> 
72 
S 
Females, per cent. 
Males, per cent. 
Females, per cent. 
Males, per cent. 
Percentage that the Seht 
Percentage of the Affe 
Latent Hype 
1 
.6 
1 
..6 
0 
2 
1.3 
7 
4.6 
5 
3.3 
4 
2.6 
5 
3.3 
1 
.6 
2 
1.3 
2 
1.3 
0 
00 
1 
.6 
1 
.6 
0 
28.5 
71.2 
80 
20 
7.3 
3.5 
0 
00 
0 
00 
0 
1 
2.6 
8 
7.8 
2 
5.2 
0 
00 
0 
00 
0 
0 
00 
0 
00 
0 
1 
2.6 
1 
26 
0 
33.3 
66.6 
... 
1.8 
.8 
1 
8 
1 
.8 
0 
1 
.8 
4 
3.5 
3 
2.7 
4 
3.6 
5 
4.4 
1 
.8 
2 
1.7 
2 
1.7 
0 
0 
00 
0 
00 
0 
25. 
75. 
80. 
20. 
5.5 
2.6 
1 
.3 
1 
.3 
0 
::: 
9 
2.8 
17 
5.4 
8 
2.6 
35 
11.1 
55 
14.6 
20 
33 
3 
.9 
5 
1.6 
2 
.7 
9 
2.9 
10 
3.2 
1 
.3 
52.9 
47. 
63.6 
36.3 
15.3 
19.5 
14 
0 
00 
0 
00 
0 
3 
3.6 
6 
7.2 
3 
3.6 
10 
12. 
15 
.18 
5 
6. 
1 
1.2 
1 
1.2 
0 
2 
2.4 
2 
2.4 
0 
50. 
50. 
66.6 
33.3 
4. 
5.3 
9 
0 
00 
0 
00 
0 
0 
00 
0 
00 
0 
1 
2.3 
2 
4.6 
1 
2.3 
1 
2.3 
1 
2.3 
0 
3 
7.2 
3 
7.2 
0 
... 
... 
50. 
50. 
2.1 
1.3 
5 
0 
00 
0 
00 
0 
0 
0 
1 
2.5 
1 
2.5 
3 
7.6 
7 
17.9 
4 
10.2 
0 
00 
0 
00 
0 
0 
00 
0 
00 
0 
... 
100 
42.8 
57.1 
1.9 
1.7 
1 
.8 
1 
.8 
0 
5 
4.4 
9 
.8 
4 
3.6 
16 
14.2 
24 
21.2 
8 
.7 
1 
.8 
3 
2.6 
2 
1.7 
3 
2.7 
4 
3.5 
1 
.8 
55.5 
44.4 
66.6 
33.3 
5. 
9.1 
0 
00 
0 
00 
0 
1 
2.5 
1 
2.8 
0 
5 
14.2 
7 
20. 
2 
5.8 
0 
00 
0 
00 
0 
1 
2.5 
1 
2.5 
0 
100 
71.4 
1.7 
2. 
3 
1.5 
6 
.3 
3 
1.5 
1 
.5 
3 
1.5 
2 
.1 
10 
5. 
14 
7.1 
4 
.2 
0 
00 
0 
00 
0 
00 
5 
2.5 
i - 
5 
2.5 
0 
00 
33.3 
66.6 
71.4 
28.5 
9.7 
6.2 
7 
3 
6.7 
5 
11.3 
2 1 
4.6 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
... 
... 
... 
... 
2.1 
1.1 
0 
00 
0 
00 
0 
00 
T 
00 
00 
0 
00 
0 
00 
2 
5.3 
3 
8.1 
1 
2.8 
0 
00 
0 
00 
0 
00 
1 
2.9 
1 
2.7 
0 
00 
... 
66.6 
33.3 
1.8 
.8 
1 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
0 
00 
1 
2.5 
3 
7.6 
2 
5.1 
0 
00 
0 
00 
0 
1 
2.5 
1 
2.5 
0 
00 
... 
... 
33.3 
66.6 
1.9 
.8 
0 
00 
1 
2.6 
1 
2.6 
T 
00 
0 
(0 
0 
00 
4 
10.5 
4 
10.5 
0 
00 
0 
00 
0 
00 
0 
co 
1 
2.6 
1 
2.6 
0 
00 
... 
... 
100 
... 
1.8 
1.3 
6 
0 
00 
0 
00 
0 
00 
"T" 
2.6 
-3~ 
7.6 
2 
5.1 
3 
7.6 
4 
10.2 
1 
2.6 
0 
00 
0 
00 
... 
0 
00 
... 
2 
5.1 
2 
5.1 
0 
00 
33.3 
66.6 
75. 
25. 
1.9 
.2 
Granulated Lids 
-Scrofulous not included in Percentage of 
Affections. 
... 
... 
... 
... 
100 
100 
63 
3.1 
7 
.3 
13 
.6 
6 J 
52 
2.5 
94 
4.6 
42 
2. 
125 
6. 
202 
9.9 
77 
3.7 
27 
1.3 
42 
2. 
15 
.7 
74 
3.6 
99 
4.8 
25 
1.2 
2.5 
2. 
6. 
3.7 
Twelve Schools Examined with the different grades. 
793 794 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In the above report (tabulated) there are 2040 pupils examined, embracing seven 
different nationalities, besides several of mixed nationality. Of 2040 pupils examined 
there are- 
1422 Americans, 67 Irish, 
129 Germans, 47 English, 
26 French, 11 Swedish, 
15 Scotch, 93 Mixed. 
Of the 1422 Americans, 300, or 21.1 per cent., have some anomaly of refraction. 
Of the 129 Germans, 32, or 24.8 per cent., are affected. 
" 26 French, 5 or 19.2 " " " 
" 15 Scotch 3, or 20 " " " 
" 67 Irish 20, or 27.8 " " " 
" 47 English 8, or 17 " " " 
" 11 Swedish 3, or 27.2 " " " 
" 93 Mixed 22, or 23.6 " " " 
The Irish, Swedish and Germans have the highest percentage of affections, the English, 
French, Scotch, and Americans the lowest percentage. Out of the whole number 
examined (2040) 1162 were girls and 878 boys. 458 had some ametropia (some 
anomaly of refraction). Of the 1162 girls 290, or 24.9 per cent., were ametropic. 
Of the 878 boys 168, or 19.1 per cent., were ametropic, being a larger per cent, of affec- 
tion among the girls than the boys. In three grades of one school, as seen in the table, 
the color of the eyes was not taken, but of those taken there was- 
629£ pairs of blue, 
364" gray, 
443| brown, 
99 hazel, 
91 black. 
Of the 629| blue ±2, or 19.3 per cent, were ametropic. 
" 364 gray 80|, or 22.1 " " " 
" 443| brown 86|, or 19.5 " " " 
" 99 hazel 32, or 32.3 " " " 
" 91 black 18, or 19.7 " " " 
blue, brown and black having the lowest per cent, of affection, the hazel having to a 
marked degree the largest per cent, of affections. Calling the blue and the gray the 
light-colored eyes and the black, brown and hazel the dark, the light have 20.3 per 
cent, of affections and the dark 21.3 per cent, of affections. In this calculation the 
eyes of the negroes are not considered. Out of the 2040 pupils- 
13, or 0.6 per cent., had strabismus, 
94, " 4.6 " were myopic, 
202, "9.9 " " hyperopic, 
42, "2.06 " " astigmatic, 
99, "4.8 " had spasm of accommodation, and 
63, " 3.1 " " latent hypermetropia. 
We find that hypermetropia predominates ; if we add latent hypermetropia and spasm 
of accommodation, saying nothing of astigmatism-of which the majority was hyper- 
opic-we have 364 hypermétropes to 94 myopes, or nearly four times as many hypermé- 
tropes as myopes, or over twice as many as all the other affections taken together. In 
the table, as seen, all the grades from the primary through the grammar school, high 
school, normal school and university are represented, but in no instance, excepting the 
Kansas State University, is there, as we would gather from Dr. Cohn's report, anything 
like a gradual increase of myopia or any of the anomalies, simply or collectively. In 
nearly all of the schools there seems to be a higher per cent, of affection in the first 
years, then a little later in the course a marked diminution, and then again an increase. SECTION XI-OPHTHALMOLOGY. 
795 
Probably many of those having some trouble, after remaining in school a short time, 
drop out, which would account for the diminution, and then spasm of accommodation 
and latent hypermetropia, becoming manifest later on, or perhaps developing into 
myopia, would account for the increase in this affection. 
School life, however, as stated above, so far as I can gather by these examinations, 
has little or nothing to do in the development of these anomalies. That they exist, 
however, in a much greater degree than is generally supposed is very evident, and that 
continuous use of the eyes (having these errors of refraction), whether in the school 
room or out of it, if not corrected, is sure to have its evil consequences. The import- 
ance of a recognition of the existence of these anomalies, of their extreme frequency, 
and of detecting and correcting them, is obvious enough. We should take into consid- 
eration that spasm of accommodation and latent hypermetropia frequently exist, and 
that these affections often develop into myopia, and if recognized early and promptly 
treated by rest and glasses, much suffering and irremediable trouble is averted. Cohn 
and others may have been able, twenty years ago, to trace the development of myopia 
to badly appointed school rooms; but here in America our school rooms are so carefully 
arranged as to light, seat, desks, ventilation, etc., that we can scarcely attribute to the 
work in the school room the cause of anomalies. In a very great degree these errors of 
refraction are congenital; frequently they are latent, and if the eyes were not over- 
taxed (for near work), they would never become manifest. The evil arising from work 
in the school room is that these errors of refraction are not perceived, and hence not 
corrected. If the teacher could be made to understand that the little pupil's com- 
plaining of headache, pain through the temples and weakness of the eyes or dimness 
of vision, arose neither from stupidity nor desire to avoid study, but that these com- 
plaints were symptoms of some defect of the organ of vision; or, what would be better 
still, let a competent oculist carefully examine each child as he enters upon each year 
of study in the school work, and his anomaly (if he have any) corrected, anomalies 
would gradually diminish. 
CONCLUSIONS. 
1. I think that the principal information gained in these examinations is that 22.4 
per cent, of the school children have some anomaly of refraction or accommodation 
which should be recognized and corrected early. 
2. That the hazel eyes, of all the colors, seem to be the ones most affected. 
3. That the light eyes, upon the whole, are less liable to be ametropic than the 
dark. 
4. That the females have a larger per cent, of anomalies than males. 
5. That there is a much larger per cent, of hypermetropia than of myopia. 
6. That spasm of accommodation is a frequent anomaly. 
7. That the far-seeing eye of the red man is bedimmed by syphilization in the effort 
of civilization. (The Indian eyes seem to be emmetropic, but invariably their corneæ 
were more or less cloudy, in consequence of catarrhal or granular ophthalmia, most 
often of specific origin.) 
Note.-Out of 458 of the full number of pupils having defective vision, the com- 
plete record of each eye of 408, taken separately, was kept, and of these 326 had both 
eyes affected, although not equally so. Of the other 83 only one eye was affected. 
The relative vision of the right eye to the left, including all cases where but one only 
was affected as well as where both were, was found to be as 231 : 225, i. e., Vision of 
R. E. : V. of L. E. : : 231 : 235. 
DISCUSSION. 
Dr. Swan M. Burnett.-According to my observation the negro is beginning, 
under education, to develop ametropia. There is one interesting fact, and one bear- 796 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
ing directly upon a question at present exciting attention, which I noted in my 
report on "the relative frequency of eye diseases in the white and colored races," 
published in the Archives of Ophthalmology in 1884, to which I have seen no allu- 
sion elsewhere, and that is the relative scarcity of strabismus in the negro, except 
as a result of paralysis. The fact seems to point to a close connection between ame- 
tropia, the use of the eyes for near work, and strabismus. I have operated on the 
negro for glaucoma, but we all know, now, that the negro does not have trachoma, 
a fact which I was the first, I believe, to point out, eleven years ago. 
LACHRYMAL DRAINAGE AND IRRIGATING CANNULA IN THE 
TREATMENT OF CHRONIC DACRYOCYSTIC FISTULA. 
DESSÈCHEMENT LACHRYMAL ET CANULE IRRIGATOIRE DANS LE TRAITE- 
MENT DE LA FISTULE DACRYOCYSTIQUE CHRONIQUE. 
ÜBER LACHRYMALDRAINAGE UND IRRIGATIONSCANULE IN DER BEHANDLUNG CHRO- 
NISCHER THRÄNENFISTELN. 
ARTHUR E. PRINCE, M. D., 
Jacksonville, Ill. 
In offering for your criticism the device which forms the subject of this brief paper, 
I am not unmindful of the prejudice which exists against all forms of styles, the use of 
which has so generally been superceded by the employment of large probes. With 
their aid and that of the galvano-cautery, and the exsection of the whole or apart of 
the lachrymal sac, such success has been attained in the treatment of lachrymal cystic 
fistulæ as to make suggestions in this direction seem of comparatively little importance; 
yet there still occur intractable cases, unconnected with cares, which do not yield to 
periodic probing, or cauterization short of obliteration of the sac. The obstruction to the 
natural escape of the tears recurs shortly after the passage of the probes, and the secre- 
tion is caused again to flow through the fistulous opening, defeating the natural ten- 
dency to heal. 
It has fallen to my lot to meet a number of such cases which have not yielded to 
probing or cauterization, but have recovered promptly upon the introduction of a per- 
forated cannula, which, in addition to carrying off the secretion, permits the patient, at 
will, to irrigate the whole tract with cleaflsing and medicating fluids. 
This treatment found its origin in the difficulties attending the management of the 
following case :- 
James Young, æt. twenty-two, farmer, presented himself on account of an exten- 
sive fistulous sinus, opening in the right cheek an inch below the eye. There was a 
narrow stricture in the lower portion of the nasal duct and an offensive atrophic rhinitis. 
Hypermetropia existed of -j- 3D., but with this exceptipn the eye was normal. He 
was often subject to conjunctival inflammation, which materially interfered with his 
work. Under an anaesthetic the fistula was cauterized, and the largest of Couper's 
probes was passed and periodically introduced for three weeks. After this a lead style 
was introduced, in the hope of securing drainage, but the tendency was so strong for SECTION XI-OPHTHALMOLOGY. 
797 
the stricture of the duct to close that no good was accomplished. Failing in this man- 
ner to secure drainage and consequent healing of the fistula, the idea occurred of intro- 
ducing two smaller lead wires, side by side, the upper end of each being sufficiently 
bent forward in the form of a spiral to enable the free end to be easily controlled by the 
finger. The double groove formed by the line of apposition of these two wires pre- 
vented the arrest of the secretion by the contractions of the stricture. These wires were 
moved upon one another daily, to dislodge any accumulations which may have formed 
about them. By this means complete drainage was secured, and the healing of this 
obstinate fistula was effected in a few days. The wires were worn for three weeks, for 
precaution, after which they were removed without return of trouble. 
The promptness with which this obstinate case yielded after a successful drainage 
was established, led to the conception that a drainage cannula might be made to admit 
the point of an accompanying irrigating syringe, whereby the constant escape of the 
secretion would be facilitated by placing in the hands of the patient the means of 
irrigating the tract at will during the healing of the fistula. 
Accordingly, in January, 1885, Tiemann made, at my suggestion, a cannula in the 
shape of the wires which had been employed, and perforated it along the sides and at 
the lower end, while the upper end was left open and turned spirally forward to admit 
the point of the irrigating syringe, which is made to fit the cannula. 
Since devising this instrument I have used it a large number of times with variable 
success in the treatment of chronic blennorrhœa of the sac, the accompanying stricture 
being kept in a state of distention, and the medicating irrigation being effected by the 
patient three or more times a day. Among the above, six cases were complicated with 
obstinate fistula, which did not yield to the various efforts which had been employed 
to close them. 
It seems needless to detail these cases, since they were, in a measure, similar and 
not connected with cares. In all the behavior was uniform. From the commencement 
the drainage was perfect, and the fistula healed without delay. 
The irrigating solution which was used was a 25 per cent, solution of peroxide of 
hydrogen, the liberated oxygen from which is found to prevent, in large measure, the 
perforations in the cannula from closing. According to the firmness of the cicatrix, the 
cannula was removed in from one to three weeks. One advantage for the use of the 
cannula, over the other methods, even when successful, is the continuous distention of 
the stricture, which increases the probability of the subsequent conduction of the 
lachrymal secretion. They are made of silver and gold, and in pairs. 
The size which I have employed has been equal to Bowman's No. 8 sound. A 
smaller size would accomplish the same effect with less difficulty of introduction, but 
would lose the advantage of distention of the stricture. 
From the limited experience no generalizations can be made. We can only say 
that thus far their behavior has been satisfactory, and express the belief that in a large 
sphere of usefulness there is a limited field, in which it will be found superior to other 
methods. 798 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
A NEW PATTERN OF AN OPHTHALMOSCOPE. 
UN NOUVEAU MODÈLE D'OPHTHALMOSCOPE. 
EIN OPHTHALMOSCOP VON NEUER CONSTRUCTION. 
BY PETER D. KEYSER, M. D., 
Of Philadelphia. 
The nearest to perfection of an ophthalmoscope that has been given to the profession 
is the larger one of Knapp, with the two discs of convex and concave glasses revolving 
over each other. This instrument, however, is too large and too expensive for general 
use. Furthermore, it is not arranged so that the rotation of the discs can be made with 
the fingers of the hand holding the instrument up before the eye. It is so large that it 
will not go under the brow and close to the eye of the examiner, but rests upon the 
brow, which keeps it at too great a distance for proper examination and calculations in 
cases of refractive defects. 
Fig. 1. 
Fig. 2. 
Fig. 3. 
The great desideratum in an ophthalmoscope is to be able to make all the changes 
in the glasses during the examination without removing it from the eye, on account of 
the activity and ready involuntary changes of the accommodation. Most all of the 
later patterns of this instrument require to be removed to adjust some weaker or 
stronger glass to make combinations with the disc that is revolved and regulated by 
the finger while making the observation. 
The instrument I present to you is an improvement on Knapp's original one. It is 
composed of two discs, containing respectively convex and concave spherical glasses, 
revolving immediately over each other on a common centre, and so arranged that either SECTION XI OPHTHALMOLOGY. 
799 
or both discs can be rotated by the finger and thumb of the one hand holding the instru- 
ment before the eye. It is much smaller, so that it will go under the brow, close against 
the eye. It has a movable mirror, and the lenses in the discs are- 
Convex-0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, 10, 12, 16. 
Concave-0.25, 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, 10, 16. 
With these glasses any combination can be made, and any amount of hypermetropia, 
myopia or astigmatism can be measured. 
It is also very handy in retinoscopy, on account of its size and close adaptation to 
the eye. 
The accompanying wood-cuts show the mechanism and arrangement :- 
Fig. 1.-Shows the instrument in its actual size ready for use. 
Fig. 2.-The back plate is removed to show the lenses of one disc, the other being 
directly under it, and the cog-wheel attachment. 
Fig. 3.-Is the back plate reversed to show the other cog wheel. 
It is manufactured by Mr. E. Fox, N. W. corner Chestnut and Seventeenth streets, 
Philadelphia, Pa. SECTION XII-OTOLOGY. 
OFFICERS. 
President : S. J. JONES, m. d., ll. d. 
J. Baratoux, m. d., Paris, France. 
Prof. E. De Rossi, m.d., Rome, Italy. 
J. J. K. Duncanson, m.d., Edinburgh, Scotland. 
Prof. B. E. Fryer, m. d., Surgeon, U. S. Army, 
Kansas City, Missouri. 
Prof. A. A. G. Guye, m.d., Amsterdam, Holland. 
VICE-PRESIDENTS. 
B. Loewenberg, m. d., Paris, France. 
F. M. Pierce, m.d., Manchester, England. 
Prof. Â. Politzer, m.d., Vienna, Austria. 
Prof. U. Pritchard, m. d., London, England. 
W. L. Purves, m.d., London, England. 
Prof. H. Schwartzs, m.d., Halle, Germany. 
S. O. Richey, m.d., Washington, D. C. | H. B. Young, m.d., Burlington, Iowa. 
SECRETARIES. 
COUNCIL. 
Prof. F. Allport, M. D., St. Paul, Minnesota. 
A. Alt, M. d., St. Louis, Missouri. 
S. C. Ayres, m. d., Cincinnati, Ohio. 
E. W. Bartlett, m. d., Milwaukee, Wisconsin. 
Prof. G. E. Frothingham, m. d., Ann Arbor, Mich- 
igan. 
Prof. J. F. Fulton, m.d., St. Paul, Minnesota. 
Prof. C. J. Lundy, m. d., Detroit, Michigan. 
Prof. W. O. Moore, m. d., New York, N. Y. 
Prof. T. E. Murrell, m.d., Little Rock, Arkansas. 
Prof. G. H. Powers, m. d., San Francisco, Cali- 
fornia. 
Prof. G. C. Savage, m. d., Nashville, Tennessee. 
Prof. A. G. Sinclair, m. d., Memphis, Tennessee. 
Prof. J. G. Sinclair, m. d., Nashville Tennessee.. 
R. Tilley, m. d., Chicago, Illinois. 
J. P. Worrell, M. d., Terre Haute, Indiana. 
Vol. Ill-51 
801 802 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
FIRST DAY. 
THE PRESIDENT'S ADDRESS. 
It is with pleasure, honored confrères, that we welcome you to this, the first, 
meeting of the Section of Otology in the Ninth International Medical Congress. 
It is alike gratifying to us and to sufferers from ear disease that such eminent 
men in the medical profession should have assembled here on this occasion, from 
widely separated parts of the world, to consider anew, and together, the long-neg- 
lected, but important, subject of otology. 
To those of us who can look back over a quarter of a century or more of pro- 
fessional life, the improvement that has taken place in that length of time in this 
one field, alone, is gratifying, and inspires a feeling of hopefulness for the future of 
otology, for much remains yet to be accomplished. 
The little assemblage of nine medical men who, in July, 1868, met in Newport, 
in Rhode Island, and organized the American Otological Society, founded the first 
special society of co-workers of which I have knowledge, in this comparatively 
unexplored field. They may be regarded as practically the pioneers in scientific work 
in otology in America. 
Following closely upon that organization came the First Otological Congress, 
when, in September of the same year, but thirteen of us met in Dresden, in Saxony, 
and held a conference of five days, and discussed some of the questions in otology 
that are not without interest now. 
It is worthy of note that no such organized efforts as these for the advancement 
of otology should ever have been made until within nineteen years of the time of 
our assembling here to-day. 
While this brief retrospect of what was not done, rather than of what was done, 
in the past may not be devoid of interest, and perhaps of profit, our greater interest 
centres on what may be done on this occasion, and in the future, for the advancement 
of scientific and practical otology. 
It may be assumed that none present doubt the importance of the subject, or its 
influence upon man's well-being, from the cradle to the grave ; in his physical com- 
fort ; in his mental condition ; in his social relations, and as a member of the common- 
wealth, in determining whether he shall be a useful, productive member of society, 
or a more or less useless and unhappy one-too often dependent upon public or 
private charity. 
The State, in its military and naval services, and life insurance associations, now 
recognize the risk to life of persons affected with suppuration within the tympanum; 
and yet only recently has the study of such conditions been made obligatory in 
medical educational institutions, which should have been of the first to recognize 
the importance of the subject and to have made proper provision for their study. 
However, a time of greater hopefulness has come. But few medical colleges now, 
in America, are without competent instructors in otology, and the educational insti- SECTION XII-OTOLOGY. 
803 
tutions of other countries are adding more, and still better, facilities for the student 
of otology. We indulge the confident hope and expectation that the work of this 
Section, during the sessions on which we are now entering, will not only show a 
growing interest in otology, but add another link in the chain of evidence that 
progress is being made in removing it from the position which it so long held 
among the opprobria medidnœ. 
The ophthalmoscope proved an aid to the neurologist as well as to the ophthal- 
mologist in accuracy of diagnosis, so essential for correct therapeutics and surgery. 
The advances made in otology during the last two decades have shown how 
critical and scientific examination of the ear may throw important light on many 
of the mysterious and embarrassing cases in neurology, as well as in the wide field of 
general medicine. From the dissimilar anatomical conditions, inspection of changes 
in the distribution of the optic and the auditory nerves are not alike possible, and 
diagnosis in affections especially of the perceptive apparatus of the ear, and in some 
of the defects in its conducting apparatus, must, perhaps, always remain less reliable 
and less certain than in affections of the interior of the eye. 
Notwithstanding these embarrassments-because of the complicated anatomy of 
the hearing apparatus, and because, as has been so truly said, the affected part can- 
not, like the eye, be removed and inspected during the life of the patient, and only 
the death of the individual can make possible conclusive evidence of the accuracy of 
diagnosis in the more difficult cases of ear disease-yet great progress has been made. 
With the instruments of precision which science and skill have within a few 
years provided, we are approaching nearer to that accuracy of diagnosis which has 
given to ophthalmology much of its present attractiveness. 
With these advances a wider sphere of usefulness attaches to scientific otology. 
It is no longer restricted to the routine of unattractive manipulation, such as once 
characterized the treatment of ear disease. This elevation of the subject makes 
more manifest the incompleteness of the work of the mere specialist, who considers 
and treats the local disease much as if it were in a detached portion of the human 
body rather than in an integral part of a complete and complicated organism, 
ignoring the fact that the local defect may be but one of the manifestations of general 
disarrangement of the system showing these special characteristics. 
Only when otologists shall have recognized more generally-in theory and in 
practice-the importance of thorough familiarity with the relation of abnormal con- 
ditions of the ear to the entire system-both as regards cause and consequence-may 
it be expected that otology will hold that position in the estimation of the medical 
profession, and of the public, to which its importance entitles it. 
If, as one of the consequences of this conference, broader and more thorough 
study of this subject shall result, substantial progress will follow. It will, moreover, 
serve to counteract the tendency to view matters from a single standpoint, with the 
evils that follow therefrom. There will be less of the superficial work and routine 
practice which are responsible for the growing disposition to regard specialism in 
medicine with disfavor, and which led a member of our profession to say that, when 
he saw the great and rapid progress in the different departments of medicine which 
resulted from division of labor and special skill, he came to look upon a well qualified 
specialist as being a doctor-and something more than a doctor-but that with the 
recent tendency to perversion of specialism, which leads to superficiality and unrelia- 
bility, he was fast coming to regard the specialist as being something less than a 
■doctor. 
If such perversion of the object of the division of labor and special lines of study 804 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by properly qualified medical men-who have been seeking to explore the unknown 
or imperfectly known avenues which lead off from the lines of study that medical 
men are accustomed to follow-should result, specialism must soon be regarded as 
an impediment to the advance of scientific medicine, and the specialist, whose course 
of study should have fitted him to become an expert adviser of the general prac- 
titioner, must soon become a superficial imitator of others. 
The needs of otology, in its present state, demand for its elevation a high order 
of qualifications. The possession of such qualifications, by contributors to the work 
of this Section, is manifest in the carefully prepared papers which are to be presented 
here. They embrace subjects which cannot fail to interest us as otologists and 
medical men, and they will elicit, in discussion, the mature views resulting from 
critical study and experience which will give an added interest, and, perhaps, form a 
stimulus to still further investigation. 
In arranging the order of presenting these papers, an effort has been made to 
adjust the programme, that subjects of similar nature should be so placed as to admit 
of their discussion as a class, and thus, as far as practicable, to avoid the necessity of 
taking any of the limited time of the Section in avoidable repetition. It is contem- 
plated to include some of the yet open questions in otology in the programme. 
Their importance is such as to make desirable careful conference regarding them by 
those here assembled, who are so competent, and, we hope, equally willing, to give 
their views upon them, in a mutual effort to eliminate them from among the doubtful 
ones and place them among the established facts. 
STATISTICAL REPORT OF 5700 CASES OF EAR DISEASES, CLAS- 
SIFIED BY AGE, SEX, OCCUPATION AND DISEASE ; CAU- 
SATION. 
RAPPORT STATISTIQUE DE 5700 CAS DE MALADIES D'OREILLE CLASSIFIÉS 
PAR ORDRE D'ÂGE, DE SEXE, D'OCCUPATION ET DE MALADIE. 
STATISTISCHER BERICHT ÜBER 5700 FÄLLE VON KRANKHEITEN DES OHRES, CLASSI- 
FICIRT NACH ALTER, GESCHLECHT UND BESCHÄFTIGUNG. 
BY SETH S. BISHOP, M. D., 
Of Chicago, Illinois. 
The following statistical tables represent the records of 5700 cases of diseases of the 
ear treated during the last eight years by the Staff of the Illinois Charitable Eye and 
Ear Infirmary, in Chicago. I have added a relatively small number of unselected cases 
from the records of my private practice to supply the place of those whose records were 
incomplete. The purpose for which the classification was originally begun was to 
establish a basis of calculation of the influence, if any, exerted by occupation, age or 
sex, in the causation of ear diseases. The condition of each patient at the time he first 
presented himself at the clinic was recorded, in order to determine the relative fre- 
quency of the different diseases. As is usual in charity hospitals, a very large percent- 
age of those who applied for treatment belonged to that class of laboring people who SECTION XII-OTOLOGY. 
805 
have no definite trade or fixed occupation. It is interesting also to note that the last 
decade embraced what might be called the vagrant era of the century in this country, 
for there never was a time in the history of America when such vast numbers of men 
were unemployed and leading nomadic lives. This may partly account for the fact 
that about one-third of the adult males are classed as being without occupation. In 
order to facilitate investigation and simplify the tables as far as possible, all those occu- 
pations which were closely related to each other in nature and effects were grouped 
under one heading, so that the twenty-four which appear really represent about double 
that number. For example, under the heading of clerks were embraced salesmen, 
book-keepers, office employés, etc. ; with teamsters were grouped car drivers, peddlers, 
etc. ; cooks and bakers were classed together ; plumbers, gas- and steam-fitters appear 
together ; brass moulders, iron moulders, etc. were classed with iron workers ; such 
closely allied occupations as stone cutters, stone masons, bricklayers and plasterers, in 
which the influences and exposures are very similar, are grouped together under the 
heading of day laborers, a term borrowed from the laborers themselves. 
The abbreviations employed are: Ac. for acute inflammation of the middle ear; Ac. 
S. for acute suppurative inflammation of the same ; C. N. for chronic non-suppurative 
inflammation of the same; C. S. for chronic suppurative inflammation of the same; Ext. 
for diseases of the external ear ; Int. for diseases of the internal ear ; D. M. for deaf 
mutes ; W. No. for whole number. 
W. NO. 
AC. 
AC. S. 
C. N. 
c. s. 
EXT. 
INT 
Miners 
10 
6 
4 
Firemen 
10 
... 
9 
1 
Coopers 
10 
i 
3 
5 
1 
Butchers 
11 
i 
6 
3 
i 
Packing house laborers.. 
12 
1 
i 
8 
2 
Engineers 
13 
10 
2 
... 
Ï 
Cigar makers 
15 
2 
i 
6 
3 
3 
Plumbers 
16 
2 
1 
7 
1 
5 
• •• 
Boiler makers 
19 
... 
3 
10 
3 
3 
Tinners 
20 
1 
4 
9 
5 
1 
Shoe makers 
22 
2 
14 
1 
4 
i 
Bakers 
22 
i 
2 
14 
4 
1 
Printers 
30 
2 
10 
12 
5 
i 
Tailors 
31 
2 
18 
8 
2 
1 
Blacksmiths 
38 
i 
2 
26 
3 
5 
i 
Painters 
47 
3 
1 
26 
10 
6 
1 
Sailors 
47 
1 
2 
28 
9 
5 
2 
Railroad laborers 
58 
2 
5 
35 
12 
3 
1 
Farmers 
74 
1 
55 
18 
Carpenters 
80 
3 
4 
57 
8 
6 
2 
Iron workers 
84 
4 
4 
54 
11 
10 
1 
Teamsters 
85 
12 
11 
33 
23 
6 
Factory hands 
108 
6 
13 
59 
19 
9 
2 
Clerks 
232 
17 
19 
117 
39 
36 
4 
Day laborers 
496 
27 
26 
300 
77 
60 
6 
- 
- 
- 
- 
- 
- 
- 
Total 
1590 
85 109 
1 
922 
279 
171 
24 806 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
W. NO. 
AC. 
AC. S. 
C. N. 
c. s. 
EXT. 
INT. 
D.M. 
Adult males without occupation 
810 
43 
31 
485 
197 
46 
7 
1 
Female adults 
1662 
75 
63 
1070 
317 
106 
27 
4 
Boys, 6 to 15 years 
557 
35 
28 
230 
205 
34 
19 
6 
Girls, 6 to 15 years 
562 
32 
22 
225 
232 
35 
11 
5 
Boys, under 6 years 
243 
11 
21 
41 
125 
26 
8 
11 
Girls, under 6 years 
276 
11 
26 
45 
139 
38 
9 
8 
Occupations 
1590 
85 
109 
922 
279 
171 
24 
- 
Total 
5700 
292 
300 
3018 
1494 
456 
105 
35 
Per centum of whole number... 
5.1 
5.3 
53. 
26. 
8. 
2. 
6. 
The tables show that more than one-half of all the occupations were indoor. Of 
the 1590 males, with fixed occupations, 920 worked out of doors and 670 indoors. Add 
1662 female adults who lead indoor lives to the 670 adult males with indoor work, and 
we have 2332 patients who spend mbst of their lives within doors. To the 920 men 
who do outdoor labor, we may add the 810 adult males who were without trades or any 
definite means of subsistence, and it gives 1730 men who probably pass most of their 
days in the open air. Thus the excess of patients of the indoor class over those who 
lead outdoor lives amounts to 602, or about 15 per centum of the whole number of 
adults. These facts are significant when we take into account the slight difference 
between the number of males and females afflicted under the age of fifteen. Sex seems 
to have no influence in the production or prevention of these diseases. Up to the age 
of fifteen years ear diseases are found in both sexes nearly equally. Probably a reason 
for the slight difference in the number of male and female cases during the first fifteen 
years of life may be found in the similarity of the lives and habits of the sexes during 
this early period. The classes of society who afford clinical material at the medical 
charity institutions of this country are such that necessity compels them to abandon 
the pursuit of an education at about the fifteenth year, and to enter upon the bread- 
winning avocations. From that time the divergence in habits increases. The males 
are either out of doors more than ever, or confined chiefly to mercantile houses or 
factories. The females become domestics, clerks and shop girls. American residences 
and business houses are heated in cold weather by dry, hot air, and kept at a tempera- 
ture of 70° F., or higher. The inmates are subjected to the action of this dry, hot air, 
often laden with dust and noxious gases, the greater part of every day. The skin, con- 
sequently, is very active in its functions, and kept moist by free perspiration. But, 
though constant exposure renders the soldier, Spartan-like, indifferent to cold and 
storms, housing the body makes it tender, like the hot-house plant, and sensitive to 
sudden and extreme changes in the air. After working all a winter day in a tempera- 
ture of summer heat, these people, with the powers of resistance reduced by hunger 
and fatigue, pass out immediately into a frigid atmosphere with the temperature per- 
haps from 40 to 70 degrees F. lower than that of the workshop. The skin is chilled, 
the perspiration checked, and a determination of blood to some internal organ occurs. 
Naso-pharyngeal catarrh is probably the most frequent consequence. This result is 
aided by high winds and the inhalation of dust. Indeed, a very large percentage of 
cases of naso-pharyngeal catarrh undoubtedly are due to the irritating effects of dust; 
this, operating in conjunction with cold, damp air, seems largely responsible for the 
widespread existence of naso-pharyngeal catarrh among Americans. It is probably the 
most prevalent disease in this country. The importance of this fact is obvious when 
we consider that so large a number of middle-ear affections originate in naso-pharyngeal SECTION XII-OTOLOGY. 
807 
inflammation, which extends from that cavity, through the Eustachian tube, to the tym- 
panum. Critical examination of the class of patients under discussion renders it evident 
that a considerable majority of them have throat trouble. This being the case, what- 
ever causes a catarrh of the nose and throat is interesting to the otologist, as a proxi- 
mate cause of ear disease. The exanthemata are frequent causes of ear trouble 
during early childhood, but youth seems also to predispose to coryza, which is often a 
forerunner of tubal and tympanic catarrh. Children under fifteen years of age consti- 
tute about 28.5 per centum, or more than one-fourth of the whole number of cases. A 
very small proportion of children were brought for treatment during the acute stage 
of inflammation. Only 13 per centum were acute cases, leaving 87 per centum, or 
more than six times as many, who were not presented for treatment until the disease 
had reached a chronic stage. The tables also show that only 11 per centum of adults 
with middle-ear diseases were seen in the acute stage. 
The tables give a somewhat large percentage of external-ear cases. Since inspissated 
cerumen may be regarded as a symptom and a consequence of chronic non-suppurative 
inflammation of the middle ear, that consideration should be given due weight in this 
connection. 
It may be permissible to cite a few facts not demonstrated by the tables, but which, 
nevertheless, were impressed upon me by a personal study of these patients. Although 
the whole state of Illinois contributed largely to the number embraced by these 
statistics, a large majority were residents of Chicago, a very cosmopolitan city. The 
foreign element predominates. The Irish constitute a very large, and the French a 
very small proportion of our clinical material. The north of Europe furnishes a far 
greater percentage of our population than the southern portions. After considering 
the nationalities it will not be surprising when it is stated that the blondes exceed the 
brunettes in number. It was noticeable, also, that the nervous temperament was the 
prevailing one. Another matter of interest to the etiologist, and to the student of 
sociology as well, was the conspicuous absence of baldness among these people, for cold 
draughts of air on heads deprived of Nature's covering are considered as being a prolific 
cause of catarrh, by eminent authorities. 
This brings us to the consideration of climatic causes. In speaking of climatic con- 
ditions as standing in a causative relation to ear diseases, it should be understood that 
reference is made to those atmospheric conditions which are characteristic of Chicago 
and its vicinity, although they may not be peculiar to it. A sudden, great fall of tem- 
perature, accompanied with increased humidity of the air, is usually followed by an 
increase in the attendance at the clinics of new patients with acute diseases, and of old 
cases with acute symptoms. These climatic variations and clinical responses have 
recurred with such -uniformity that one may predict an increase or decrease in the 
number of acute diseases, with a reasonable degree of accuracy, by observing the 
meteorological variations. Our climate is rugged, but the people born and raised in it 
do not appear to share its robust character. The altitude is low, in the Mississippi val- 
ley, the air moist and the thermometric changes sudden and great. It is not unusual 
for the thermometer to fall 20 or 30 degrees F., or more, in a few hours. Indeed, cold 
waves sweep suddenly over the country in summer time, cooling the heated atmosphere 
so quickly and thoroughly that one must needs change from summer to winter gar- 
ments, with haste, or suffer from the chilling winds. Add to these causes of great 
circulatory disturbances the irritating effects of constantly inhaled dust which the 
ceaseless winds keep in never-ending motion, and the problem of the prevalence of 
naso-pharyngeal, tubal, and tympanic catarrh in this climate is largely solved. 808 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Professor G. E. Frothingham, of Ann Arbor, Michigan, said that he had been 
much interested in the valuable statistical report presented by Dr. Bishop. It is 
upon carefully collected and carefully considered statistics that we must largely rely 
for progress in the development of otology. The statistics presented by Dr. Bishop 
tend to establish the fact that those who live in large cities, especially if exposed to 
sudden changes of temperature, as are residents of Chicago, become more frequently 
affected with inflammatory conditions of the middle ear than those who reside in the 
country, since the institution from which the statistics were gathered receives 
patients from all parts of the State. 
The statistics also show that a larger proportion of the foreign population were 
thus afflicted. He believed we might find an explanation of these facts in consider- 
ing the important relation existing between naso-pharyngeal catarrh and inflamma- 
tory affections of the middle ear, and the important factors in producing nasal 
catarrh. The air of cities is loaded, often heavily, with germs that have a tendency 
to excite inflammation in mucous membranes with which they come in contact. 
Their power to produce inflammation of the air passages, and even to produce 
phthisis, has long been recognized. That they may escape from this influence, we 
send patients who are afflicted or threatened with consumption to a high mountain 
region, where the air is not only free from such germs, but is also free from particles 
of dust and vitiating gases. The nasal passages serve the purpose of a strainer 
for the air passing to the lungs, and they not only warm and moisten the inspired 
air, but they partially free it from solid vitiating substances. These particles, lodged 
upon the mucous membranes of the nasal passages and pharynx, act as irritants, and 
so do many of the gases that are inhaled in such an atmosphere. If we combine 
with this irritation the effect of a sudden change of temperature, by which the sur- 
face of the body becomes cooled and the cutaneous exhalations are checked, we 
have the important factors in the production of naso-pharyngeal catarrh, and the 
consequent liability to middle-ear disease. When such a sudden lowering of the 
temperature occurs, and the external surface of the body is not duly protected, the 
mucous surfaces most irritated are most likely to become involved in inflammatory 
action. Baron Larrey, who investigated the causes of the prevalence of conjunctiv- 
tis in Egypt, has ascribed it to a similar cause, namely, the irritation of the eye by 
exposure to dust and bright light during the day, and the exposure of the surface of 
the body to considerable change from the warm atmosphere commonly experienced 
by day, to the cool atmosphere which prevailed during the night,. He declared that 
those who protected themselves by proper covering at night did not suffer from 
Egyptian ophthalmia, as did those who neglected this precaution. In the same 
way inflammation of the mucous lining of the intestines is produced more frequently 
when irritated by the ingestion of unripe fruit and other indigestible food, during 
that period of the year when the days are warm or hot, and the nights are cool, 
the body, commonly, being insufficiently protected from the chilling atmosphere. 
That the germs lodged upon the naso-pharyngeal mucous membrane by breathing 
such an atmosphere play an important part in the production of the aural disease, 
Professor Frothingham is quite convinced, and that prompt and efficient treatment 
of the post-nasal catarrh is very important in the prevention and treatment of aural 
catarrh. In this treatment germicides are of great importance, as he had become 
convinced by resorting to them for this purpose. He had found an application, by 
means of an atomizer, of a solution of bichloride of mercury, 1-2000 parts, one of SECTION XII-OTOLOGY. 
809 
the most efficient remedies for post-nasal catarrh, and he believes it acted thus bene- 
ficially by destroying germs deposited from the air upon the naso-pharyngeal surface, 
which, in certain conditions of the system, might excite more reaction than at other 
times, when the vital forces of the patient might successfully resist their morbid 
influence. That the foreign population furnished the larger proportion of these 
cases is consistent with such an explanation. It furnished the larger proportion of 
laborers, and those who lived under bad hygienic circumstances, sleeping in small, 
illy-ventilated bed rooms, in which the atmosphere literally swarmed with germs. 
Dr. R. Tilley, Chicago, Illinois, said-I wish to express my appreciation of the 
presentation of the statistics relative to the study of otology. There is, however, in 
connection with this presentation, a factor which has scarcely received its due weight 
in the tabulation. It is stated that youth is a predisposing cause. Now, I fail to 
perceive that youth, in itself, can, under any circumstances, be a cause of any disease 
whatever. If, under certain circumstances, the youthful organism is ushered into 
the world under a decided disadvantage, and on that account certain diseases 
are developed, we must not say that it is the youth which is the cause. Relative to 
the percentage of cases of youth, in proportion to the cases of adult life, the import- 
ant fact of the much larger proportion of children in the world, relative to adults, 
must not be forgotten ; but for the decease of a large number of the youthful 
members of the race, the proportion would be different. A similar observation 
should be made relative to those whose occupation requires them to spend their 
time for the most part indoors ; unless we know the relative number of the individuals 
engaged in indoor and outdoor work, the proportion of those afflicted is of compara- 
tively small importance. I fail to find in the report, notwithstanding the special 
reference to occupation, any such occupations as unquestionably tax the aural tissues; 
I refer to the vocation of boiler makers. It might have been an advantage, also, to 
have referred to such as are engaged wholly with the telephone. If there were no such 
case in the table it would be desirable to mention the absence of persons so engaged. 
Of the influence of a mere change of temperature from warm rooms to that of the 
external atmosphere, those who visit and live in severe regions should furnish some 
evidence which would contribute to the elucidation of the question. 
Professor E. De Rossi, Rome, Italy.-I agree perfectly with Professor Froth- 
ingham, that a very large part of the diseases of the ear are caused by diseases of 
the nose and pharynx. Therefore I desire that the Congress express wishes that 
studies on laryngo-rhinology be united with those on otology, rather than to 
unite this last one with ophthalmology, with which it has no connection, and by 
which nothing would be gained in the interest of scientific progress. 
Dr. H. B. Young, Burlington, Iowa.-As regards the influence of change of 
climate in the prevalence of ear diseases, it is questioned whether the sudden changes 
of temperature with moisture, necessarily increases ear diseases. Pointing to this is 
the fact that during the past year the thermometric changes have been slight and 
the rainfall at the minimum, at least in the northern part of our country, and yet 
there has been an unusual increase, relatively, of ear troubles, both new and relapsing 
old cases. 
Dr. C. M. Hobby, Iowa City, Iowa, endorsed the remarks of Dr. Young, and espe- 
cially in the statement that the temperature was extraordinarily high and remarkably 
uniform in the Mississippi Valley during the last summer, and that there was a great 
increase in the number of diseases of the ear and nose, especially acute diseases, while 
the heat lasted and before the evenings became cool. 810 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. G. W. Allyn, Pittsburgh, Pennsylvania, remarked that the warm winds 
from the Gulf of Mexico and the cold winds from the great lakes made of Western 
Pennsylvania a perpetual battle-field. As a result, there were great and rapid changes 
in temperature and the moisture of this region, aqd if such changes were directly or 
indirectly the cause of middle-ear disease, these troubles should prevail there, and 
nose, throat and ear troubles are very prevalent there. 
Professor J. F. Fulton, St. Paul, Minnesota, spoke of the increasing interest 
which is being taken in otology. He said that climate is not only a great factor in 
causation of diseases of the ear, but a most important one in the treatment and cure 
of such diseases; that many cases which could not be benefited in one climate may 
be cured by a change of climate. He referred to the favorable influence of a high 
and dry region in many forms of middle-ear catarrh; referred to a distressing case of 
chronic suppurative inflammation, which could not be cured in its native climate, 
but which soon recovered by a change of climate. 
Dr. S. 0. Richey, Washington, D. C., said that in the moist climate of Wash- 
ington during the season of high temperature catarrhs are frequent; not virulent, 
but also, not very tractable, though slight. In the fashion of the day bacteria are 
made responsible for much of which they are doubtless innocent. They are mis- 
chievous, but nasal catarrhs may be due entirely to chilling of the surface of the 
body, with determination of blood to the more central and better protected regions. 
Professor Frothingham said that he wished to correct the impression, if such 
had been created by his remarks, that he regarded all, or nearly all cases of post-nasal 
catarrh, and consequent aural disease, as due to these inspired germs. What he did 
intend to assert was his belief that this is a frequent cause, and that germicides should 
be more frequently used in the treatment, and that, as a germicide for these cases, a 
solution of the bichloride of mercury is by far the most efficient of any that he had 
used. 
In closing the discussion of this paper, Dr. Bishop said:- 
In answer to the doubt expressed relative to my inference from the tables, that 
youth is a predisposing cause of diseases of the middle ear, I will say that since it is 
generally conceded that youth is a predisposing cause of exanthemata, as is illus- 
trated in the cases of scarlet fever and measles ; and, as it cannot be denied that a 
large proportion of ear affections are directly traceable to the diseases of childhood ; 
and, in view of the facts that children are particularly prone to attacks of coryza, 
which is a proximate cause of tympanic inflammation ; and, that a large percentage 
of this class of patients refer their ear troubles to the earaches and running ears 
of childhood ; and, that the tables show that children under the age of fifteen years 
constituted about 28$ per centum of the whole number of cases, it appears to be a 
logical deduction that youth is a predisposing cause of diseases of the middle ear. 
Professor Fulton remarked that one-half of all cases of middle-ear diseases are 
associated with a catarrhal condition of the naso-pharynx. He resides in what is 
regarded as a high and dry part of our country, St. Paul, Minnesota ; while the 
patients who afforded the material for this paper live in a low, moist climate, lying 
between Lake Michigan on the east, the Mississippi river on the west, and the 
Ohio river on the south. Under these circumstances it is not surprising that a 
larger proportion than one-half of the patients, in the statistical report, were 
afflicted with one or another form of naso-pharyngeal catarrh. The most prevalent 
form was of a hypertrophic nature. There were frequent cases of enlarged tonsils, 
associated with granulations on the posterior wall of the pharynx, adenoid vegeta- SECTION XII-OTOLOGY. 
811 
tions in the vault of the pharynx, and a thickened, roughened, red and boggy 
appearance of the mucous membrane generally, lining the pharynx and post-nasal 
space. In others, the tendency was not to cell proliferation, but to an atrophic con- 
dition. The columns of the fauces were extremely thin and pale ; the membrane 
covering the posterior wall of the pharynx pale, thin and shining, with tortuous 
vessels, in some cases dilated and injected with blood, and conveying the impression 
of a weakened state of the coats of the blood vessels. This condition is quite often 
found in those individuals of middle age who have sulfered much in early life from 
coryza and pharyngitis. 
ON THE TREATMENT AND THE BACTERIOLOGY OF AURAL 
FURUNCLES. 
SUR LE TRAITEMENT ET LA BACTERIOLOGIE DES FURONCLES AURICULAIRES. 
ÜBER BEHANDLUNG DER OHRENFURUNKELN UND DIE BACTERIEN DERSELBEN. 
DR. B. LOEWENBERG, 
Of Paris, France. 
I communicated as early as in 1880 to the Second International Otological Congress 
(Milan, 6th September, 1880) a paper "On micrococci in the ear, and on the part they 
play in the generation of boils and of general furunculosis."* A short abstract of the 
principal results of these researches has been presented in the author's name, by Profes- 
sor Marcy, to the Academy of Sciences of Paris, and published in the Transactions of that 
Society.! Besides, I published in 1881 an exhaustive paper on furuncles of the external 
ear and furunculosis in general, written in French.! 
In the two preceding papers, as well as in the latter work, I, for the first time, 
theoretically and practically utilized the discovery of the parasitic nature of the dis- 
ease recently made by Professor Pasteur, and corroborated by myself, with regard to 
boils of the external ear. 
Prolonged and careful meditation upon this subject led me to these conclusions :- 
1. Boils are caused by an infection from without, viz., through the ducts of the 
cutaneous follicles. 
2. The successive outbreak of furuncles on the same individual takes place by auto- 
contagion, that is, through transport of the cocci upon the skin. 
3. Infection from one person to others is possible, and originates from the same pro- 
cess as in No. 2. 
Several years later Dr. Garré's interesting researches have furnished the experimental 
proof of the entire correctness of my previous statements, but my anterior claims have 
been completely overlooked by this author as well as by all others. 
Proceeding from the knowledge of the parasitic nature of boils, I rejected all emol- 
* B. Loewenberg. " Recherches sur la présence de Micrococcus dans l'oreille malade; Considéra- 
tions sur le Rôle des Microbes dans le Furoncle auriculaire, etc." Transactions of this Congress, 
pages 11, 12 (in English, in the Archives of Otology, 1881). 
f " Comptes Rendus de l'Académie des Sciences," 1880, Vol. n, pages 555, 556. 
J " Le Furoncle de l'Oreille et la Furonculose." (An exhaustive abstract of this paper 
appeared in the, unfortunately discontinued, American Journal of Otology, Vol, IV., pages 139- 
144.) 812 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
lient treatment, considering it as contrary to the end to be aimed at, because of its ten- 
dency to favor pullulation of bacteria. I substituted for it a special modification of the 
antiseptic treatment, intended to act at the very outset of the boils in an abortive way, 
as well as to prevent the return of the affection. This method I will now state, as well 
as the results of six years' practice with it. After various experiments, I more and more 
confined myself to the treatment which I originally had devised for otorrhœa,* that is, 
instillation of au over-saturated solution of boracic acid in strong alcohol. The effect of 
this mixture is excellent, with regard both to its powerful anti-bacterial action and its 
absolute painlessness. Concerning the first of these points, I refer to what I have given 
in detail in a previous paper on ozæna.f I here only lay stress upon the importance of 
using the mixture pure in purulent aural discharge and, à fortiori, in boils, having seen 
in publications of several authors, especially American ones, who had adopted my 
method in otorrhœa, that they employ the remedy diluted with more or less water. 
This modification is, at best, only to be used in otorrhœa with very large perforation of 
drum membrane ; but even in such cases the mixture ought to be employed in rapidly 
increasing concentration, and, as soon as possible, be dropped in pure. With boils, this 
should be done at once, for here we have not to deal, as in the case of otorrhœa, with 
the mucous lining of the tympanic cavity, so sensitive in many people. Besides, it is 
most important in these cases to proceed as energetically as possible, and to open a way 
for the remedy into the very follicle ducts. This result, however, is only to be expected 
from strong alcoholic solutions, on the following grounds. As I formerly explained, J we 
have to do here with capillary canals provided with a fatty lining. Now the level of 
watery liquids sinks in these, while alcohol, because of its chemical affinity for fats, 
ascends-in other terms, advances-while the former only, on the contrary, recede. 
In the present case, therefore, only strong alcoholic solutions are able to penetrate as far 
as to the sedes morbi, the interior of the follicle. We are, furthermore, authorized to 
expect this penetration to be favored by the spirit of wine dissolving the fatty contents 
of the follicles, too. Thus the alcohol and the boracic acid dissolved in it are enabled to 
attack the cocci energetically. (Watery solutions could only progress in this case, when 
strongly alkaline, by successively saponifying and dissolving the fat, but this would take 
a long time, and, besides, alkaline liquids are the least apt to exert an anti-bacterial 
action. ) 
The mixture of strong (even of absolute) alcohol (100 grammes) and extremely fine 
powder of boracic acid (20 grammes) is well shaken, and then poured into the meatus, 
cold or slightly warmed, as by holding a test tube Containing it in the palm of the hand. 
The patient keeps his head inclined toward the healthy side, so much as to place the 
axis of this canal, its curb apart, in a vertical position. The strict keeping of the 
aforesaid position is the more important as it alone enables us to fill the meatus to the 
brim and thus, surely, to bathe superficially situated boils. § 
*B. Loewenberg. " On the occurrence and the significance of cocco-bacteria in purulent otor- 
rhœa, etc.," (Knapp and Moos, Archives of Otology, 1881, Vol. x, page 356 and following ones). 
f Same author. " De la Nature et du Traitement de l'Ozène." Paris, 1884. Published in the 
Union Médicale. | B. Loewenberg, " Le Furoncle, etc.," p. 36. 
§ With regard to these instillations or ear baths, I lay great stress upon a practically impor- 
tant point, which does not seem to me to have been sufficiently urged. Some physicians consider 
it as extremely difficult, nay, as impossible, to pour in liquids so as to fill the meatus entitely, and, 
furthermore, to make them remain ad libitum in this canal without flowing over. As to the first 
point, it is only necessary to pour in the liquid into the concha in such a way as to make it flow 
down slowly into the meatus. If, on the contrary, the jet is directed toward the aperture of this 
canal, it indeed happens that air bubbles remain in the same, and thus prevent its being entirely 
filled. But this is unimportant in comparison with the presumed difficulty of maintaining the 813 
SECTION XII-OTOLOGY. 
As long as we have to deal with the unopened boil, it is quite sufficient to employ 
only a saturated solution of boracic acid in alcohol. But if pus is already discharging, 
I recommend the over-saturated solution, for I deem it most important in these cases 
to have an excess of boracic powder, destined to be gradually dissolved in the pus, and, 
in this way, to exert a continual antiseptic action, as I statedin a previous publication.* 
With regard to the incision of boils, even a superficial opening often facilitates the 
success of the abortive treatment, especially so, as I presume, when the incision just hap- 
pens to divide the follicle duct. It is, however, very difficult to direct the knife just 
that way ; in cases of deeply situated furuncles one will find this even impossible, for 
then we have to do with a diffuse swelling, entirely filling up the canal, and, moreover, 
we can only use one eye and must work in a perspectively foreshortened tube. 
On the other hand, deep incisions, especially in the beginning of the disease, are 
extremely painful ; they frequently only convey a passing relief and have often to be 
repeated on the same boil, the more so as renewed operations may be rendered necessary 
by the surfaces of the wound merely sticking together. Failing to secure relief, 
and the necessity of repeating a very painful operation, are liable to shake the 
patient's confidence, a fact I repeatedly ascertained in cases operated upon by preceding 
physicians. 
In case the aperture of the follicle should be distinctly visible, one might try to 
inject the solution directly into it with a very fine hypodermic syringe. 
According to my observation, the very painful inflammatory period can be relieved 
by instillation of cocaïnum muriaticum. In order to obey at the same time the anti- 
bacterial plan, I employ this preparation dissolved in strong alcohol. It is difficult 
to understand how the cocaine can act through the epidermis, but I have clearly noted 
the good effects of its applications in several cases, even with watery solutions, a fact 
which removes at once any doubt as to whether the effect may not be ascribable to the 
alcohol alone. 
.RESULTS OF THE TREATMENT. 
In a certain number of cases these instillations of boracic alcohol directly arrest the 
development of the boil, while they fail in others. I am still unable to account for this 
diversity of action. Very likely we have to attribute it to this : In favorably ending 
cases the treatment had been begun at a moment when the opening of the follicle was 
neither too much swollen, nor too obstructed to prevent the liquid from penetrating. 
In cases of boils arrested by this treatment, their characteristic sensibility f disap- 
pears after one or more instillations. As soon as this sensibility ceases, the cause is 
gained and the process is arrested. In every case of aural boils it is worth while to try 
liquid any chosen time in the meatus. Well, this, too, is very easily obtained, provided that this 
be poured in so as to avoid all overflowing. Should this, on the contrary, happen, the meatus 
will be drained more or less completely. This, in my opinion, takes place by the overflowing part 
of the liquid acting after the manner of the longer branch of a siphon. We, therefore, have 
simply to take care to avoid, during the instillation, that the level of the liquid rises above the 
external faces of tragus and anti-tragus, and it will remain as long as it is desirable in the audi- 
tory meatus. * Loe. cit. ("On the occurrence, etc.," p. 357). 
j- In order to the results of this treatment, we, of course, have to make the diagnosis 
of the disease at the earliest period possible. This can be obtained, in my opinion, by two 
considerations- 
(а) Limited acute inflammation of the skin of the meatus nearly always is of a furunculous 
character. 
(б) Boils possess, especially in this locality, a striking inadequateness between the apparent 
slightness of the inflammation and its extreme painfulness, an inadequateness which I deem 
characteristic. 814 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
this abortive treatment, for a positive result is invaluable for the patient, who is spared 
excruciating pain, lasting sometimes for many days and nights. 
Should this course of treatment not succeed in stopping the development of an 
aural boil, it still attains another end of primary importance, that is, the avoiding of 
what I have called auto-contagion, in other words, the successive forming of new boils 
in the affected ear. We all know this to be almost the rule in this locality, and often 
to render life unbearable for an incredibly long time, especially to.female patients. To 
arrest auto-contagion is the more important in aural furunculosis, as, according to my 
experience, the longer this disease lasts the greater is the tendency of the boils to form 
in parts situated nearer and nearer the drum membrane, and consequently to prove 
more and more painful. 
Well, in every case I have succeeded by a persevering use of this treatment in stopping 
this local furunculosis, and I consider it as my duty to lay the greatest stress upon this 
result, the more important, as it had never been obtained, I dare say, before my publi- 
cations. 
According to the same principles, and with the same happy results, I use the same 
treatment with female patients who before or during each monthly course suffer from 
ear furuncles. As early as in 1881,* I tried to explain the latter fact, which the discovery 
of the parasitic nature of boils rendered the more incomprehensive. I examined the 
problem in the following way : After the termination of a first boil, cocci, originated 
with its pus very likely, remain upon the skin of the meatus, especially in its deeper 
parts, which escape all cleansing of this canal, or even in follicles close to the first one 
attacked. But these microorganisms are prevented from multiplying, either by the 
want of every condition favorable to their increase, or by successful resistance of the 
cells, or, as I first urged, I dare say by the nature of the cutaneous, especially seba- 
ceous, secretion. Now with certain persons troubles of the general health or disorders 
in special organs precede or accompany each catamenial period, and we may well sup- 
pose that, now and then, the cutaneous nutrition and secretion-for instance, in the 
auditory meatus-may then be altered so as to allow the cocci to multiply, and finally 
to produce fresh boils, f Since the idea of the latency of bacteria remaining inoffen- 
sively in or upon the body and producing trouble, only when perturbations arise in the 
organism, has become quite commonplace. I am sure that my explanations, given six 
years ago, have contributed to this result. ( Vide, also, my remarks at the first French 
Congress of Surgeons, during the discussion on Osteomyelitis.) 
With regard to the treatment of this singular aural furunculosis setting in periodically 
with the menstrual flux, I have adopted the following measures. Besides treating the 
existing boils with boracic acid and alcohol, when the patients first apply to me, I, in 
a prophylactic way, order the same instillations to be practiced previously to the time 
when the disease usually occurs. (This refers as well to each catamenial period in 
these cases as to the seasons, spring and fall, at which times aural boils frequently affect 
some persons. ) 
The success is very striking in many cases, and it seems to me the more valuable, as 
this method offers absolutely no drawback. The only caution to be recommended is, 
whenever the patients continue for a certain time to instill the over-saturated solution, to 
direct them to have their ears syringed from time to time with a watery solution of 
boracic acid, in order to remove mechanically the accumulated powder, and thus to 
avoid any obstruction of the meatus. 
• B. Loewenberg, "Le Furoncle, etc.," p. 29. 
j- The same local troubles can account for the origin of a first boil during catamenia, by favor- 
ing the pullulation of cocci originating from the atmosphere and simply deposited in the meatus. SECTION XII-OTOLOGY. 
815 
I have undertaken bacteriological researches in a certain number of cases of still 
unopened boils of the meatus. In each case I first syringed this canal, and then filled 
it for ten minutes with a lukewarm solution of bichloride of mercury joViu Immedi- 
ately afterward the boils were opened with a previously well heated knife. A small 
parcel of the pus was inoculated into Agar-agar, or nutrient gelatine, and plate cultiva- 
tions made of the whole. 
I obtained the following results :- 
The microorganism most frequently found was Staphylococcus albus, which was 
absent in only one case; then came Staphylococcus aureus, and sometimes citreus. Only 
in one case all these three Staph, were traced together. 
These results differ from those obtained by my friend Dr. Kirchner, of Würzburg,* 
who only found Staphylococcus albus. 
DISCUSSION. 
Professor G. E. Frothingham, Ann Arbor, Michigan, thinks the subject intro- 
duced by the two papers important, and that the paper of Dr. Loewenberg suggests 
that the microbe is not yet " mustered out of service," as it were. Originally, Pro- 
fessor Frothingham said, he had been a skeptic as to the part that microorganisms 
played in inflammatory affections, and still he cannot give his consent to all the 
claims made in this direction. Careful observation of diseases and the effect of anti- 
bacterial remedies had, however, convinced him of the great influence these organ- 
isms have in the production of various affections, and he believes we have not yet 
fathomed the subject, and that new developments are yet in store for us. The 
detection of these pathogenic organisms in aural furuncles by Dr. Loewenberg con- 
stituted a positive contribution to the subject which we must accept, unless other 
sufficiently extensive observations should prove him mistaken. Dr. Loewenberg's 
theory of the production of furuncles would explain certain long-observed facts 
which have before received no such plausible explanation. It had long been observed 
that furuncles have a tendency to appear in successive outbreaks, and that the new 
crop commonly appears near the part originally affected. Popular belief, the result 
of experience, exists, that the early opening of furuncles seems to conduce to this 
succession. One of the most experienced surgeons of his acquaintance, and, indeed, 
he himself, had come to that conclusion a dozen years ago. Professor Frothingham 
believes that, in the absence of antiseptic precautions, such early openings may lead 
to auto-contagion, and such precautions have not, heretofore, been taken. Some, it 
is true, might resist this contagion, as they do that of syphilis, or gonorrhoea. Gene- 
ral constitutional conditions and certain conditions of the nerve centres play, un- 
doubtedly, an important part, resisting bacterial action in some cases, allowing even 
exaggerated action in others. This is true of syphilis and other well-established 
contagions. 
Dr. R. Tilley, Chicago, Illinois, said :-In reference to the question of the influ- 
ence of micrococci in the production of furuncles, we must give full importance to 
the observations of Dr. N. Kirchner, of Würzburg, Germany. 
According to Dr. Loewenberg's note, the observations of Dr. Kirchner demon- 
strated only the presence of staphylococcus albus in such cases, so that we have only 
BACTERIA IN EAR FURUNCLES. 
* Dr. W. Kirchner, " Zur Ætiologie des Ohrfurunkels." Monatachrift für Ohrenheilkunde, 
etc., 1887. 816 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the testimony of Dr. Loewenberg relative to the presence of the staphylococcus 
aureus, which is the important organism in question. Under these circumstances, 
while we give due importance to Dr. Loewenberg's observations, it would be advan- 
tageous to refer to the observations of other investigators in connection with the pre- 
sence of micrococci in the pus of unopened abscesses. Without looking up the 
question in particular, I am persuaded that the evidence is against the conclusions of 
Dr. Loewenberg. 
The statement of the power of alcohol to dissolve the fat in the sebaceous fol- 
licles, requires more definite reference. Alcohol will dissolve fatty acid, but it will 
not dissolve ordinary fat. I have personally used alcoholic solutions of boric acid, with 
an addition of ether, to dissolve the fat in connection with suppurative conditions ; 
not, however, on furuncles. I refer, with some hesitation, to the use of the term 
furunculosis. It is important, as scientific men, that we exert special care in the 
selection of appropriate terms. I am unable to see the special appropriateness 
of the term for the expression of the idea involved, and, if I am in error, I should 
be glad to be corrected. 
Dr. L. Tfrnbull, of Philadelphia, Pa., said: We differ from our distin- 
guished friend, Dr. Loewenberg, in that we believe that in the great majority of 
cases boils depend upon some constitutional derangement of the system, more espe- 
cially the blood, and arise in the system, not, as he states, " by an affection from with- 
out ; viz., through the ducts of the cutaneous follicles. ' ' Secondly, that the number 
of these furuncles depends upon the defective system and a loss in certain constitu- 
ents of the blood, or, on the other hand, an increase of the fat globules, not alone 
" by auto-contagion," else the same results would follow on the skin of other parts of 
the body when boils are opened. Thirdly, we have never known of a case of " infec- 
tion of one person by another. " In a recent instance of a boy in a family of six 
boys, no case occurred but one, and they slept and were in constant contact with 
each other ; and in the severe case reported by me, the girl was one of a large 
family of girls sleeping together, and yet no other case occurred. So far as we have 
been able to notice, no reports of any series of severe cases of furuncles have been 
given following out the treatment of Dr. Loewenberg. 
In the use of boracic acid, we have found it to cause irritation, and sometimes 
small abscesses in and around the meatus. Boracic acid is one of the most feeble of 
the class of antiseptics ; it does not compare with the bichloride of mercury or even 
with carbolic acid. Incisions of a free character, the use of iron with the salts of 
potash, wine and, above all, nourishing diet to complete the cure, with change of air 
subsequently, is the one successful method of treatment for the relief of boils of the 
ear. No operation should ever be attempted upon the tender and sensitive ear 
without the administration of an anæsthetic, like bromide of ethyl, or the use of a 
five per cent, solution of cocaine, dissolved in one or two per cent, of pure phenol, 
or crystallized carbolic acid, and applied hypodermically. SECTION XII OTOLOGY. 
817 
PECULIARITIES IN THE STRUCTURE AND DISEASES OF THE EAR 
OF THE NEGRO. 
PARTICULARITÉS DANS LA STRUCTURE ET LES MALADIES D'OREILLE CHEZ 
LE NEGRE. 
EIGENTHÜMLICHKEITEN IN DER STRUKTUR UND DEN KRANKHEITEN DES OHRES 
BEIM NEGER. 
BY T. E. MURRELL, M.D., 
Of Little Rock, Arkansas. 
The negro in this country is rapidly losing his African cast of features by miscegena- 
tion, so that the pure type is becoming comparatively rare, even in the Southern States. 
The mulatto partakes of many of the characteristics of his white progenitor, including 
that of a roving disposition. Hence he is met with in the cities and on the railroads 
in all parts of the country, both North and South. But the more distinct type of 
African, with his black skin, woolly hair, flat nose, small auricles, large mouth, thick 
lips, prognathous jaw and dolicocephalic head, is seen chiefly on the plantations and in 
the cities in the cotton and rice regions of the South, and is only occasionally met with 
in the Northern States. 
One practicing medicine in a Southern region will have so many types of so-called 
negroes under his observation that he may overlook some of the characteristic peculi- 
arities of this people. He will, most likely, enter on his record book ' ' white ' ' and 
"negro," without discriminating between grades of caste, and following the custom in 
the South, of classing as negro, or colored, to use a popular word, any person whose 
associates are negroes-a matter which inflexible social custom forces upon any one 
bearing the faintest suspicion of African lineage-he will have mulattoes, quadroons, 
octoroons and every imaginable shade of color anti type of feature recorded in one 
category. The census returns are faulty in the same particular, in that they make only 
two general racial classes, and are, for this reason, next to worthless for our present 
purpose. Fully ninety per centum of the affections occurring among the colored, as 
ordinarily classed in the census returns, belong to the mixed types-mulattoes of 
various shades of color. In my own records I have entered as negroes all socially so 
regarded, but have carefully differentiated between the castes in my study of the pe- 
culiarities hereinafter mentioned. 
In its strict sense, therefore, negro, as here used, is intended to mean the full blood, 
and not the mixed races ; but the slight admixture of white blood is not considered 
where the general features are satisfactorily African. 
For several years I have been impressed with certain peculiarities in the negro, both 
as to some features of anatomy and as to the class of diseases most and least frequent 
in his ears. Since medical literature hitherto has taken no cognizance of these differ- 
ences, I was the more impressed on noticing them. Excepting Dr. C. H. Burnett's 
mention, in his ' ' Treatise on the Ear, ' ' of the large and straight external auditory canal 
noticed in the negro, I have nowhere met with any special references to this race of 
people in otological literature. Formerly I considered the facial contour and racial 
features, on the one hand, and mode of life, occupation and hygienic surroundings, on 
the other, sufficient to account for all the differences observed ; but a larger experience 
and more thorough study have convinced me that there exist anomalies in these people 
which cannot be accounted for except by some racial peculiarity. In the Southern 
States we know the negro is typically odd in many respects-normally, mentally, 
socially and physically, and that he can live in the enjoyment of health where the 
white man would soon succumb to mephitic influences. 
Vol. Ill-52 818 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
It became apparent to me some years ago that ear, throat, and nose affections were 
very infrequently met with in a genuine negro, while eye diseases were, perhaps, more 
common than in the white race. 
I set about to ascertain, if possible, some of the reasons for the exemption of black 
people from these affections, with the results which follow :- 
PECULIARITIES IN ANATOMY. 
The structure of the pinna, in so far as its aid to hearing is concerned, is of minor 
importance, and the peculiarities in this appendage in the negro belong, therefore, rather 
to the study of the ethnologist than the otologist. Allowing for many exceptions, it is 
ordinarily quite small, with smaller and less graceful development of the sinuous eleva- 
tions and depressions on its anterior surface, than in the Caucasian. The large, flat sur- 
face between the helix and anti-helix, so common in white people, is usually of more 
limited extent in blacks. Instead of standing off from the head, it most generally 
adheres quite closely to it, often lying quite flatly against it. One reason for this posi 
tion of the auricle may be the small size of the mastoid process, which is ordinarily 
but little developed and quite insignificant in external appearance. This, with the 
small transverse cranial measurement, presents a great narrowness to this part of the 
head, viewed from behind. Another reason for the closely set auricle is the predomi- 
nance of the face over the occiput in the negro, by which it is thrown backward on its 
posterior outline. The external auditory canal presents such striking features that they 
cannot well be overlooked. The canal is often abnormally large in a full-sized African, 
sometimes almost admitting the little finger, while the largest-sized speculum in Toyn- 
bee's set can, in such cases, be introduced nearly to the drum membrane. The canal is 
also very straight, so much so that a speculum is seldom required to view the drum 
membrane. In fact, this peculiar straightness of the external auditory canal in the 
negro is so strongly typical that it is one of the last to be lost in approximating the 
Caucasian type of man, and so is to be found in nearly all mulattoes. The drum mem- 
brane can often be inspected in every detail, to its very periphery, including the 
annulus tympanicus, by merely turning the outer end of the canal toward a window 
and looking down it. The canal is also of slightly shorter average depth than in 
a white person, as would be inferred from the smaller transverse measurement of the 
negro skull. The integument liningihe canal is commonly black, or deeply pigmented, 
but occasionally it is free from pigment in the blackest individual. The membrana 
tympani offers but few peculiarities, if we except the distinctness and ease with which 
it can ordinarily be seen. It is of necessity large in its diameters, to correspond with 
the size of the outer canal. The angle it forms with the axis of the external auditory 
canal is somewhat less than with the tortuous canal seen in many white persons, while 
the angle it forms with the sagittal plane does not materially differ. As is well known, 
however, differences in these angles occur in the white races. But actually, the angle 
the membrana tympani makes with the axis of the external auditory canal is due more 
to the direction of the canal than to differences in the position of the membrane. If its 
angle be measured by a line drawn straight through the head from the centre of one 
membrane to the centre of the other there will be really but little, if any, difference in 
the angle thus formed and that similarly formed in the white person. The membrana 
tympani in the negro, therefore, by reason of its larger size, more direct position relative 
to the external auditory canal, and the large diameter, less depth, and almost per- 
fect straightness of this canal, whereby it can sometimes be seen binocularly by view- 
ing it at some distance, so as to admit the binocular pencil into the canal, presents a 
most beautiful picture of this structure, exhibiting in every detail its many interesting 
features with a pleasing distinctness. 
No measurements of the middle ear have been made, nor have any well-marked SECTION XII-OTOLOGY. 
819 
peculiarities in this part presented themselves. The mastoid process, as has been 
already mentioned, is usually quite small and contains less cell surface within than is 
common in white adults, while the bony exterior is generally excessively thick. It is 
a well-known fact that all the sinuses about the face of the negro are of much smaller 
dimensions than in the white race, and are encased in extremely thick bone ; in fact, 
all the bony structures of his cranium are unusually developed. The Eustachian tubes 
open into an extremely wide and capacious pharynx, opposite very broad and unob- 
structed inferior nasal meati. The pharynx is peculiarly large in the full-blooded 
negro, with large mouth and great width between his malar eminences, presenting an 
inter-faucial space of remarkable dimensions. His nose is flat and extremely broad, 
with flared alæ nasi and a very low septum, which is almost never deflected. The great 
breadth to the inferior meati gives a large area to the choanae and allows of unobstructed 
respiration. 
DISEASES COMMON AND UNCOMMON IN THE NEGRO. 
External Ear.-The auricle is less liable to cutaneous affections than in whites, 
owing, perhaps, to the greater thickness and toughness of the skin covering it. Eczema, 
so common in the delicate integument covering the auricle in fair-skinned and light- 
haired children, is quite rare in black children. 
Deformities are more common than in whites, as the result of traumatism, negro 
children being usually very rough in their plays, and disposed to quarreling and fight- 
ing, using their teeth as a weapon of defense and offense. 
The external auditory canal, being large and straight, is a trap for foreign bodies, 
and especially for insects. Quite a large bug can find its way into the canal. I have 
removed such that could by no means penetrate the ordinary canal of a white person. 
On the contrary, impacted cerumen is very rare in the negro. I have had about ten 
cases in white persons to one case in a negro, in the same number of ear patients of each. 
It is quite common to find an excess of wax in the canal, but there is little tendency 
to its complete impaction. 
It is probable that the straightness and more uniform size of the canal allow of easy 
egress of dried cerumen, and it rids itself of such accumulations. 
I have never met a case of otitis parasitica in the negro. This may be due, in part, 
to the fact that they mostly live in small cabins, and have fires during summer as well 
as winter, to do their cooking, hence mould is rare in their dwellings. Nor have I ever 
seen a furuncle in the external auditory canal of the negro, an affection so frequent in 
white people, and so very painful that, in his great abhorrence of pain, the negro would 
be certain to seek relief. 
Middle Ear.-It is in this part, where the greater portion of all aural affections are 
located, that we would wish to know if these people enjoy an immunity from disease. 
Suppurative processes occur, both acute and chronic, but are confined almost exclu- 
sively to children. Otitis media suppurativa acuta is a not infrequent affection in 
children, particularly those exhibiting a strumous diathesis, in whom there is often 
associated a catarrhal rhinitis, and rarely it goes into the chronic form, but most gen- 
erally reparation takes place with little or no care. Even the chronic form in children 
disappears in process of time, as in the adult it is almost unknown. This is far from true 
in the other and more careful race, and hence there must be a reason for it. In my 
many examinations of the ears of negroes, I have not met an instance of chronic sup- 
puration in the adult; but in mulattoes, who are in all respects more vulnerable than 
either of the pure races, it is quite common. I have never seen a case of mastoiditis 
in a pure negro. The rarity of suppurative processes in the middle ear, together with 
the small development of the mastoid process, will sufficiently account for this. The 
catarrhal affections are also infrequent in the typical negro. Subacute catarrh of the mid- 
dle ear rarely occurs from a cold in the head, and the negro is but little subject to acute 820 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
rhinitis. Otitis media catarrhalis acuta occurs in children in whom nasal and pharyn- 
geal disease exist, but in a far less proportion than in mulattoes and whites. 
Chronic aural catarrh is so extremely rare in this race of people, that they may be 
considered to enjoy almost a complete exemption from it. Out of 421 aural affections 
among negroes, notone of chronic aural catarrh has been met. Yet, no doubt, it does 
occur. Certainly they do not apply for treatment, and were it as common as in the 
white races, there would be a far greater proportion of dullness of hearing among them. 
We would seek for the cause of this immunity from affections of the middle ears in 
the condition of the nose and pharynx. 
As has been mentioned, strumous children often suffer from chronic rhinitis, with 
free discharge from the anterior nares, but it invariably disappears with bodily develop- 
ment and is not seen in the adult. In the adult, nasal and pharyngeal diseases are 
quite infrequent. Out of a large number of negroes treated for eye, ear, throat and 
nose affections, I have treated only one adult for chronic rhinitis, which speedily dis- 
appeared under very simple remedies, a success I have never attained with a similar 
case in my white patients. 
Frequent examinations of the naso-pharyngeal structures of negroes has rarely 
shown any sufficiently morbid condition to call for treatment. Hypertrophic rhinitis 
is extremely rare in these people, and a case of adenoid growths in the vault of the 
pharynx has not been met with by me. In fact, as a general rule, the naso-pharynx in 
the negro comes as near habitually presenting a true healthy condition of these parts as is 
ever to be seen. In how far peculiarities in anatomy lend an influence to this exemption 
from disease, and in how far vigor of body, out-of-door life and plain living conduce to 
such end, is a question not yet fully solved. It is known that persons who live in 
open houses are much less prone to head colds than are those living in close houses. 
The negro in the Southern States commonly lives in a very open house, and burns wood 
for fires, so that he does not have a sore throat, or an attack of sneezing, for every change 
in the weather. Moreover, his life is one almost unexceptionally out of doors and 
engaged in some active labor. The women as well as the men venture out in all kinds 
of weather, and seldom know what it is to be delicate, like white ladies. In a state of 
slavery their lives were very methodical, but now they are far from it. They are par- 
ticularly gregarious individuals, and love almost any kind of a big gathering, and as it 
falls to the lot of the most of them to earn their bread by their daily labor, they choose 
nights for their social and religious gatherings, in which they display anything but 
prudence in the hours they keep. Nevertheless, they seldom suffer from such dissipa- 
tions. Upon the whole their lives are simple, they are a strong, hearty people, and 
notwithstanding their readily succumbing to certain affections that the stronger willed 
white man bears up under, they are particularly free from catarrhal affections of the 
naso-pharyngeal, or tubal region. Not that they are altogether exempt from the conse- 
quences of exposure, far from it; for the negro is very subject to pneumonia and bron- 
chitis; but his middle ears commonly escape, by reason of the greater exemption from 
invasion of his naso-pharynxby such processes. It is, therefore, upon the ground of the 
anatomical conformation of the naso-pharynx on the one hand, and the mode of life and 
physical training upon the other, that these people enjoy so much greater freedom from 
catarrhal processes in the middle ear, and consequent deafness, than their white fellow- 
citizens. It may be argued that the negro manifests an indifference about his physical 
well-being not seen in the white American citizen, but this is not the case when any of 
his special senses are involved. Besides, were the middle-ear affections as common in 
them as in white people, we would meet with more cases of partial deafness among 
them than we actually find to be the case. In almost any city of a few thousand popu- 
lation, one can pick out numbers of persons more or less disagreeably deaf from some 
chronic middle ear process, but rarely, indeed, is one of them a negro. SECTION XII OTOLOGY. 
821 
In very old people, in whom senile changes in their ears produce more or less deaf- 
ness in white persons, there are seldom such cases met with in the negro. It is true a 
few old negroes are dull of hearing, but not in the proportion that the same prevails in 
aged white people. Excluding deaf-mutes, then, there are very few negroes who have 
not sufficient hearing power to understand any ordinary conversation, and I have never 
known one have to resort to an ear trumpet or conversation tube. 
Internal Ear.-Affections involving the terminal acoustic apparatus are inflamma- 
tory, central, or traumatic. The inflammatory may be primary, as in Menière's disease, 
or secondary by extension from an otitis media, commonly with necrosis of the petrous 
bone. The central causes are lesions involving the portio mollis at its origin or in 
some part of its course. The traumatic may be direct, or remote. As slight affections 
of the auditory nerve are more or less obscure, both in diagnosis and etiology, only the 
graver forms will here be considered, which means, generally, more or less entire deaf- 
ness, commonly associated with mutism. 
As previously mentioned, chronic suppuration of the middle ear is quite rare in 
the negro, and I have never had a case in which there was necrosis of the temporal 
bone; hence, I have never seen an exfoliation of the cochlea, and deafness from this 
cause, in this race of people. It may rarely occur, however, as I have seen no statistics 
on this subject. Menière's disease I have not met in the negro, but I see no reason why 
it should not occur, as negro children frequently suffer from convulsions. It is proba- 
ble they fall into the hands of general practitioners, who overlook the nature of the dis- 
ease. This is true of all the cases in white children I have had to treat, and when they 
have been brought to me for consultation for deafness; afterward I have made the 
diagnosis from the history of the case. No such case has ever been brought to me in 
the negro child. The only instance of very great deafness in a negro child I have had, 
in twelve years' special practice amid a dense negro population, was a little boy about 
seven years old, who was suffering from obstruction of the Eustachian tubes caused by 
enlarged tonsils and pharyngitis, of which he was readily cured. As to traumatic 
causes of deafness, the negro is on an equal footing with the white man. In affections 
of the auditory nerve, of central origin, however, he has many things in his favor. It 
is a well-known fact that nervous diseases are much more infrequent in these people 
than in those higher up the scale of cerebral development. There is hardly a portion 
of all this country that has not at some time or other been swept by an epidemic of 
cerebro-spinal meningitis, leaving in its wake a very large percentage of its surviving 
victims inheritors of blindness, or deafness, and sometimes of both. In the Southern 
States many such epidemics are recorded in various localities, with their thousands of 
victims, but so rare is the occurrence of this affection in full-blooded negroes, that phy- 
sicians of large experience who have seen a single case are few indeed. 
As the result of many inquiries on this subject of physicians who have practiced 
medicine in southern cities and on southern plantations for many years, dating back to 
slavery times, I have found only one who could cite a case of cerebro-spinal fever in the 
negro, and this was his only instance. 
It has been observed in epidemics of this strange and fatal malady that those who 
are in a state of high nervous tension, over-anxiety, or great mental worry, are far more 
likely to be stricken than are the more equable-minded, and less solicitous, or care-bur- 
dened. 
The negro is proverbially light-hearted and care-free, and seldom allows a responsi- 
bility to weigh upon his mind. His inferior cerebral development also doubtless protects 
him from hyperæmia, and acute congestions of his brain and meninges. 
Deaf-mutism, however, occurs in the 'negro to some extent. Statistics are unsatis- 
factory on this subject. The only source of information outside of the testimony of 
individual observers, is to be had from the United States census reports. A much 822 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
larger percentage of deaf-mutism in the colored race is here given, than my observations 
and inquiries had led me to imagine. But the very great error undoubtedly exists here 
of reporting all shades of color as colored, or negro, when by far the majority are of the 
mixed types. 
Inquiries of many intelligent and experienced persons, both white and black, have 
proven to me that a deaf-mute pure negro must be somewhat of a rarity. Mulatto deaf- 
mutes are not so rare. And as no distinctions are made in the census tables as to shades 
of color, or caste, it must therefore be taken for granted that all socially regarded as 
negroes are so classed, which, as has been shown, will include every shade from black 
up to almost pure white. This fact, then, for our purpose, deprives the census returns 
of a greater portion of their value. Examination of these reports for 1880 shows the 
following proportion of deaf-mutism in white and colored in eleven States, containing 
the greatest negro population. 
Alabama, { } wl?ite ,in. population. 
' ( 1 colored in 2083 " 
Arkansas / 1 white in 1418 " 
Arkansas, | j colored in 2926 
™ J 1 white in 2593 " 
Honda, |i stored in 2011 
•„ J 1 white in 1637 " 
' ' 11 colored in 2266 " 
J 1 white in 1387 " 
Louisiana, j r in 2467 u 
Wisconsin /1 white in 1328 " 
Wisconsin, | ! œlored in 1938 u 
■kt -ii. n v fl white in 1197 ' ' 
North Carolina, | in 1725 
~ J 1 white in 1000 " 
South Carolina, | j colored in 2298 « 
Tennessee / 1 white in 1310 " 
lennessee, | ! colored in 1679 «< 
Texas / 1 white in 1949 " 
' 11 colored in 2505 " 
,r. . . fl white in 1249 " 
irginia, | j C(dored |n 2155 " 
We here see a very much larger ratio of white deaf-mutes than colored; almost 
double. Florida is the only State showing a greater proportion of deaf-mutism among 
the colored than the white. To account for this I am unable to offer an explanation. 
By taking an average of the whole eleven States we find the ratio to be as follows :- 
White 1 in 1484 population. 
Colored 1 in 2186 " 
or about three white to two colored, in a given population of each. 
If we leave out Florida, the other ten States give a ratio as follows :- 
White 1 in 1383 population. 
Colored 1 in 2204 " 
or nearly two for the white, to one for the colored. 
Arkansas and South Carolina, both containing a large negro population, show more 
than two white to one colored in the same population of each. 
The causes of deaf-mutism among negroes is not sufficiently well known to serve the 
purpose for which it would be very desirable here to use it. Another factor in ear 
affections, to which attention has of late been called, should be left out almost altogether 
in considering aural patients in the pure type of negro; that is, malaria. If malaria SECTION XII-OTOLOGY. 
823 
play any active rôle in the production of aural troubles, our well-favored black man 
could stalk the most miasmatic regions with next to perfect ears. In conclusion, I will 
say I have omitted tables of statistics and reports of cases from my records, in order 
to avoid unnecessary tediousness, but have endeavored to present facts as they have 
impressed themselves upon my mind from a careful study of all the cases in my private 
and dispensary practice, and gathered from other physicians, and from any and all 
sources available. The subject is a new one, and worthy of further investigation, for 
scientific reasons, if for no other. My investigations have been alone and single- 
handed ; but it is to be hoped those engaged in special practice in the Southern States 
will give this subject careful attention in future, and make known their observations 
through the proper channels. 
DISCUSSION. 
Dr. C. M. Hobby, Iowa City, Iowa, thinks the excellent paper of Professor 
Murrell suggests the necessity of a more thorough investigation into the influence of 
race upon the production of disease. The census reports show fifty cases of mutism 
among colored people to sixty-six cases among white people. Is this difference due 
to race influence, or to the neglect or inability of the negro to receive observation and 
attention ? The only reports in reference to causation of mutism among the negroes 
show a nearly equal proportion of mutism from cerebro-spinal fever with the white 
race, and the same is true of all kinds of alleged causes. Professor Murrell's objec- 
tion to including under the term ' ' colored ' ' all possessing acknowledged African 
blood is undoubtedly good, but even his extensive experience among the so-called 
"colored '' people cannot have brought to his attention any very great number of 
those of uncontaminated African blood. 
Dr. R. Tilley, Chicago, Illinois.-I wish to express my high appreciation of the 
paper which has just been read, and I am sorry the author is not present to receive 
my compliments. The subject is so completely new to us who practice in the North 
that it is necessarily difficult to speak upon it. The subject is, however, peculiarly 
interesting to me in connection with the relative susceptibility of the negro to the 
ravages of syphilis. I refer to this subject in a paper which I hope to have the 
honor of presenting to the Section. The statistics presented to us are exceedingly 
interesting, but require further corroboration, and it would be important if we could 
bring any influence to bear upon the officers of the next census, to render its reports 
more exact on this question. The writer's theoretical explanation of the absence of 
impacted cerumen among the negroes, because of the large size of the external 
meatus, scarcely corresponds with my observation. For, although I have had very 
little experience with the negro, yet there is a marked difference in the size of 
individual canals, and it has been my observation that large canals are more associated 
with impacted cerumen than the smaller ones. 
Dr. L. Turnbull, of Philadelphia, Pennsylvania, remarked that if he understood 
the paper, no mention has been made of fibrous tumors of the lobe of the ear in the 
negro. In his manual, ' ' Diseases of the Ear, ' ' published in 1872, he had made special 
mention of the great tendency of the negro to this form of disease. He had seen 
several cases among negro girls of one, two, and in one instance three such tumors, 
which he removed by operation. In his clinic he has every year several cases, in the 
negro and mixed races, of acute otitis media; by negro he meant, not a brown or 
yellow, but a black man. 
Dr. S. 0. Richey, Washington, D. C.-Among charity patients of this country 
are to be found many Irish. Those of them over forty years of age who have ear 824 
troubles commonly have very large meati, often impacted cerumen, and persistently 
impaired hearing, associated together. No one of these symptoms is the cause of 
any other, but we have to look to a more central common cause in the nervous system. 
The torpid mental and nervous organization of the negro stands in strong contrast to 
his exaggerated emotional nature, the offspring of his ignorance and superstition. 
But in this torpor of his nervous system we may find some explanation of his com- 
parative freedom from progressive deafness. Keloid of the lobe of the ear is not 
uncommon in the negro race. 
Professor G. E. Frothingham, Ann Arbor, Michigan, said that though Pro- 
fessor Murrell's paper had already been quite thoroughly and ably discussed, he 
wished to call attention to the statements it contained that were important in 
connection with the report made yesterday by Dr. Bishop, of Chicago. He desired 
to do so because they tend to support the theory which he advocated in the discus- 
sion of Dr. Bishop's paper. Professor Murrell declares that middle ear inflammations 
seldom occur among the colored people, and that they nearly all live in dwellings 
thoroughly ventilated, not from architectural design, but from incomplete construc- 
tion. They were thus freed from exposure to contaminated atmosphere, which has 
a tendency, through the germs which it contains, to produce naso-pharyngeal 
catarrhs, and acute and chronic inflammations of the middle ear, especially when the 
changes of temperature are sudden and extreme. The conditions under which the 
population lives from which Dr. Bishop has gathered his statistics, and, so far 
as inflammatory diseases of the naso-pharyngeal and tympanic cavities are concerned, 
the results, are just the reverse; Dr. Bishop finding these inflammations prevailing 
to a great extent; Professor Murrell finding them very infrequent. Professor 
Frothingham believes the infrequency of impacted cerumen can best be explained by 
the absence of chronic aural catarrh. He has found this to exist in a large propor- 
tion of the cases of impacted cerumen, to such an extent as to impair the hearing 
seriously, often leading to progressive deafness. In many of these cases, the 
ceruminous glands are stimulated, and in many other cases of over stimulation of 
glands, we get an excessive and pathological secretion. This, with the desquamated 
epithelium, from the same cause, also in excess, leads to impaction. He is more 
inclined to this view than the one offered by Dr. Richey. 
Dr. H. B. Young, Burlington, Iowa, agrees with Dr. Tilley in the idea that 
large, straight canals do not, per se, tend to prevent accumulations of cerumen. 
Experience shows that large and straight canals are quite commonly affected in this 
way. It has also been noticed that in some cases there appears to be an hereditary 
tendency. If parents have it, adult sons and daughters may expect it. 
NINTH INTERNATIONAL MEDICAL CONGRESS. SECTION XII-OTOLOGY. 
825 
ACUTE PRIMARY INFLAMMATION IN THE MASTOID CELLS. 
INFLAMMATION PRIMAIRE AIGUË DANS LES CELLULES MASTOÏDES. 
AKUTE PRIMÄRE ENTZÜNDUNG DER MASTOIDZELLEN. 
BY JOHN F. FULTON, M.D., PH. D., 
.St. Paul, Minnesota. 
This disease is so extremely rare, or so imperfectly understood, that only a few of 
the standard works on otology notice it as an individual disease, but speak of it as 
extending from the surrounding parts; as from the tympanic cavity, or the external 
auditory canal. It has always seemed to the author of this paper that acute primary 
inflammation of the muco-periosteal lining of the pneumatic spaces of the mastoid 
process is sufficiently common to merit a much more careful study and better classifica- 
tion, than it has yet received. Several cases of this disease have come under my obser- 
vation within the last few years, in which, had the true nature of their maladies been 
diagnosed, the patients would have been relieved of pain and agony which extended 
over weeks and months. 
The chief symptom of this malady is pain, which is mild at first, but soon increases 
and becomes stinging, tearing, throbbing, until it is necessary to relieve the sufferer by 
anodynes. Usually the pain radiates from the region of the mastoid process in all 
directions, but mostly to the occipital region. Sometimes it extends downward to the 
neck and shoulders and upward to the temples and eyes. It is constant, gives the 
patient no rest, day or night. Unfortunately this symptom is not always referred to 
the seat of disease. It is sometimes referred to spots remote from the mastoid, and 
thus renders an absolute diagnosis almost impossible. Typical cases of this disease 
are rendered all the more obscure from the fact that there may be no indication of any 
other trouble with the ear, and no external manifestation of the disease. These, appar- 
ently, give us but one symptom to depend upon, as not until late in the attack is there 
any swelling or tenderness over the external mastoid, and when this does occur, it is 
apt to be diagnosed periostitis, or sub-periosteal abscess. I have operated on several 
cases of so-called sub-periosteal abscess, and found a small fistula leading into the mas- 
toid cavity, and careful study of the history of such cases plainly indicates that they 
were those of primary suppurativè inflammation of the mastoid cells which had 
opened externally. 
A very characteristic symptom of this trouble is a feeling of fullness and pressing 
about the mastoid region. The patients place their hands there, feeling a need of sup- 
port, and obtaining some relief from the pressure. But, even with the most painstaking 
care, this trouble cannot always be diagnosed with certainty. Often it is thought 
to be neuralgia and is so treated, the patient allowed to suffer for months, to run down 
in general health, and finally be relieved by nature, by the spontaneous opening of the 
abscess through the external plate. 
These preliminary remarks indicate the great importance of a careful clinical his- 
tory of this disease, together with faithful reporting of cases illustrating it. The case 
which first drew my attention to the disease came under treatment about three years 
ago. The patient was a young lady nineteen years of age. She was sent to me by one 
of the leading dentists of this city, for whom she was working as an office girl. Her 
trouble began with a slight pain behind the ear, which increased in severity from day 
to day ; at times extended over the whole side of the face and down her back, neck and 
shoulders. All the pain seemed to radiate from the mastoid region. The patient had 
been thus suffering for several weeks. She was much run down in health, low in spirits, 
emaciated, and had a most careworn expression. A careful examination failed to reveal 826 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
any indication of disease of the middle ear or Eustachian tube. The drumhead was 
normal in appearance, and the acuteness of hearing normal. There was no accumula- 
tion of wax. The mucous membrane of the posterior nares and Eustachian tube was 
healthy. She complained of slight tinnitus and at times became slightly dizzy, but the 
pain antedated all other symptoms. Her temperature was taken and found to be 99° F. 
An opiate was given to relieve pain. This continued every day for nearly two weeks. 
Inasmuch as there was no swelling or redness over the mastoid region, I could not per- 
suade either the patient or her physician that an operation was indicated. At last, as 
the suffering became unendurable, and as a very slight redness, with tenderness, showed 
itself immediately behind the ear, an operation was submitted to. The patient was 
placed under ether, the usual incision for opening the mastoid process was made behind 
the ear, a small piece of bone chipped out with a chisel and the mastoid cavity entered 
with a drill. Quite a large abscess was found, and carefully washed out and emptied 
of all the pus. The lining membrane was smooth, red and tumefied. There was no 
evidence of caries. The external plate was very thin, showing that the abscess was 
opening in that direction. The relief obtained by this operation was most marked. All 
the pain and pyrexia immediately subsided, and the patient made a most excellent and 
rapid recovery. 
All cases of primary mastoiditis interna are not suppurative, however, as we some- 
times meet with cases of very severe inflammation of this part, which do not go on to 
suppuration. Such condition can be best illustrated by giving in brief detail the 
following case:- 
A young man, twenty-two years of age, was referred to me by Dr. Hand, of this 
city, with the following symptoms : He had had vague and indefinite pain about the 
head for several months. It was impossible for him to sleep; he was constantly groan- 
ing with the disagreeable symptoms about the head; was confined to his room and bed 
for days at a time; had been treated by various kinds of home remedies for his pain, 
which was supposed to be of a neuralgic nature. He was unfitted for any business. 
Careful examination showed a perfectly normal condition of the sound conduct- 
ing apparatus. There was but very slight tenderness over the mastoid. He had 
some naso-pharyngeal catarrh. His acuteness of hearing was normal. There was no 
elevation of temperature. At times he had complained of a sensation of great pressure 
over the mastoid, or a sensation of fullness. Primary inflammation of the mastoid cells 
was diagnosed and an operation for its relief advised and performed, but no secretion 
whatever was found in the mastoid cells. They were extremely vascular and found to 
be undergoing a sclerosing process. After the operation he was completely relieved of 
his pain, and under the influence of tonics and supporting treatment, he was able to 
return to his work completely cured, in a mouth from the time of the operation. 
Three cases of primary inflammation of the mastoid cells have been reported by Dr. 
Webster,* of New York. Speaking of one of his cases he says, "the membrana tym- 
pani was found intact, and there was no evidence that it had ever been perforated. The 
primary inflammation of the cells was such that caries of the bone was produced, result- 
ing in a permanent fistulous opening into the external auditory canal. In Case 2 it 
will be remembered that the mastoid inflammation existed for some time before there 
was any discharge from the ear, and the latter, indeed, did not make its appearance 
until the former had subsided; although, in the majority of cases, there is no doubt 
that inflammation extends from the posterior nares along the Eustachian tube through 
the middle ear into the mastoid cells. Yet there is no good reason for believing that 
inflammation cannot, in the nature of things, originate in the mastoid cells themselves, 
and travel, perhaps, in the opposite direction." 
* .ArcÄtve« of Otolfigy, Vol. ix, No. 1. SECTION XII OTOLOGY. 
827 
Dr. Roosa* also reports a case similar to Dr. Webster's. Politzer says, "the course 
of primary ostitis-mastoi'dis is very short in the spontaneous cases and those confined to 
the mastoid process; as after six or eight days the acme of the inflammation is reached, 
and even in suppuration and external rupture, recovery takes place after three weeks. 
On the other hand, the traumatic and syphilitic inflammation, which ends in caries, 
has a long and uncertain course, and also those forms in which the inflammation spreads 
at the tympanic cavity, and the membrana tympani becomes perforated. In such cases 
the perforation is usually found in the postero-superior quadrant of the membrane, at 
the apex of the nipple-shaped elevation." 
The object of this paper is to draw the attention of this Section to a disease which 
is most frequently overlooked, as it is one most difficult to diagnose. More careful 
study of the clinical features of this disease, and more extensive reports of cases illus- 
trating it, may render its diagnosis more easy in future. It produces great pain, agony, 
and most alarming symptoms. It can generally be relieved by a comparatively simple 
operation. 
DISCUSSION. 
Professor E. De Rossi, Rome, Italy, said that pain cannot be regarded as a 
pathognomonic symptom of primary inflammation of the mastoid. He said that on 
that one symptom alone he would never decide to perform an operation such as tre- 
phining the mastoid process. He spoke of a case of primary epithelioma of the 
mastoid, of which the principal symptom was pain. Tuberculosis of the temporal 
bone is also accompanied by persistent pain. 
Dr. J. Baratoux, of Paris, Prance, said-I believe that the mere symptom 
"pain" is insufficient to allow the giving of the diagnosis of inflammation of the 
mastoid apophysis. I would not be guided by this mere symptom to decide upon so 
serious a surgical operation as trephining of the mastoid apophysis, inasmuch as it 
is extremely rare that we do not meet some other symptom than that of pain. 
There exist, in fact, in these cases, other signs of the middle-ear disease which attract 
the practitioner's attention. 
Dr. S. 0. Richey, Washington, D. C., believes pain alone, or even in case of 
chronic suppuration of the middle ear, is an insufficient indication for perforation of 
the mastoid process in all cases. He gave a brief history of a case of chronic sup- 
puration, of eighteen years' duration, in which there was absence of the drum 
membrane and of the ossicula, except the stapes. There was also persistent pain, 
extending from the mastoid region of that side, over the occiput to the vertex. The 
patient, twice in two months, fell unconscious, the fall each time being followed by 
an escape of dark, fetid pus from the ear. He recovered with a cicatricial drum- 
membrane, without trephination. Such cases make a surgeon doubtful when he 
should trephine. 
Dr. H. B. Young, Burlington, Iowa, said, concerning the unreliability of pain 
alone, as an indication for perforating the mastoid, his experience with at least one 
case will encourage conservatism. This case had the characteristic mastoid pain, 
without external signs of inflammation. Perforation was suggested and Knapp's 
position explained. It was acceded to, but before it was done the mouth was 
examined, and carious teeth found. The perforation was postponed, the teeth were 
extracted, and eventually, though slowly, the pain subsided. 
* Archives of Otology, Vol. IX, No. 1. 828 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
THE INDICATIONS FOR THE ARTIFICIAL PERFORATION OF 
THE MASTOID PROCESS, AND THE BEST METHOD OF 
PERFORMING THE OPERATION. 
INDICATIONS POUR LA PERFORATION ARTIFICIELLE DU PROCES MASTOÏDE, 
ET LA MEILLEURE MÉTHODE D'OPERER. 
DIE ANZEIGEN ZUR KÜNSTLICHEN ANBOHRUNG DES WARZENFORTSATZES, UND DIE 
BESTE METHODE ZUR AUSFÜHRUNG DER OPERATION. 
BY G. E. FROTHINGHAM, M. D., 
Ann Arbor, Michigan. 
From its tendency to involve the brain and thus endanger or destroy life, inflam- 
mation of the tympano-mastoid cavity is, perhaps, the most important of aural affec- 
tions, and one that, in spite of the progress which has been made in otology within 
the last twenty years, has many mooted points that must be settled before we can 
diagnose them with sufficient accuracy or lay down positive rules for treatment. 
Among these questions, " What are the indications for the artificial perforation of the 
mastoid process ? " and " What is the best method of performing the operation? " are, 
perhaps, the most practical. They stare not only the specialist, but the general prac- 
titioner, in the face, and upon their correct answers the life of the patient will often 
depend. It is true, we have much more precise knowledge on these subjects than we 
had even a dozen years ago, but our knowledge is still so vague, and our rules for 
action still so indefinite, that the most accomplished aurist will often be undecided 
how to act. He may regret, perhaps, after the autopsy, that he did not perforate, as 
thereby he might have saved his patient.* On the other hand, he may regret that he 
did, or that he did not operate by a different method .f To a certain extent this uncer- 
tainty is due to the inherent difficulties of the subject, and will, perhaps, always exist; 
but to a large extent it will probably be removed by accumulated experience and wis- 
dom, and further records of cases are desirable as contributing to this result. Some of 
this vagueness may be eliminated, I believe, by a more extended discussion and analy- 
sis of facts already recorded, and it is in this hope that I present this paper for the con- 
sideration of the Section. 
A brief consideration of the anatomy of the mastoid and its more important anatomi- 
cal relations, and also some of its more important abnormalities in form or structure, 
or in the relation of those surrounding parts that affect operative procedure, will be 
essential to the discussion of the more practical questions found in the heading. I 
shall, therefore, enter into a description of these before considering the main subjects 
before us. 
The conical projection of bone situated just behind and below the external auditory 
canal is the prominent anatomical feature of this region, and gives the name to this 
portion of the temporal bone, which is called the mastoid portion, from the Greek word 
y.aaroç (a nipple or teat). The projection itself is called the mastoid process, though 
many limit this term to the apex or lower extremity. In this paper the term will 
include the whole of this prominence, which contains so important a portion of the 
middle ear, namely; the mastoid cells. These cells are found to occupy the whole 
interior of this process, and communicate with the cavity of the tympanum by means 
of a large cell, or space, known as the antrum mastoideus. The mastoid portion of the 
* Archives of Otology, Vol. xn, page 55. 
f Archives of Otology, Vol. xn, page 52; also Vol. vm, pages 263 and 265. SECTION XII-OTOLOGY. 
829 
temporal bone articulates by means of a rough, thick border above, with the postero- 
ini'erior angle of the temporal, and posteriorly, with the inferior border of the occipital. 
The outer surface is rough, and perforated by numerous openings for the transmission of 
blood vessels. One of these openings is of large size and is known as the emissaurium 
mastoideum, or mastoid foramen. It is variable in its situation. Generally, it is near 
the posterior border, though I have found it as far forward as the centre of the external 
surface of the mastoid process. Quite frequently it is absent from this bone, being 
situated in the occipital bone, near the mastoid articulation. This opening transmits 
a small artery and a considerable vein, which generally, though not always, communi- 
cates with the lateral sinus. When it is situated far forward, it may come in the way 
of the knife in making Wilde's incision, or opening the cells. The internal surface of 
the mastoid bone is smooth, and presents, as one of its prominent features, a deep 
curved groove known as the sigmoid fossa, in which is lodged a portion of the lateral 
sinus. In this fossa is generally found an opening for the vein transmitted to the 
lateral sinus through the mastoid foramen. The situation of the sigmoid fossa, with 
reference to the mastoid process and posterior wall of the external meatus auditorius is 
of great importance, and until recent years its variations were undetermined and little 
regarded. According to Hartmann's measurements, which agree with those of Bezold 
and others, the distance between the posterior wall of the meatus and the sigmoid fossa 
is often only a few millimetres. A sharp forward curve of the transverse sinus toward 
the wall of the auditory canal is very common. In 100 temporal bones measured by 
Hartmann it was but five millimetres in one case. In five cases it was only six milli- 
metres. In six cases it was only seven millimetres, while in 41 of the cases it was one 
centimetre or less. The maximum was 19 millimetres, while the average was only 11} 
millimetres.* In the operation of opening the mastoid process the danger of wounding 
the transverse sinus will be greater in proportion as this distance is smaller, and, as no 
operator can tell when he may chance upon one of these cases, he should avoid those 
methods of operating which do not allow of ready inspection of the wound as he pro- 
ceeds. 
The floor of the middle cranial fossa has an important relation with the superior 
mastoid cells that must be constantly borne in mind, while opening into them. The 
floor of this fossa lies but a little above the external auditory canal, being separated 
from it by only a thin lamella of bone. The course of the facial nerve in the canalis 
facialis turns sharply backward on reaching the inner wall of the tympanum, and, in 
its course from above the oval window, downward and backward to the stylo-mastoid 
foramen, it lies quite near the upper and deeper mastoid cells, and is in danger if these 
are perforated carelessly, or too deeply. It may be reached, in some cases, at a depth of 
five-eighths of an inch. In penetrating with a drill some observe the rule to go no deeper 
than this. In using the chisel, as the wound is open for inspection, this structure may 
be avoided. The posterior and horizontal semicircular canals have also such relations 
to the mastoid cells that, in penetrating with the drill at a depth of more than five- 
eighths of an inch, they are liable to be encountered, especially if the drill is directed too 
far forward. In operating with the chisel they may be more surely avoided. The occi- 
pital artery is lodged in a deep groove at the lower and inner side of the process. The 
apex of the process serves for the attachment of the sterno-mastoid, splenius capitis, 
and trachelo-mastoid muscles. The digastric muscle is inserted into a deep fossa, 
situated on the inner and posterior surface. A mastoid abscess occasionally makes an 
opening for itself at this fossa, where the outer wall is often thin, or at the apex of the 
process, and burrows under these muscles deep into the neck. I have met with two 
such cases in my practice. 
* Archives of Otology, Vol. XIII, page 139. 830 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
The size of the whole process varies much in different individuals, generally being 
larger in those who are strong and muscular; and in males, than in females. The num- 
ber and size of the mastoid cells vary greatly in different individuals, and even in the 
same individual, on the two sides. They are separated from each other by thin, perfor- 
ated walls of bone, and generally communicate quite freely with each other, and through 
the antrum, with the tympanic cavity. In some cases a single large space is found in 
the centre of the bone, and the cells exist in the form of diploe, in the walls of this 
central space. In the child, the wall separating this cavity, or central space, from the 
lateral sinus is quite thick relatively to the outer wall, and hence meningitis, or cere- 
bral abscess, as a result of inflammation of the mastoid, is comparatively rare. The 
outer wall is also so thin in childhood that it is often penetrated with the knife on 
making Wilde's incision, and is easily opened with a blunt probe or gouge in cases 
requiring it. The antrum mastoideum is situated, in the adult, at the upper and posterior 
part of the inner half of the osseous meatus, and is separated from it by a thin layer of 
bone, perforated at its anterior and upper portion, to allow communication with the 
tympanic cavity. This opening is variable in size and position, and in some cases is 
more liable to become obstructed during inflammation of the middle ear than in 
others. 
Although it is now twenty-six years since the operation of perforating the mastoid 
process was revived and established as a necessary operation under certain circum- 
stances, the indications which call for the operation are still imperfectly formulated, 
and even the evidences of retained pus are so imperfectly understood that the most 
experienced operators have frequently been mistaken in their diagnosis, and disap- 
pointed by finding no pus where they had confidently expected, and thoroughly sought 
for it. It is hardly sufficient consolation, under such circumstances, to find, as often 
happens as an outcome, that the operation has done good by the influence of the trau- 
matism upon the diseased bone, but until very many more cases are reported and 
studied, such disappointments will continue frequent and the operators will be obliged 
to explain the mistakes, and justify the operations as best they can. Indeed, the prob- 
abilities are that a considerable element of uncertainty will always exist as to the 
presence, or not, of pus, or as to the exact condition of the interior of the bone, even 
though the indication is plain for perforation. There will probably be certain cases 
where the diagnosis can only be made by its aid, and where it will be called for as the 
only means of knowing whether, or not, to exclude mastoid disease in the diagnosis of 
certain cases of cranial disease in this region, associated with pain or disease in the ear. 
There are many cases, however, in which little doubt need exist. In these cases 
there is severe pain in the mastoid, increased perhaps at night, and shooting in every 
direction, and accompanied by tenderness and swelling over the bone, with elevation, 
and forward displacement of the auricle. The patient has a weak and rapid pulse, an 
anxious, haggard countenance, dry and coated tongue, is unable to sleep, or take suffi- 
cient food. There is a failure of mental and muscular power, irregular chills and fever, 
while every effort at moving, especially every jar, causes increased pain in the region of 
the mastoid. Such symptoms point most positively to the nature of the affection, and 
constitute a positive and urgent indication for immediate perforation. Yet, such cases, 
not a generation ago, were generally misunderstood, disregarded, or vaguely diagnosed 
as cerebral disease. Dr. Roosa tells us that during his student days he had his attention 
called to the importance of mastoid inflammation by some cases which he saw under 
the care of his preceptor, Professor Alfred C. Post, and by his recital of several others, 
which had come to a fatal termination, as a result of the non-recognition of the danger- 
ous nature of the affection.* Such cases are still quite frequently neglected until past 
* New York Medical Record, Vol. v, page 436. 831 
all help, not only from failure on the part of the attending physician to recognize the 
condition, but also from the dread which inexperienced operators feel to use the trephine, 
or perforator, in this region. Many of them, we have little doubt, would attempt, and 
with success, the more safe operation with the chisel and gouge, were it properly 
brought to their notice, and urged for adoption in the text-books which they consult. 
In the child, such mistakes are often remedied by nature, the pent-up pus finding its 
way outward through the comparatively thin and imperfect outer table of bone. In 
the adult, however, the pus finds a more easy exit through the thin inner wall, espe- 
cially in the vicinity of the sigmoid groove, and only in exceptional cases, by necrosis 
of the outer and thicker wall, or by enlargement of some unusual opening or fissure, 
does the pus find its way to the external surface without involving the cerebrum. 
In all cases in which acute pain arises deep in the mastoid during the course of sup- 
purative inflammation of the middle ear, and is accompanied by tenderness and swell- 
ing over the bone, and leeches and other measures calculated to relieve periosteal 
inflammation afford no relief, or relief for but a few hours, and on making Wilde's 
incision a normal or nearly normal condition of the periosteum is found, the external 
table of the mastoid should be opened; and the opening should not be delayed, but 
made at once.* Even in cases where, by reason of the early swelling and tenderness of the 
soft tissues covering the process, and superficial character of the pain, it seems probable 
that the disease is mastoid periostitis, if Wilde's incision shows not only change in the 
periosteum, but the bone to be also changedin appearance, then the operation should be 
extended and the cells opened into, as the change in the bone may be, and most likely 
is, due to disease in the mastoid cells instead of the periosteal inflammation, the dis- 
ease beginning in the bone and extending to the periosteum and other tissues over the 
process. 
Many cases are recorded showing the danger of even a brief delay in opening the 
cells, and it would, in my opinion, be safer, in all cases of mastoid disease in adults, 
where the symptoms are sufficiently severe to call for Wilde's incision, to extend the 
operation, and open into the cells. The diagnosis as to whether the periostitis, or a bone 
affection, causes the acute symptoms cannot be made with any certainty, and it is safer 
to make the operation at once, than to wait for subsequent developments to decide the 
diagnosis. The patient is etherized usually, and should be, in making the incision. It 
adds but a trifle, if any, to the danger of the operation to open the cells, when the 
operation is properly performed. If only the incision is made, and the subsequent 
symptoms are waited for to determine whether the cells are implicated, the reluctance 
of the patient to submit to another operation will most likely lead to dangerous delay. 
As there must always be an element of doubt in these cases, we shall give the patient 
the benefit of the doubt, and take the course of least danger, by opening the cells at 
once. 
In chronic disease of the ear, with symptoms of subacute mastoid inflammation, 
the operation may be longer delayed, but in all cases where the patient suffers much 
distress from pain in the mastoid, especially if there is tenderness on palpation, and 
the ordinary measures do not afford relief in a few days, artificial perforation is war- 
rantable; and if these symptoms have continued for a much longer time, rendering the 
patient an invalid on that account, then the operation is called for, whether the disease 
in the mastoid cells be purulent in character, or be a sclerosis, cholesteatomata, necrosis, 
caries, or any other form of disease, the result of inflammation. With acute symp- 
toms, early operation cannot be too strongly insisted upon, for the danger of delay is 
SECTION XII-OTOLOGY. 
*Seea full discussion of this subject by F. C. Hotz, M.D., in Archives of Otology, Vol. ix, p. 
159. See also articles and reported cases in Archives of Otology, Vol. xin, p. 151, and Vol. 
xvi, pages 99, 110 and 111. 832 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
great in all cases where pus is contained in the mastoid cells. To operate early, is only 
to follow a general principle that acute abscesses should be opened early, and, consider- 
ing the close proximity of mastoid abscess to the brain, this rule becomes all the more 
imperative, especially when we consider the slight danger of an operation and the little 
prospect of spontaneous cure. According to Dr. A. H. Buck's analysis of sixty-seven 
cases, more than half of which occurred in persons under twenty-five years of age, and 
two of which occurred in children ten years of age and under, only three made a spon- 
taneous recovery, and all of these were under the age of sixteen years.* When we 
consider that Schwartze attributes but two per cent, of the deaths occurring after opera- 
tion to the operation itself, and that seventy per cent, of the cases were cured, and only 
twenty per cent, died from the disease when operated upon, including those operated on 
at a late period in the course of the disease, we shall see that conservatism here is an ele- 
ment of danger, and that, when in doubt, it is best to operate. From cases that have 
come under my observation, I should say that it is a general custom to delay operation 
too long, or to omit it altogether, even in cases where it is evidently called for. There 
is, up t<* the present time, too much reluctance, even among aurists,f to resort to this 
operation, and it is only eight years since one of our most progressive and justly cele- 
brated otologists, in an extended article on "Acute Purulent Inflammation of the 
Middle Ear, ' ' said : ' ' Opening of the Mastoid Process was never resorted to in the series 
of cases under consideration. Of this operation, also, I am not a great admirer, and 
perform it only when the cerebral symptoms are threatening, especially when at 
the same time the secretion has ceased more or less suddenly, the mastoid region 
red, swollen and tender on pressure; i. e., in cases that show some probability of reten- 
tion of morbid substances in the cells of the mastoid process."J If one so progressive 
and eminent confessed so recently his reluctance to resort to this operation, and his 
delaying to do so until the cerebral symptoms were threatening, we can hardly wonder 
that those less progressive, and less impressed with the dangers of delay, often allow 
patients to pass that stage at which life may be saved, or a cure effected by its perform- 
ance. 
The tendency is now to extend the indications for opening the mastoid cells, and 
several cases have been reported in which mastoid abscess has existed, and has been 
evacuated by operations, in which the surface of the mastoid was free from tenderness, 
and presented in every way a perfectly normal appearance. This normal appearance 
and condition of the external surface of the mastoid may exist together with an 
absence of pain in the region, the pain existing in a distant part of the head, as in the 
case reported by Knapp, in which he was misled by this condition and deterred from 
operating, the patient dying from the effect of mastoid abscess. (See Archives of Otology, 
Vol. XII, pages 44 and 55.) In a similar case, N. F. Tilden Brown perforated the 
mastoid process, evacuated the abscess and saved the patient. (See Archives of Otology, 
Vol. xil, page 56.) Schwartze declares that if the skin covering the upper and poste- 
rior wall of the external meatus is bulging, and there is retention of fetid pus in the 
middle ear, with pain in the region, and general fever, the mastoid may often require 
perforation, even though the external surface is sound and gives no evidence of disease 
in the cells. In many of these cases the indications cannot be clearly made out, and a 
considerable degree of uncertainty must exist as to the necessity, or even propriety, of 
an operation. 
* "Diseases of the Mastoid Process," by A. H. Buck. Archives of Otology, Vol. in, page 216. 
f See discussion of Dr. C. H. Burnett's paper read before the American Otological Society, 
1883. Referred to on page 215 of Vol. xm of Archives of Otology. See also statements made 
by Strawbridge and Theobold, quoted by Roosa in Archives of Otology, Vol. xvr (June, 1887), 
page 132. J Professor H. Knapp. Archives of Otology, Vol. vm, page 24. SECTION XTI-OTOLOGY. 
833 
When, in the course of a suppuration of the middle ear, the temperature rises 
rapidly, and continues in spite of antipyretic measures, even though there is no marked 
pain or tenderness in the region of the mastoid, it is warrantable to perforate the mas- 
toid, as there is reason to suspect pus; and pus has several times been found on perfora- 
tion, with this as the only indication for making the operation. In such cases it will 
always be doubtful, whether or not pus is pent up in the mastoid cells, as the symptom 
of increased fever and general headache may be due either to retained pus, sinus- 
thrombosis, or brain abscess. I believe the opening should be made, however, as in 
some cases it may evacuate pus, prevent extension to the brain, and save life. If it 
should be brain abscess in the vicinity of the affected ear, the opening may subsequently 
be enlarged, and allow of evacuation of the abscess. This was done in one case by 
Truckenbrod, and the patient saved.* Even if it is sinus-thrombosis, the suggestion of 
Zaufal f to expose the sinus, ligate it, lay it open and remove the thrombus, is worthy 
of consideration. 
In cases of relapsing mastoid periostitis, and in all cases of persistent pain in and 
about the mastoid, even though there seems to be an abundant discharge of pits and an 
unobstructed outlet for it, or in case no disease of the tympanum exists, the mastoid 
should be perforated, as there is probably in these cases a hyperostosis, which the oper- 
ation alone is likely to relieve. If there has been long continued or repeated attacks 
of otitis purulenta, then the suspicion of this condition is strengthened, and if the bone 
is enlarged, the evidence may be considered as quite positive. In cases of long-standing 
suppuration of the middle ear, with frequent exacerbations attended with pain in the 
mastoid, the cells should be opened. 
As to the methods of perforating the mastoid process, they have been quite various. 
When Joseph Toynbee wrote his classical work, in 1860, speaking of disease of the 
mastoid process, he said: "Perforation of the mastoid process also suggests itself, 
and this operation may doubtless be performed in those cases where the matter is pent 
up in the cavity of the ear, and is causing such urgent and serious symptoms as are 
likely, if not relieved, to terminate in death. I have never performed this operation, 
but I should not scruple to do so in a case where the life of the patient was threatened. 
Considering the large extent of the mastoid cells, it appears to me that the best plan of 
operating would be to use a trephine over the middle and posterior part of the process, 
and to remove a portion of bone three-quarters of an inch in diameter." At the pres- 
ent time the trephine is probably never used in this operation, but a small trephine, 
about one-fourth of an inch in diameter, was for some time commonly used in perforat- 
ing this process. The directions given for the use of the trephine were altogether too 
indefinite, considering the important relations of the part. When Wilde recommended 
his incision in his book published in 1853, he did not specify very exactly where it 
should be situated. If we take his practice as a guide, it should be situated about 
half an inch back of the attachment of the auricle, t a position at first commonly selected 
in making the primary incision for perforating the mastoid, as will be seen by reference 
to reported cases. 
When Dr. Roosa wrote his extensive and valuable work on " Diseases of the Ear," 
in 1873, after consulting all the best authorities on the subject, he could give no more 
definite guide for the use of the trephine in opening the mastoid process than to direct 
an incision, after the manner of Wilde, parallel with the attachment of the auricle, and 
that after the periosteum had been dissected up, ' ' the trephine should be worked 
inward, forward and upward." He says : " There can be no positive directions given 
* Archives of Otology, Vol. xv, page 176. 
f Archives of Otology, Vol. xv, page 182 ; also Vol. xiv, page 230. 
J Wilde on "Diseases of the Ear," pages 178 and 245, first American adition. 
Vol. Ill-53 834 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
as to the depth to which the instrument should go." The operation should go on very 
slowly, frequent pauses being made to see how deep the instrument has gone. It is 
impossible to say in a given case at what depth we shall reach the cells or free spaces, 
and thus make an outlet for the pus. Dr. Agnew was obliged to go five-eighths of an 
inch in one of his cases, and then only found sclerosed bone. Dr. D. C. Ambrose 
removed a piece one inch long from the mastoid process of a young woman of twenty- 
one years of age. The cell structure will ordinarily be found at a depth of from one- 
sixth to one-fourth of an inch.* 
We can hardly wonder that with such directions there was a hesitancy on the part 
of physicians to attempt this operation. Nor would the reports of cases operated upon 
in this manner increase their confidence, or inspire them to undertake it. In the 
report made by Dr. Ambrose of the case above referred to by Dr. Roosa, he says, ' 'After 
making an incision two inches and a half long, down to the bone, parallel with the 
auricle, and half an inch from its attachment, I separated the periosteum from the bone 
to an extent sufficient to admit a quarter-inch trephine, and inserted that instrument 
on a line with the superior border of the external meatus, and about half an inch from 
the attachment of the auricle, directing the instrument slightly forward in a horizontal 
position. After the trephine had penetrated to the depth of half an inch, and finding 
myself on just as firm bone as at the commencement, I heartily wished the affair was 
over with ; but remembering that Tröltsch says that ' the depth to which we must go 
is sometimes considerable, ' I gained courage, and persevered with the operation until I 
felt a slight yielding beneath the instrument. I immediately withdrew it and tried 
with moderate force to extract the plug of bone with bone forceps, to which, however, 
it did not yield in the slightest degree. Again the trephine was replaced, and after a 
few more gentle turns there was a very perceptible sensation of further yielding beneath 
the instrument; and a second time the trephine was withdrawn and a second ineffectual 
effort made to extract the plug, though it yielded slightly to lateral pressure. The tre- 
phine was again renewed, and after a few gentle turns withdrawn; and now the plug 
was easily extracted. The instrument was repeatedly withdrawn and very lightly 
worked after the first yielding was detected, lest by a sudden giving way of parts 
beneath it should be suddenly plunged into the mastoid cells, and in a moment defeat 
all my hopes from the operation." This plug was an inch in length, and when we con- 
sider the position of the trephine with relation to the lateral sinus and middle fossa of 
the base of the skull, we can but congratulate the operator that no injury to these parts 
caused him to wish as heartily that he had never attempted the operation, as he at one 
stage wished it completed. 
The employment of drills soon succeeded the use of the trephine in opening the 
mastoid cells. Those known as Buck's drills, because recommended by him, were most 
used, and are generally recommended even in the latest text-books by American authors. 
These drills are entered usually about a quarter of an inch behind the external auditory 
meatus, and a little below the level with the upper wall of the canal, and by pressure 
and a rotatory motion caused to penetrate the bone in a direction upward, forward, 
and inward. The pressure exercised is often considerable, and one of the best authors 
(Burnett) declares that a " few turns will usually be sufficient to perforate the mastoid 
wall, which at the point indicated is about one-fifth of an inch." The opening thus 
made is usually enlarged by the use of a bit, conical in form, which grinds through the 
external surface, enlarging the opening, it is true, by bruising the bone, and leav- 
ing a ragged surface, which is incapable of perfect cleansing, and liable to lead to 
absorption of poison, and consequent constitutional disturbance. Owing to the pressure 
that must be exercised in order to penetrate solid bone with reasonable quickness, the 
* " Treatise on Diseases of the Ear." St. John Roosa, pages 418 and 419. SECTION XII-OTOLOGY. 
835 
drill may be driven suddenly inward, as the cell structure is reached and resistance 
ceases, and do fatal injury to the lateral sinus, or membranes of the brain. No ordinary 
precaution, such as stop arrangements, extension of a finger by the side of the drill 
while at work, etc., etc., which are usually adopted in operating, will wholly guard 
against this, and in the excitement of an operation these precautions are sometimes 
wholly forgotten. Arthur Hartmann tells us (see Archives of Otology, Vol. xin, page 
139) that when he operated on the cadaver with these drills, after the manner recom- 
mended by Buck (Archives of Ophthalmology and Otology, Vol. Ill, page 212), who sets 
the drill a little below the upper border of the external canal and penetrates inward 
and a little upward and forward, he penetrated the middle cranial fossa with the drill, 
in three cases out of one hundred. If this happened in operating upon the cadaver, 
with nothing to disturb the operator, how much more frequently might it happen to an 
operator disturbed by the responsibility of an operation upon a patient who is, perhaps, 
acting badly under an anæsthetic, and where, in seeking pus, he often penetrates to the 
greatest depth sanctioned by the authorities ? When we consider, also, the variable 
position of the lateral sinus as determined by Hartmann* and others, we shall not 
wonder that Schwartze characterizes this mode of operating as a " drill into the dark- 
ness." (Archiv für Otologie, Band XIV, 202, referred to in Archives of Otology, Vol. VHI, 
page 414.) 
The use of a dental engine to drive the drill, by its rapid rotation, allows the 
operator to penetrate the bone with very slight pressure, and to determine when the 
cell structure or a pus cavity is reached, without so much danger of a sudden plunge 
of the drill, as when using ordinary hand drills, but it is still a '1 drill into the dark- 
ness," and the opening made needs further enlargement, which is usually made by a 
burr, which bruises the bone and leads to dangers already mentioned. It may be said 
that the sharp gouge, or chisel, may be used to enlarge the opening, instead of the burr, 
but in that case there is no need of a previous use of the drill, attended as it is with 
these dangers. 
We are told by von Troltsch that the first operation of this kind ever made was 
performed by Jean Louis Petit, by means of a gouge and hammer. In modern times 
we have not only seen the operation itself firmly established, but Professor Schwartze 
has also plainly demonstrated that the method employed by the great French surgeon 
is the best and safest that has ever been devised. 
The labors of Schwartze, Hartmann, Bezold, and others have so accurately settled 
the anatomical questions that should determine the mode of operating, and the position 
of the opening, that little is left for future observation upon these points. To avoid, as 
far as possible, the dangers which their anatomical investigations have disclosed as 
incident to the older methods, the operation should be thus performed : A vertical 
incision should be made through the soft parts down to the bone and close to the 
attachment of the auricle, or but one or two millimetres behind it, and so situated that 
its centre is very nearly on a level with the centre of the external meatus auditorius. 
A second incision, about an inch long, should be made backward from the centre of the 
first incision and vertical to it. The soft parts should be dissected up and the peri- 
osteum raised from the bone, so as to expose an oval portion of its surface to the extent 
of about two centimetres in vertical diameter and one centimetre in horizontal diameter. 
The chisel should be applied on a level with the upper wall of the meatus, at first at an 
angle of about 45°, and the bone chipped off in thin layers as close to the posterior wall 
of the meatus as possible, and extending downward well toward the apex of the process. 
* A. Hartmann, in Von Langenbeck's Archiv für Chirurgie, Vol. xxi; also Archives of 
Otology, Vol. xiii, page 139, and " Diseases of the Ear," by A. Hartmann, page 125, first Ameri- 
can edition. 836 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
In working the chisel, either pressure by the hand or light blows from a small wooden 
hammer may be used. The opening in the bone should be funnel-shaped, large exter- 
nally, and made cautiously inward and forward, parallel with the axis of the meatus, 
and as near as possible to it, until the cells are reached, or until the opening is made as 
deep as prudence will permit. Five-eighths of an inch is the limit as to depth, according 
to many authors, and beyond that we are in danger of injuring the facial nerve, semi- 
circular canals or other important structures. Schwartze, who at one time countenanced 
a penetration to a depth of three cm., or more, in certain cases of sclerosis, subsequently 
meeting with an accident, changed his views, and set 2.5 cm. as the greatest depth we 
should penetrate (see Archives of Otology, Vol. vm, page 4141. In making the opening, 
frequent examinations should be made, not only as to the character of the tissue at the 
bottom of the opening, but also as to the position of the opening itself in relation to the 
auditory canal. The insertion of a large, blunt probe ipto the meatus, and pressing it 
against the roof, will enable us to judge whether or not we are getting above it, thus 
endangering the middle fossa of the base of the skull, and pressing the probe against 
the posterior wall of the meatus will, in the same way, enable us to judge whether we 
are getting too far back, and thus endangering the lateral sinus. The insertion of a 
small cylindrical cork, just fitting the external meatus, will serve as a convenient guide 
while making the opening, and save frequent insertions of a probe into the meatus to 
determine our whereabouts. The position of the temporal ridge is too variable to serve 
as a landmark as to the position of the floor of the middle cranial fossa, as at one time 
advised ; besides, it is sometimes impossible to trace it, owing to the swollen condition 
of the parts covering it. 
The cellshaving been entered, they should be explored carefully, and caseous material 
should be removed with a small, sharp spoon, about three millimetres wide, and 
necrosed or carious bone should be broken up, if necessary, and removed by the spoon, 
or some other instrument. The chisel should have a curved cutting edge of about five 
mm. and be made of good steel. It is convenient to have two chisels, one with a 
straight shank to make the first part of the opening, and one with both edge and shank 
curved, or gouge-shaped, to work in the deeper portion. Antiseptic precautions should 
be observed, both during the operation and the after treatment. The opening should 
be kept patent by means of a small silver or rubber drainage tube, and the most care- 
ful attention bestowed in every respect, as the after-treatment often requires the exer- 
cise of even more knowledge and skill than the operation itself. 
Though it is difficult to decide in all cases j ust when to remove the drainage tube, 
it is safer to retain it longer than it is actually needed than to remove it too soon. In 
the former case it would only prolong the healing process, while in the latter case it 
might defeat the object of the operation, which was nearly accomplished, and would 
have been secured but for too much hurry in removing the tube. It is best to retain 
the tube until all discharge from the middle ear has ceased, or until it is extremely 
slight. Schwartze declares that all granulation processes in the middle ear and auditory 
canal, and swelling of the soft parts in the external meatus auditorius, must have 
disappeared, and, finally, water injected through the Eustachian tube into the middle 
ear must continue for a considerable period of time to escape from the outer mçatus, in 
a perfectly clear state, and without showing particles of bone-sand, before the drainage 
tube should be permanently removed. 
Although the second division of my subject seems to me nearly equal in importance 
to the first, it is regarded with indifference by many authors, as evidenced not only by 
their lack of uniformity in practice, but by occasional open avowal in their writings. 
In a paper entitled ' ' Clinical Observations upon the Diseases of the Mastoid Pro- 
cess, with an Historical Sketch of the Origin of Operations upon it," read by Professor 
D. B. St. John Roosa, M. D., before the Section on Ophthalmology and Otology in the SECTION XII OTOLOGY. 
837 
New York Academy of Medicine, March 21st last, the author, in conclusion, says : "I 
have said very little upon methods of operations, because I lay comparatively little 
stress upon them. Schwartze forsook the trephine at an early day, and took up with 
chisels. In this he has many followers. I have continued to use a stiff probe, and a 
drill. Buck continues to use the drill, while Crosby preferred a gimlet." * I was once 
influenced by similar views, and was long deterred from adopting Schwartze's method 
by some harsh criticisms which I read soon after it was brought to the notice of the 
profession. Until within the last two years I had used Buck's drills in all cases except 
two. One of these I operated upon with a drill driven by a dental engine, and in one 
case of extreme urgency, with no better instrument at hand, I operated successfully 
with a common carpenter's brad-awl and gouge. Dissatisfied with the operation by 
means of the drill, I made numerous operations on the cadaver, and thus compared 
Schwartze's method with the method by drills, and became convinced of the great 
superiority of Schwartze's method over that of any other that has heretofore been pro- 
posed. Since then I have operated successfully twice upon patients by means of the 
chisel, both cases requiring a quite deep penetration of hard bone, and the ease and 
rapidity with which the operations were accomplished, and the sense of relief expe- 
rienced during the operation, by having the parts open to inspection, were such as to 
cause me to regret that I had not sooner adopted this method, though I had, fortunately, 
escaped any accident by the other. I am now fully impressed that the method of 
operating is a matter upon which great stress should be laid, and that the method which 
allows of the most complete and permanent drainage, is most free from accidental 
injury to important surrounding structures, and generally best adapted to meet the 
exigencies that arise during operation, should be determined as fully as possible and 
urged for general adoption, to the exclusion of less safe and efficient methods. While, 
with great care, it may be quite safe to perforate the mastoid process with a drill, safety 
must often be purchased by the sacrifice of efficiency, and the method is not, as lately 
claimed, "as worthy to be adopted by surgeons as Schwartze's."f It is acknowledged 
by those who prefer the use of the drill, that there are "pathological conditions of the 
mastoid process in which the drill alone could not possibly suffice for the attainment 
of the purpose desired. ' ' J Even in the cases where it is regarded as applicable, the 
drill leaves too small an opening, very liable to close early by granulations, or cheesy 
pus, and thus lead to a recurrence of the symptoms, or necessitate another operation to 
remove the obstructions. The opening made by the drill, even when made by skillful 
operators, may, from its necessarily limited extent, fail to reach the pus, and patients 
so operated upon have died with symptoms that caused the operator to think that pus 
existed at the time the operation was made, but was retained in a portion of the process 
not penetrated. $ In chiseling, we generally lay open more of the cells, and, if we wish, 
can lay them open extensively, while with the drill we open into the antrum, or but few 
cells at most. The other cells may not freely communicate with the cells opened into 
by the drill, and thus retention of pus is more likely to occur than after the extensive 
opening of the cells and thinning of the external table of the mastoid that results in the 
perforation with the chisel. 
Another objection of great importance, is the nature of the wound made by the drill. 
The blood vessels and lymphatics of the bone are bruised, and injured in such a way, 
that it becomes difficult to cleanse their extremities from septic material, which is more 
likely to be absorbed, and lead to severe constitutional symptoms, than when the wound 
« See Archives of Otology, Vol. xvi, page 132. 
f " Perforation of the Mastoid Process and the After-treatment," by A. H. Buck, m.d. New 
York Medical Journal, August 28th, 1886, page 229. | Ibid. 
g See cases reported in Archives of Otology, for June, 1887, pages 99 and 103. 838 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
is made with a sharp-cutting instrument, leaving a smooth surface, which is easily 
cleansed and kept free from poisonous germs. 
The method of opening the mastoid process by the chisel is adapted to all classes of 
cases. It is easier of execution than perforation with the drill, and, according to my 
experience, does not require for its execution " more time and more manual skill," as 
stated by Dr. Buck in his paper above referred to.* It is, I believe, also safer; for, even 
if Schwartze does cite one case of death from injury done by a spicula of bone during 
the operation, the method is not at fault, and by proper care, accidents may be more 
certainly avoided by operating with the chisel, since the approach to important struc- 
tures can be more surely foreseen and injury to them guarded against. When an injury 
is done by the chisel, the nature of the opening is such that it can be detected, the extent 
of the injury appreciated, and the suitable treatment adopted, and, perhaps, the patient 
thus saved, as was done by Dr. Knapp, in the case where he accidentally opened the 
lateral sinus while so operating, f 
Another advantage of this method is that the opening made by the chisel may be 
conveniently enlarged to almost any desirable extent, to meet indications that may 
arise, and allow not only exposure of all the mastoid cells, but such exposure of the 
dura mater as to allow of detection and successful evacuation of cerebral abscess, as in 
the case recently reported by Professor C. Truckenbrod, of Hamburg, j: T. H. Gluck, 
also, by such use of the chisel, removed the posterior wall of the meatus, a portion of 
the mastoid process and temporal bone, extensively exposed the dura mater, and detected 
an abscess situated between it and the pia mater, and opened it, evacuating about 60 
grammes of thick fetid pus. His patient, however, died the next day.§ 
It is not a sufficient objection to this mode of operating to urge, as some have, that 
a larger wound of the soft parts is needed, and hence a more conspicuous scar left after 
recovery, or that removing a large portion of the external table of the bone leaves an 
ugly depression in the skin behind the ear after the parts have healed.(| Such objec- 
tions are too trivial to be considered where so important advantages are gained. 
The discovery and establishment of improved methods of operating is justly regarded 
as among the most important steps in surgical progress, and, in ovariotomy and scores 
of other operations, has contributed immensely to the life saving and other objects of 
this great science and art. The saying that Wenzel had spoiled a hatful of eyes in 
order to learn the art of cataract extraction, was not so exaggerated a statement at the 
time it was made, before the difficult and dangerous methods then in vogue had become 
obsolete, and more simple and safe methods adopted. Such was the power of von 
Graefe that he was able to establish rapidly the improved method he devised, and 
thus, no doubt, he saved thousands of eyes that would have been sacrificed by a con- 
tinuance of the less perfect methods which his replaced. Although the old flap opera- 
tion has long been obsolete, a description of it still lumbers the pages of most of our 
text-lx>oks, and one of our very latest reviews contains regrets that so much space in a 
new ophthalmic work should be devoted to this discarded operative This 
conservatism on the part of authors of ophthalmic works is of little moment, since the 
authors themselves, in the text, set forth the greater facility in performance, and also 
the greater safety of the modern operation, and every teacher of note impresses it fully 
upon the minds of his students. It is different in the case of operations on the mastoid. 
* New York Medical Journal, Vol. xliv, page 230. 
f See ArcÄives of Otology, Vol. X, page 365. J See Archives of Otology, Vol. xv, page 176. 
§ See Archives of Otology, Vol. xn, page 176, from N. Langenbeck's Archiv, Vol. xxxvni, 
page 556. 
|| See Buck's article, New York Medical Journal, Vol. xliv, pages 229 and 330. 
See Archives of Ophthalmology, Vol. xvi, page 248. SECTION XII-OTOLOGY. 
839 
Nearly all American authors give a detailed account of the method of perforating 
with the drill, and figure in a conspicuous manner the instruments used, while they 
either omit, or briefly mention, the more easy and safe method recommended by 
Schwartze, and adopted so generally in Europe, and by so many leading operators on 
this continent. Dr. Pomeroy, in the last edition of his excellent book on diseases of 
the ear, I think fairly represents the teaching of most American authors in this regard. 
He says : " Some form of hand drill is just now very much- in vogue for opening the 
mastoid. The one figured here is known as Buck's. I believe it to be the best instru- 
ment for the purpose I am acquainted with."* 
I believe the superiority of Schwartze's method is sufficiently well established, and 
its advantages are of so great importance, that it should be generally urged for adoption 
until some still more improved method may be devised. 
DISCUSSION. 
Prof. De Rossi, Rome, Italy, asked if Prof. Frothingham had ever practiced 
opening the mastoid in cases of chronic suppuration of the middle ear. He noted 
that Professor F. had first indicated the operation in these cases, despite the fact 
that an authority such as that of the German professor was against it. It was not 
the custom to practice this operation in cases of simple chronic suppuration, not- 
withstanding they frequently do not dry up for many years. 
Dr. J. Baratoux, Paris, France, said - I fully agree with the opinion 
expressed by Professor De Rossi relative to surgical interference in affections of the 
mastoid process. I believe that we are too often tempted to perforate this process 
for affections which can be efficiently relieved by other means. In actual practice 
I rarely have to resort to this operation. I almost always resort to other means, 
such as early ice applications, or Wilde's incision ; even in those cases which 
exhibit fever, delirium and pain. I have often made Wilde's incision when I 
have felt sure that I should find no pus beneath the periosteum, but experience 
has convinced me that such an incision often suffices, if the precaution is taken 
to give a free exit to the excretions from the external auditory canal. In many 
cases when, according to my observation, other surgeons would have opened the 
mastoid cells, I have succeeded in affording permanent relief by the use of insuffla- 
tions, perforating, or enlarging old perforations of the membrane, antiseptic dressing, 
and Wilde's incision. So far, these simple measures have given me such satisfactory 
results that I do not hesitate to say that cases demanding perforation of the mastoid 
cells are rare. I say this, conscious of the fact that many surgeons do not hesitate 
to perform the operation, even in comparatively insignificant affections of the middle 
ear. My observations are based on an experience similar to that of my confrères, and 
I have never yet been obliged to perform perforation of the mastoid cells when, 
according to my judgment, Wilde's incision and the other precautions! have referred 
to have been deemed at the time sufficient. I consider the opening of the mastoid 
cells to be rarely a necessary operation. 
Dr. S. S. Bishop, of Chicago, Illinois.-We are much indebted to Professors 
Fulton and Frothingham for discussing a topic which has not received the attention 
which its importance merits. Professor Fulton treats not only of primary inflam- 
mation of the mastoid antrum, proper, but of the mastoid cells, which constitute the 
«- "Diseases of the Ear," by 0. D. Pomeroy. Second revised edition, 1886, page 297. 840 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
whole interior structure of the mastoid process. Had he maintained that the mastoid 
antrum, proper, is the seat of a primary circumscribed inflammation, limited to that 
part only, my experience could not have corroborated his assertion, for I do not 
remember to have met with a case in which such a diagnosis would have been 
warranted. Indeed, I cannot think that primary inflammation of the mastoid cells 
is frequent, except as the result of traumatic injury. I have witnessed the occurrence 
of the latter, but am not satisfied that it occurs independently of traumatism, or 
middle-ear disease. I have frequently treated cases which might have been diag- 
nosticated inflammation of the mastoid cells, but which I believe to have been 
periostitis, in which the inflammation was controlled by cantharidal collodion, or 
essential oil of mustard, or leeches, combined with anodynes. The pain, redness, 
swelling, and tenderness, have often entirely disappeared under this treatment without 
operative interference, but I have always found such cases either associated with, or 
following, inflammation of the tympanic cavity. 
We should heartily thank Professor Frothingham, for his paper is a most valu- 
able contribution to the history of mastoid disease, and its treatment. To be brief, 1 
will give only an outline of my treatment of such cases as require operative proced- 
ures. If the abortive measures mentioned fail to arrest the inflammation, and the 
formation of pus is inevitable, it is my practice to cut down at once upon the bone. 
If a sinus has formed, it is rimmed out with a drill, and sufficiently enlarged to 
admit of a thorough examination of the interior of the cavity. All unhealthy tissue 
is removed ; the cavity is treated with scoop and drill, on much the same principle 
as the cavity of a tooth is prepared by a dentist for a filling ; a solution of mercuric 
bichloride (1-2000) is used to cleanse the cavity, and iodoform, or powdered boracic 
acid, is dusted into and about it. I, like the author of the last paper, use drainage 
tubes, but the cases in which their use has been omitted have been attended by as 
fully gratifying results. In closing the wound, the periosteum, which has been pre- 
served, is replaced ; the sutures are frequent and deeply inserted, and the parts are 
sealed with antiseptic gauze, absorbent cotton, and net bandage. 
My experience is not so extensive as that of some of the authorities quoted, but 
eighty-five per centum of my cases recovered completely ; the other fifteen per 
centum passed from under my observation before a fair opportunity for a cure, and 
they are classed as doubtful. 
I wish to express my dissatisfaction with the use of the trephine in operations on 
the mastoid where a sinus exists. The sinus does not afford a steady support to the 
fixation shaft, unless the opening in the bone is very small. If the sinus is large, 
the superficial layer of bone is likely to be undermined, and softened to such a degree 
that it gives way under the trephine, letting the instrument settle into the cavity 
suddenly, jeopardizing the dura mater and the lateral sinus. I have never been so 
unfortunate as to have injured these structures, although I have removed necrosed 
bone until the dura mater was exposed ; but too much care cannot be exercised to 
protect these vital structures. 
Dr. C. M. Hobby, Iowa City, Iowa, called attention to the hand bone-gouge of 
the ordinary general operating case as possessing the requisites, when sharp, of per- 
fect control, rapid work, and of making the best possible wound of bone. 
Professor F. C. Hotz, Chicago, Illinois.-In regard to the indications for early 
operation in acute suppurative inflammation of the middle ear, there is one point 
which cannot be emphasized strongly enough. Surgeons do not see any justification 
for operating in such cases as long as the pus has a free outlet through the perfo- SECTION XII-OTOLOGY. 
841 
rated membrana tympani. I have held and expressed, and I still hold the same views 
as Professor Frothingham, viz., that, if judicious treatment continued for several 
weeks has proved insufficient to control the suppuration, or if any medicinal applica- 
tion, even of the mildest character, aggravates the symptoms, and the purulent dis- 
charge is very profuse, the mastoid should be opened, there being no doubt that the 
inflammation has extended beyond the tympanic cavity, and, though the pus has a 
free outlet through the drum membrane, the amount of pus in the mastoid cavity is 
too great to be readily drained off through the perforated drumhead. I have been, 
quite recently, again impressed with the importance of early operation, by a case of 
acute suppurative inflammation of the middle ear, which had existed over two 
months. I saw the case in consultation ; there was no tenderness or swelling over 
the mastoid region ; no pain in a distant part of the head ; the membrana tympani 
showed a large central perforation, through which the pus kept welling out as 
fast as it could be wiped off. All means had proved inefficient, the discharge being 
as copious as during the first week. My opinion was that the mastoid was undoubt- 
edly involved, and should have been opened long before. The attending surgeon had 
not thought of doing so, nor that there was any special indication for the operation, 
because the discharge of pus was so free and uninterrupted through the drumhead. 
The operation was not done, and a week later the patient died of acute meningitis. 
Dr. G. W. Allyn, Pittsburgh, Pennsylvania, wished to know if the writer 
would include in his indications for opening the mastoid cells cases of chronic sup- 
puration of the middle ear which had, for years, resisted the usual means of treat- 
ment. 
Dr. R. Tilley, Chicago, Illinois.-When the statement is made that suppuration 
of the middle ear demands operation, it is too general ; we must distinguish between 
the kinds of suppuration. If the suppuration persist, regardless of special atten- 
tion to cleanliness and the use of antiseptic fluids, and the pus wells up in great 
abundance, and unquestionably arises from the mastoid region, then the operation 
may be justifiable. But when the suppuration is from the roof of the tympanic 
cavity, then the perforation of the mastoid cells would be of no avail, and it is just 
these cases, namely, a persistent discharge from the upper and anterior part of the 
middle ear, which have given me personally the greatest trouble. 
Dr. S. 0. Richey, Washington, D. C.-Trephination of the mastoid is like 
tracheotomy for diphtheria, inadvisable until the last moment, and yet we must be 
sure not to defer the operation until too late. The Scylla of a needless operation, 
and the Charybdis of not performing it, or of doing it too late, must both be 
avoided ; and the way in which this is done depends greatly upon the judgment of 
the individual surgeon. The treachery of chronic suppuration is well known. Often 
there is no symptom of the approaching fatal termination until too late for the 
operation. My mind is not clear as to the unquestioned indications for the opera- 
tion, and these I would like to hear clearly set forth. 
Dr. A. Blitz, Minneapolis, Minnesota.-As far as my experience goes in mastoid 
disease, I am convinced that the operation could very often be avoided if the disease 
could be recognized by the practitioner of general medicine, and appropriate treat- 
ment be at once instituted, as the family physician sees the patient first, and often 
treats the patient until the aggravated symptoms and increased suffering frighten 
both physician and patient into consulting some specialist, who finds the case so far 
advanced that nothing but perforating the mastoid process will save the patient. 
Often the patient neglects to attend to a suppurative otitis media ; the disease 842 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
becomes chronic, the tissues more and more break down, until exposure to cold, or 
this gradual extension of the disease, affects the mastoid cells. In acute inflamma- 
tion of the mastoid cells, I have found continued applications of broken ice, in a 
rubber bag, placed over the ear day and night, together with other remedies indi- 
cated by the symptoms, best. In regard to the indications for the operation, I fully 
agree with the author of the paper, and am glad these points are made so clear. As 
to the method of operating, I must beg leave to differ with the author. The use of 
the chisel and hammer seems barbarous, when we can use so nice and efficient an 
instrument as the drill-not a small, ordinary one, of perhaps one-eighth inch in 
diameter-but a round burr-head drill of at least one-half inch in diameter ; for if 
the operator has mechanical dexterity he will use the drill to far greater advantage, 
with more nicety and certainty, and without injury to the parts. If the opening 
needs to be increased, this can easily be done, and all the rough edges of the wound 
be made smooth and clean. With our present antiseptic precautions there is no 
more danger from sepsis after one operation than the other. 
The operation is not so dangerous in itself as was formerly believed, and there is 
no reason to dread it so much, because it certainly cannot do so much harm as the 
disease, if the operation be delayed or not done, as many such cases, unfortunately, 
might show. 
Dr. H. B. Young, referring to Professor Hotz's remarks, said-It occurs to me 
that no mention was made of a post-mortem in your case. Professor Hotz replied 
that there was no post-mortem. Dr. Young then reported a fatal case, in which the 
mastoid was opened post-mortem and no pus was found, although it was, from con- 
comitant circumstances, certainly to be expected. 
Professor M. F. Coomes, Louisville, Kentucky, said-He wished to enter a pro- 
test against the use of the chisel in opening the mastoid cells, as he thought the 
method a rude one, to say the least, and one that ought not to be practiced when 
other methods are at command. He had opened the mastoid in two cases in which 
pus was supposed to exist ; in one the cells were healthy ; in the other a small quan- 
tity of sanious fluid was found. One of the patients improved for a time, after the 
opening was made, was able to be on his feet for fifteen days, and finally died in 
convulsions. No post-mortem was permitted. The other patient died in a comatose 
condition a few days after trephining. The autopsy showed that the pus passed from 
the middle to the internal ear, thence through the bony wall into the cranial cavity. 
The auditory nerve in the canal was in a state of high inflammatory action. 
Dr. M. Toeplitz, New York, N. Y., said-In his practice opening of the mastoid 
has never been made without a distinct indication, i. e., tenderness, pain, swelling, 
localized headaches, increased temperature, etc. Chronic suppurative otitis, with 
only a suspicion of pus in the mastoid cells, is not considered a sufficient indication. 
The operation was always performed with the chisel, which has proved satisfactory 
in every respect. Are we justified in performing the operation in cases where the 
brain and the meninges have been involved? I had occasion to make two observa- 
tions as to this point :- 
1. A patient had suffered from chronic suppurative otitis five years previously 
to the last affection. When I saw him first I diagnosticated sinus thrombosis, and 
although I had for him no hopes, the operation was performed. The patient died 
four days later. The autopsy confirmed the diagnosis. 
2. Three and a half months after opening the mastoid the patient showed distinct 
brain symptoms, intense headache and paralysis of the external rectus of the left SECTION XII-OTOLOGY. 
843 
eye. I opened the mastoid process, which had completely closed, whereupon the 
symptoms subsided. Cure, after two months. 
Dr. W. F. Holcombe, New York, N. Y.-I am firmly convinced that the drill 
used by dentists is the best which can be used for opening bony parts for the exit of 
pus. These drills are of many sizes. Great care must be used in not pushing the 
drill too hard, as it cuts more rapidly than the hand drill. 
Dr. Paddack, New York, N. Y.-Found the drill run by the dental engine 
valuable for drilling into the mastoid cells, when the operator preferred the drill to 
the gouge, as it is perfectly under the control of the hand of the operator, and, with 
a small drill, any size of opening can be cut. The small amount of pressure required 
makes it useful. 
Professor Frothingham, in closing the discussion of his paper, said, he would be 
very brief, as the subject had been already very fully debated. In answer to Pro- 
fessor De Rossi, he had not been in the habit of perforating the mastoid for simple 
chronic suppuration of the middle ear, and he advised it only when an examination 
and study of the case revealed a greater amount of secretion than would be ordina- 
rily furnished by the tympanic cavity alone, with a further probability that it was 
poured into the tympanic cavity from the mastoid cells, and not from some other 
direction. This is a matter for careful study and consideration, and from the result 
of this study of the case we should determine whether, or not, benefit would be likely 
to follow the operation. He had no doubt many obstinate cases of chronic suppura- 
tion of the middle ear could thus be cured. He would further remark. that the 
situation of the mastoid cells and antrum, with reference to their communication 
with the tympanic cavity, is such as to lead usually to a retention of pus in the mas- 
toid in most cases where the cells had become extensively involved in the suppura- 
tive process. In order to drain this cavity he believes an external opening prefer- 
able, more safe than any that can be made through the wall of the meatus or tym- 
panic cavity. The external table of the mastoid in such cases should not only be 
opened, but the opening should be large and extend well down toward the apex of 
the process ; indeed, the temporal bone which he had exhibited to the Section 
showed a distance between the posterior wail of the external meatus and the sigmoid 
fossa of only four and six-tenths millimetres ; it showed, also, the necessity of 
making the perforation so low down that the cells should not be reached above the 
central axis of the auditory canal. An objection had been made that surgeons dread 
to do the operation, and that it should be resorted to only when the indications are 
plain. In his paper he had advocated a more frequent resort to the operation than 
he had been accustomed to practice. In reviewing his past experience he did not 
doubt that he could have safely relieved many patients by an operation-have effected 
a more speedy cure than nature had done without this aid. Fortunately, he had 
had no case of death where operation had thus been omitted in his private practice, 
but several cases had come to his clinic at a stage of the disease beyond any hope, in 
which an early operation might have saved life. 
He did not wonder that surgeons dreaded the operation with drills. While 
engaged in general surgery, he had performed nearly all the capital operations, and 
had approached no operation, not even opening the sac of an aneurism of the com- 
mon carotid, with more solicitude than some of these operations upon the mastoid 
with a drill, which he regarded, with Schwartze, as a "drill into the darkness." 
Who, with such a method of operating in such an important and variable anatomi- 
cal region, can feel that he is not placing his patient in great danger from the opera- 844 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tive procedure alone. The object of treatment is to lessen the dangers to which the 
patient is exposed, and not to increase them. With only unsafe methods of operat- 
ing, we may rightly withhold surgical interference, when, with available safer 
methods, we should urge it. After careful study of Schwartze's method, he is con- 
vinced that it is attended with so little danger and difficulty that we may urge it in 
many cases which formerly would have been left to the expectant plan. He believes 
that the cases of spontaneous cure reported could have been more speedily cured by 
perforation, and with less danger. The subject is too extensive for exhaustive con- 
sideration at any single conference, but that the mastoid is as liable to primary 
inflammation as other bony structures, seems to be a fact overlooked, or but imper- 
fectly considered by the profession. Professor De Rossi had very truly said that 
pain, alone, is not generally regarded as a sufficient indication for the operation. The 
pain that calls for perforation of the mastoid must be studied. It is generally a deep- 
seated, throbbing pain, more severe at night, and resists all other efforts for its relief. 
The patient is unable to attend to any duty. We often find it affecting other bones, 
without external evidence of disease. He has seen many cases in which the tibia 
was affected. His esteemed colleague, the late Professor A. B. Crosby, had taught 
him how speedily to cure many of these cases, by boring into the bone with a com- 
mon gimlet, and he opened into the mastoid in this way. An opening into the bone 
affords most speedy relief in inflammation of the bone. He has seen operations of 
the kind followed with immediate and permanent relief, though no pus was found 
and no appearance of sclerosis was visible to the eye. There are numerous cases in 
which perforation of the mastoid in search of pus has led to relief without finding 
pus or sclerosis. He believes pain alone, under some circumstances, constitutes a 
positive indication for perforation. 
INHERITED SYPHILIS AS A FACTOR IN SUPPURATIVE INFLAM- 
MATION OF THE MIDDLE EAR. 
SYPHILIS HÉRÉDITAIRE EN TANT QUE FACTEUR DANS L'INFLAMMATION 
SUPPURATIVE DE LA MI-OREILLE. 
HEREDITÄRE SYPHILIS ALS EIN FAKTOR BEI EITERIGEM CATARRH DES MITTELOIIRES 
BY ROBERT TILLEY, M.D., 
Of Chicago, Illinois. 
In looking over the literature of inherited syphilis, of diseases in children, and spe- 
cial otological literature, for some information relative to the opinion of the profession as 
to the part which inherited syphilis may play in the production of acute and chronic 
suppurative inflammation of the middle ear, I was somewhat astonished at finding so 
little definite reference to the subject. For the past six years it has been with me a 
fixed conviction, which has apparently grown from personal observation, that whenever 
otorrhœa was associated with such other symptoms as are usually associated with 
inherited syphilis, although no one of these other symptoms may have been very pro- 
nounced, to regard the otorrhœa and its direct cause, inflammation of the aural tissues, 
as a manifestation of inherited syphilis. It is this settled personal conviction that SECTION XII-OTOLOGY. 
845 
accounts for my surprise in finding so little reference to the subject in the collected 
literature referred to above. 
Professor Adam Politzer, as translated by Dr. J. P. Cassels, p. 387, in speaking of 
the etiology of acute purulent inflammation of the middle ear, says: "Acute purulent 
inflammation of the middle ear either takes place primarily, in consequence of external 
influences, after colds, or is caused by propagation of acute, or chronic naso-pharyngeal 
catarrh to the middle ear. It may also be developed in the course of scarlatina, 
measles, smallpox, typhus, tuberculosis, diphtheritis, pneumonia, influenza, whooping- 
cough, and in the puerperal state. Traumatic acute suppuration in the middle ear is 
sometimes caused by paracentesis, or by other operations in the membrana tympani, 
also by contusions of the cranium, or of the ear by a blow or a fall, by forcible attempts 
at extraction of foreign bodies from the ear, and by scalding and cauterization of the 
ear. Acute suppuration of the middle ear may also be caused by Weber's nasal 
douche, by injections of cold water into the external meatus, and by cold river, or sea 
baths. " He further states that it occurs more frequently in children than in adults, and 
that climate seems to have but little influence on its development, citing Knapp as 
having carefully compared statistics from European and American sources to sub- 
stantiate the statement. Neither in the section on the acute form of suppurative 
inflammation of the middle ear, nor in the section on the chronic form of this affec- 
tion, is there any allusion whatever to inherited syphilis as a possible cause of the 
disease. 
Dr. Albert H. Buck, in his work, 1880, " Diagnosis and Treatment of Ear Diseases, " 
does not mention inherited syphilis. He details in the main the same list of causes as 
Politzer. The chronic affection, he concludes, is due to neglected acute affections, 
practically, always. I may, however, be permitted to refer to a shorts eparate section 
by Dr. Buck on syphilis in the ear. He says, page 227, "Writers on diseases of the 
ear are, I believe, nearly unanimous in the statement that lesions characteristic of syph- 
ilis are never observed in the middle ear or membrana tympani. While I," he con- 
tinues, "do not feel justified as yet in disputing this statement with any degree of posi- 
tiveness, owing to the scantiness of the material which has come under my observation, 
I cannot help feeling that we shall learn in time to recognize in these parts textural 
lesions as distinctly characteristic of syphilis as are most of its external manifestations. ' ' 
He then assigns two cases in order to show that the lesions developed in the middle ear 
and membrana tympani were in all probability due to syphilis. I cite this quotation 
from Dr. Buck because it may be said that it would be necessary to establish, in the first 
place, that primary syphilis affects the middle ear before we can with prudence suspect 
the inherited manifestations to show any proclivity toward that region. But I think 
we shall see later on that such a position can scarcely be sustained. 
I will make another reference to primary syphilis in the middle ear. Keyes, 
Wood's Library ed., p. 235, says: " There is an inflammatory condition of the middle 
ear due to syphilis which is not a catarrh. No suppuration occurs, but a thickening of 
the drumhead and of the tissues of the middle ear leading to a restraint in the move- 
ments of the ossicula. It is a sort of plastic myringitis. Schwartze and Roosa," he 
says, " believe that this condition originates in a periostitis of the middle ear." 
The strong assertion quoted above, from Dr. Buck, may j ustify still another quota- 
tion. Dr. Alfred Cooper, of Lock Hospital, London, says: "The tympanum, or 
middle ear, is the part of the organ most frequently affected, owing to the extension 
of syphilitic lesions from the throat and nose. The membrana tympani and the mucous 
membrane lining the cavity become infiltrated and thickened, the ossicles are more or 
less changed, and eventually the membrane may become perforated by ulceration, the 
result of inflammation of the tympanic cavity. When this is the case, all the struc- 
tures are more or less disintegrated and purulent discharges escape from the ear." 846 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Dr. St. John Roosa does not mention inherited syphilis as a cause of suppurative 
inflammation of the middle ear, but refers to its occurrence in primary syphilis in the 
affections of the pharynx and posterior nares. 
Dr. Thomas Barr, of Glasgow, after the general enumeration of the accepted associ- 
ated affections, says : " As in nearly all the diseases of the ear, hereditary tendency 
playsan important part in the causation." There is no specification, however, as to 
the character of the " hereditary tendency. " 
Although confessedly a disease, par excellence, of children, Eustace Smith, in his 
" Disease in Children," does not mention inherited syphilis as a cause. He seems to 
take his etiology from the writers on otology. 
Dr. P. Diday, as edited by Dr. F. B. Sturgis, p. 96, after stating that affections of 
the ear found to be dependent upon inherited syphilis are usually nervous diseases, ad- 
mits that " Cases of suppurative otitis media are also seen associated with this type of 
disease, but it is open to some doubt if it is dependent directly on syphilis." Sturgis 
himself, in the appendix to his edition of Diday, says, p. 291, " The lesions of the ear " 
(he is speaking, of course, of inherited syphilis) "are even yet but little understood, and 
are nearly all confined to deafness which comes on suddenly and is frequently unaffected 
by treatment." Sir W. B. Dalby, as quoted by Sturgis, seems decidedly opposed to 
the supposition of inherited syphilis playing any part in middle-ear affections. He is 
quoted as saying: "It is of the utmost importance that this affection, " inherited 
syphilis affecting the ear, " should be clearly recognized as having no connection what- 
ever with changes that may be found in the tympanum. ' ' Space forbids my entering 
further into his discussion of the subject. In Ziemssen's Cyclopædia, however, we find 
a more definite positive statement of inherited syphilis as a cause of suppurative aural 
affections. In Vol. Ill, page 225, English edition, we read, " In the account of the 
syphilitic affections of the pharynx it was observed that it was not uncommon for them 
to cause a temporary or permanent occlusion of the orifices of the Eustachian tubes. 
This is the starting point for catarrh of the tympanum and a frequent cause of deafness 
and tinnitus aurium, which are apt to occur in the course of syphilis. Such a catarrh 
may have the same issues as those due to other causes, and lead to perforation of the 
membrana tympani, purulent infiltration of the cells of the mastoid process, etc. 
These conditions are especially apt to occur in consequence of inherited syphilis." On 
page 239, we read, " Deafness due to changes in the middle or the internal ear may 
also be present at this time." The time here referred to is the development of iritis 
from inherited syphilis. 
It is fair to conclude from the above quotations that, while the writers on otology 
have not hitherto regarded inherited syphilis as a cause of suppurative affections of the 
middle ear, some of the writers on syphilis are quite positive in the expression of their 
convictions that inherited syphilis constitutes a definite cause of suppurative inflamma- 
tion of the middle ear. 
To further elucidate the question, we turn our attention for a moment to the cornea. 
There is scarcely a dissenting voice in the profession relative to the significance of cer- 
tain pathological changes of the corneal tissue. It is unnecessary to take up your time 
by citing authors to show that interstitial keratitis constitutes one of the most convinc- 
ing manifestations of inherited syphilis. It is claimed, of course, by some that keratitis 
interstitialis does sometimes exist in the offspring without any evidence of syphilis 
being demonstrated in the parents. Without fear of encountering serious opposition, 
however, the general voice of the profession may be thus stated : that interstitial kera- 
titis in the vast majority of cases is a manifestation of inherited syphilis. So settled 
is this conviction, that keratitis interstitialis is sometimes called syphilitic keratis- 
meaning, of course, inherited syphilis. 
I have referred to the cornea on account of a certain resemblance which the cornea SECTION XII-OTOLOGY. 
847 
may be supposed to bear to the membrana tympani. Their development in the embry- 
onic state is not dissimilar. They are both developed from the ectodermic membrane, 
with a contribution in both cases from the mesodermic tissue. Their period of develop- 
ment cannot be greatly different. Both present peculiarities of differentiation for their 
special functions. Their respective areas are not greatly different in point of measure- 
ment ; and they are both protected in a peculiar manner by the surrounding parts of the 
respective organs of which they are members. With these points of resemblance, and 
the recognized fact that inherited syphilis plays a very important part in the develop- 
ment of the nervous affections of the ear, in the development of mastoiditis in eczema 
of the auricle, may it not be logically urged that we are not only justified in asking the 
recognition of its influence, but that we are even illogical in ignoring its bearing? With 
the evidence that exists in support of the part which syphilis plays in producing patho- 
logical conditions of other parts of the auditory organ and of the various corresponding 
tissues of the eye, why should we expect exemption for the middle ear ? 
But we must not confine our attention wholly to the membrana tympani. The 
mucous membrane lining the middle ear is a continuation of the same membrane in the 
nose. Now the evidence that keratitis interstitialis is a manifestation of syphilis is not 
more firmly rooted in the mind of the profession than is the conviction that an early 
manifestation of an abnormal condition of the mucous membrane of the nose is another 
form of its manifestation. 
Trousseau, "Clinical Med.," page 5S4, Vol. n, English edition, speaking of inher- 
ited syphilis, says : ' ' Coryza is one of the signs which appear earliest, and, also, one of 
those which have been the best studied. The infant breathes with increasing difficulty. 
Soon there is a running from the nose and a few drops of blood exude, 
but there is no true epistaxis. The secretions become more and more sanguinolent 
without being profuse; they irritate the alæ of the nose, the upper lip, etc." Now, if 
it is conceded that syphilis works such changes in the nose, is it not reasonable to sup- 
pose that under some conditions that same affection may continue through the Eu- 
stachian tube to the middle ear, and, under modified circumstances, may even start up 
independently in the middle ear.itself? 
In the quotation above, Trousseau was speaking of the very early manifestations of 
inherited syphilis. Sturgis, in his appendix to Diday's work, says: "The mucous 
membranes, notably of the throat, nasal cavities, and mouth, are the seat of manifesta- 
tions of late hereditary syphilis." On page 293, he says: ".Ozæna from ulceration of 
the bones of the nose is not an unfrequent lesion in the hereditary forms of syphilis." 
Further on he continues, ' ' The viscera also present lesions which are to be attributed 
to this cause." I might refer to other authors on this subject, but I forbear, because I 
do not think there can exist a dissenting voice in this Section as to the possibility of 
inherited syphilis affecting practically any part of the human organism, and, of course, 
with it the middle ear and membrana tympani. It does not, however, seem to have 
been duly recognized in the standard otological literature. 
There is a tendency on the part of some contributors to current medical literature 
to expatiate at length on the condition of the nasal mucous membranes and their sub- 
jacent tissues, as an original or prime cause of special pathological conditions both of the 
eyes and ears. My conviction is, that in a large majority of such alleged cases, the true 
explanation is to be found one step further removed, namely; that the difficulties of 
eyes, and ears, and nose are referable to a vitiated constitution from some cause; and 
further, that among such causes inherited syphilis stands prominent. 
There is an interesting study, hitherto little prosecuted, which may be capable of 
throwing valuable light on the question; namely, the study of the relative extent of 
affections of the middle ear among the negroes. I have examined such literature as is 
at my disposal, in vain, for information on this point. I am not conscious that any rela- 848 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
tive statistical information has been published. Moreover, I have not been able to find 
any statistics as to the comparative susceptibility of the genuine negro to syphilis; but 
from general medical literature, I have the conviction that the ravages of syphilis among 
the negroes are not nearly so disastrous as among the white races. If such be the case, 
statistics relative to the middle-ear affections in the negro should contribute evidence 
either for, or against, the argument here advanced. 
I urge this question more emphatically on account of its practical bearing. You are 
all acquainted with the various "methods" advocated in treatment of suppurative 
inflammation of the middle ear, antiseptic method, dry method, etc. A few years ago, 
some were claiming to cure all cases of otorrhcea by the insufflation of powdered alum. 
Little was said of the cases of death from meningitis which followed the drying of the 
alum. That "method " subsided, and boric-acid insufflation and packing had its day; 
the bichloride solution and iodoform are still exerting their influence. All of these 
remedies, and still others, are excellent when judiciously used, but it is only when we 
form a definite and fundamental idea of the causes of the real difficulty that we can act 
with confidence. 
It is well known that almost all the manifestations of syphilis of a functional character 
yield under judicious use of anti-syphilitic remedies. It is further known that patho- 
logical changes of very marked character in the tissues themselves begin at once to 
assume a more normal aspect under similar treatment. If such good results can be 
obtained in syphilides on the leg, or arm, or scalp, correspondingly satisfactory results 
should be secured w hen the same affection invades the middle ear and membrana 
tympani. 
I may be reminded here of hundreds of cases cured with boric acid, and nitrate of 
silver, and the question may be justly asked, if any large percentage of these cases were 
the manifestation of inherited syphilis, would they have yielded so readily to such reme- 
dies ? To which it may be replied, is it not a fact that such cases are very frequently 
subject to relapses, and that some of them defy the most painstaking local treatment, and 
respond only when appropriate constitutional measures are associated with the local 
treatment? It may further be added that nitrate of silver is of recognized value in 
mucous patches, and boric acid is of value as a drying agent in certain syphilides. 
Although Politzer, in his section on etiology, does not refer to inherited syphilis, 
yet, in his chapter on treatment, he says, p. 487: "Where there is constitutional 
syphilis the suppuration is often arrested only by a suitable anti-syphilitic treatment," 
and in his section on prognosis, p. 398, he sayg: " The prognosis is, however, unfavor- 
able in scrofulous, tubercular and syphilitic individuals." 
The difficulties associated wfith the demonstration of a given lesion of the middle 
ear or membrana tympani being syphilitic, are unusually complicated. I do not pre- 
tend to give demonstration. The demonstration of inherited syphilis, as a whole, 
even, would certainly afford an extensive subject for dispute. And the point which is 
interesting to us as otologists, the demonstration of its existence under the circum- 
stances associated with which we see many patients, but adds to the difficulty of 
making a positive demonstration. Let the complicated difficulties associated with the 
parents be passed over in silence. Suppose, for a moment, that the membrana tympani 
were the seat of textural changes, similar in character to the textural change existing 
in interstitial keratitis, how often would it be possible for the most painstaking inves- 
tigator to obtain such a view of the membrane as to give him the necessary conviction 
of that peculiar pathological condition ? How is it possible to get a view of the mucous 
membrane of the middle ear to compare it with the condition of the mucous membrane 
in the nose, which is said by Trousseau to be characteristic? It not infrequently hap- 
pens, however, that the discharges from the ear correspond, in children, exactly with 
the discharge described by Trousseau as coming from the nose. He says, p. 584: "Soon SECTION XII-OTOLOGY. 
849 
there is a running from the nose (substitute ears). The secretion becomes more and 
more sanguinolent without being profuse; it irritates the alæ of the nose, and the upper 
lip (substitute the external canal and furrows of the auricle), causing ulcerations which 
become covered with crusts when dried by the external air. On making a more 
attentive examination, there will often be found at the angles of the alæ of the nose (the 
furrows of the external ear) small, ulcerated fissures, already characteristic, inasmuch 
as they exactly reproduce the special aspect of the fissures seen in the commissures of 
the lip." 
It is not clai med, herein, that every case of suppurative inflammation of the middle ear 
presents the above characteristics, nor is it desired to imply that every case of middle-ear 
suppuration is associated with inherited syphilis, but the claim is made that the above 
characteristics, in acute suppurative inflammation of the middle ear, are not infrequent. 
I have said that I do not pretend to demonstrate this question. I do not consider that 
interstitial keratitis, nor the peculiar pathological condition of the nose, nor its corres- 
ponding condition in the ear, are demonstrated features of inherited syphilis. The 
demonstration will be possible only when the entity causing the clinical features which 
constitute syphilis has been isolated, and its peculiar influence in the various tissues has 
been demonstrated. I regard keratitis interstitialis, however, as well as the other pecu- 
liarities referred to above, as clinical manifestations, which have been so often observed 
and recorded by our worthy predecessors, and encountered by ourselves, that, in the 
absence of a more absolute method of demonstration, we are bound and glad to accept 
them as a guide in our efforts as healers of the sick. 
My general plan in determining the presumptive cause of a case of suppurative 
inflammation of the middle ear is, after thorough cleansing of the affected organ, to 
inspect the nasal and pharyngeal spaces; to examine the condition of the teeth; to 
observe well the scalp; to explore the region of the cervical glands; to take a general 
survey of the features; to exercise judgment relative to inquiry about other mem- 
bers of the family, and then if numerous deaths or miscarriages have occurred in the 
family; if in the patient the cervical glands are enlarged; if the features are puny and 
shriveled, the hair thin and dry, pustules in the scalp, hypersecretion with swollen 
tissues in the nose, teeth irregular and decayed, especially the characteristic teeth 
of Hutchinson; any special disposition to disturbance of the alimentary canal, any 
abnormal condition about the eyes ; if there be found a limited number of these conditions, 
together with a suppurative condition of the middle ear, to give the patient the benefit 
of the doubt, and if it is not concluded that he is syphilitic, it is inferred that he will 
thrive best, that his suppurative middle ear will heal more effectually and quicker, and 
the improvement be more lasting, by the use of what are called anti-syphilitic remedies. 
Cases might be added to illustrate the subject, but unless they were detailed with a 
minuteness which would occupy too much of your time, they would be of no practical 
value. The personal equation of the reporter enters so largely into the report of many 
cases, that it is difficult to estimate the value of such reports without personal knowl- 
edge of the reporter. Moreover, if anything that has been said shall lead to belief 
that suppurative inflammation of the middle ear is probably more often associated with 
inherited syphilis than has hitherto been supposed, the associated treatment will follow 
independently of recorded cases. 
Vol. Ill-54 NINTH INTERNATIONAL MEDICAL CONGRESS. 
850 
CHANGES IN THE INTERNAL EAR IN HEREDITARY SYPHILIS. 
CHANGEMENTS DANS L'OREILLE INTERNE SURVENUS À CAUSE DE LA 
SYPHILIS HÉRÉDITAIRE. 
VERÄNDERUNGEN IM INNEREN OHRE BEI HEREDITÄRER SYPHILIS. 
BY J. BARATOUX, M.D., 
Of Paris, France. 
Daring the last few years much attention has been paid to the changes developed in 
the internal ear in syphilis. 
It has thus been recognized that the walls of the vestibule, the semicircular canals, 
the lamina spiralis and the cochlea may be affected with periostitis; that the soft parts 
of the labyrinths become implicated with round cells; that the auditory nerve has 
been greatly modified in structure, and, finally, that the membranes of the internal ear 
have been injected and bathed in a sero-sanguinolent fluid which had taken the place 
of the lymph. I have myself, in a work on "Syphilis of the Ear," called atten- 
tion to the inflammation of the vascular loops of the external walls of the canal of 
Corti on a level with the spiral angle, and of those which run along the basilar mem- 
brane. I have also demonstrated on several preparations a dilatation, and even a 
rupture of the walls of the vessels. 
But among the new-born, afflicted with hereditary syphilis, the changes in the 
internal ear have been but little studied. As a fact, Hutchinson attributes the asso- 
ciated deafness in such cases to a lésion of nervous origin. Lancereaux, and St. John 
Roosa hold the same opinion. Wreden refers the lesion to a gummous degeneration of 
the auditory nerve. Hinton, however, demonstrated congestion of the vestibule. 
In a series of autopsies, partly made at the Hospice des Enfants-assistés, and partly 
in the Obstetric Department of the Hôpital Cochin and St. Louis, in Paris, I have 
found, on different occasions, that the internal ear was the seat of important primitive 
lesions, or arising secondarily from lesions of the middle ear. 
Among the numerous autopsies which I have made, I present only the report of 43 
cases. All these 43 cases were affected with hereditary syphilis, demonstrated either by 
lesions on different parts of the body, or by lesions on the parents, which lesions had 
manifested themselves in the year previous to the birth of the child. 
Of the 43 subjects, 19 were still-born, and 24 lived a period varying from several 
hours to four years. 
Of the 19 still-born, 17 were from the Obstetric Department of St. Louis and two 
from the Cochin hospital. Eight presented lesions of the tympanum, three of the 
labyrinth, and eight of both the middle ear and the internal ear. 
Of the 24 autopsies of those not still-born, 13 came from the Hospital St. Louis, 
three from Cochin, seven from the Service of Parrot and one from that of M. L. P. 
Fournier. 
In 19 cases there were lesions of the middle ear; in one, alterations of the internal 
ear alone; and in four, lesions of the middle ear and labyrinth. 
Thus, there was demonstrated 27 times, lesions of the middle ear; four times, lesions 
of the labyrinth; and 12 times, lesions of both parts. 
I confine myself here to lesions of the internal ear. 
A certain number of the changes of this part of the auditory apparatus arise from 
the tissue of the tympanum, by propagation to the labyrinth. It is thus that inflam- 
mation of the middle ear may reach the internal ear by destroying the windows, or even 
in traversing the bony wall. In cases where pus does not exist in the labyrinth, cases 
which we now leave out of the question, I have frequently demonstrated a vascular SECTION XII OTOLOGY. 
851 
injection of the soft parts of the labyrinths, with cellular infiltration of the principal 
membranes on a level with the cochlea, and of the ampullæ of the semicircular canals. 
The walls of the ampullæ, and of the cochlea have a reddish aspect. The axis of 
the cochlea is also injected and infiltrated with round cells, the parts are bathed in a 
sero-sanguinolent liquid which has taken the place of the normal liquid of the canals of 
the internal ear. Such are the lesions which I have observed in the internal ear, when 
the internal ear was affected simultaneously with the middle ear, with an absence of 
pus in the internal ear. 
But when the internal ear is affected alone, we find more important changes. It is 
thus that the vessels developed in the spiral angle, and even the vessel which follows 
the membranous lamina spiralis, exhibited on several occasions a cellular proliferation 
of their tunics, developing in this way a diminution of the caliber of the vessels, and 
later complete obliteration by fibrinous clots, developing, as I have also seen in the 
adult, an aneurismal dilation, and even more frequently a rupture of the walls and 
hemorrhage. 
There was one case of a fœtus, the specimens of which I showed to Dr. Balzer, 
then at the head of the laboratory of Professor Fournier. The labyrinth presented 
marked congestion, with hemorrhagic points on the membranous labyrinth of the turns 
of the cochlea. Such was also the case in a second fœtus of the same age. I was able 
to demonstrate to Dr. Merklen, on service at the hospital, a blood clot filling up the 
tympanic scale and the canal of Corti throughout the whole length of the first turn of 
the left cochlea. 
In a third petrous bone, taken from a full-term child, I found a hemorrhage embrac- 
ing the last turn of the canal of Corti, where it was easy to demonstrate the rupture of 
a spiral vessel. In consequence of this effusion of blood in the canal of Corti, the canal 
was rendered plainly visible. In a transverse section it was visible as a round form, 
with bulgings in the scale of the vestibule. The ordinary inflammatory changes were 
easily observed in the vessels. 
Finally, in the last autopsy of a child who lived several hours, the labyrinth showed, 
at the level of the ventricle, certain hemorrhagic points, with rupture of the spiral 
vessels at the level of the first turn of the cochlea, and of a vascular loop at the external 
spiral angle, near the insertion of the membrane of Reissner. The lungs, the only 
organ which I was able to examine in conjunction with the ear, were also the seat of 
hemorrhagic points. 
The internal ear may then be the seat of hemorrhage in hereditary syphilis. 
In fact, it is acknowledged at the present day that syphilis may develop in the 
organism of the infant a lesion of the vessels, especially the capillaries, and the small 
and large veins. The walls of these vessels become thickened, and the lumen of the 
vessel is diminished by the cellular inflammation of the tunics. This, in its turn, 
develops a local cessation of the circulation, which forces the blood into the neighboring 
parts, as has been demonstrated by the works of Epotein, Behren, Petersen, Zischl and 
others. 
My observations corroborate the views of those authors, who have demonstrated in 
the new-born syphilitic child hemorrhage in the cellular tissue, in the lungs, in the 
pleural cavity, in the heart and pericardium, in the brain and its membranes, in the 
liver, in the stomach, in the pancreas, in the thymus gland, in the testicle and cords, in 
the bone and periosteum, in the retro-peritoneal cavity and the omentum, in the tunics 
of the large vessels, and in the buccal mucous membrane; which facts prove that all 
these lesions belong to the same cause. 852 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
DISCUSSION. 
Professor G. E. Frothingham, of Ann Arbor, Michigan, thinks the papers of 
Drs. Tilley and Baratoux are valuable productions, since they deal with a subject 
hardly, if at all, discussed in the works on aural affections. To cite his own custom, 
for example, inquiry as to hereditary syphilis in ear diseases did not receive the 
attention it deserves from otologists. While acquired syphilis is duly considered, 
the pains of investigating the possible influence of hereditary syphilis in the etiology 
and progress of certain aural affections, are seldom taken. Of course, when other 
well-marked symptoms of inherited taint are present, they are generally weighed, 
and the case is treated on the general principle that any constitutional disease should 
be cured, if possible, as a means of combating any local expression. It is not his 
custom, however, to attempt any special inquiry in this direction, and he does not 
think many others do. He readily conceives that inherited taint might give no other 
manifestation than, perhaps, general debility, which might be attributed to other 
causes. Happily, the custom of giving tonics, and alteratives as well, in the treat- 
ment of aural affections, compensates somewhat for this neglect, since cod-liver oil 
and the iodides, administered for other reasons, answers the best purpose in such 
inherited disease, when conjoined with proper outdoor exercise, bathing, cutaneous 
friction and nutritious food, elements which enter into the therapeutics of most 
such cases. Dr. Baratoux is entitled to the thanks of the profession for his careful 
researches in this field, and Dr. Tilley as well, for calling attention to the subject. 
He thinks it will be wise to give heed to the facts they have presented, and to 
remember them in examinations and the treatment of ear affections. 
CEREBRO-SPINAL FEVER AS A CAUSE OF DEAFNESS. 
FIÈVRE CÉRÉBRO-SPINALE COMME UNE CAUSE DE SURDITÉ. 
MENINGITIS CEREBRO-SPINALIS ALS URSACHE DER TAUBHEIT. 
BY C. M. HOBBY, M.D., 
Of Iowa City, Iowa. 
The sources of information used in this paper are, first, personal experience in gen- 
eral practice, with a small number of cases of cerebro-spinal fever ; second, the record of 
cases, showing the after consequences of cerebro-spinal fever, seen during twelve years of 
special practice ; third, observations made at the "Iowa College for the Blind," and at 
the "Iowa Institution for the Deaf and Dumb," the first averaging about one hun- 
dred and fifty, the last about two hundred and seventy-five inmates; fourth, the aggre- 
gation of statistics of various institutions for the deaf and dumb, and the United States 
Census for 1880 ; fifth, correspondence with those having opportunity for observation, 
literature as specified, etc. 
Iowa being a comparatively young State, settled with the most vigorous immigrants 
from the older States and from Europe, having an equally distributed population of 
about 1,800,000, containing no large cities on the one hand, nor waste land on the 
other, combining the least illiteracy and the greatest diffusion of education, offers a 
good average field for investigation ; the papers preliminary to the admission of deaf 853 
SECTION XII-OTOLOGY. 
and dumb pupils presenting a greater average accuracy of detail, while local or circum- 
scribed influences productive of deafness are reduced to a minimum. I have therefore 
used the statistics drawn from Iowa as a standard with which to compare general sta- 
tistics, but in other respects have given no extra weight to the results deduced from 
Iowa. In fact, with few exceptions, the Iowa statistics give the same results as the 
general average. 
Cerebro-spinal fever occurs in all parts of the United States, occasionally in an epi- 
demic form, frequently as an endemic, and sporadic cases are of common occurrence. 
For example, the very incomplete reports of the State Board of Health of Iowa (for 
1882) give 73 cases of cerebro-spinal fever, based on 76 reports out of a possible 2000 or 
more. Yet these 73 cases were scattered among 27 out of 99 counties. That there 
were many hundred cases of cerebro-spinal fever each year would appear from the fact 
that from 20 to 60 cases of total deafness result from this disease each year. 
Any estimate, based upon the accessible vital statistics, of the total number of cases 
of cerebro-spinal fever occurring in the United States each year, must be taken with a 
great deal of allowance. I think 15,000 may be assumed as a minimum, probably far 
under the actual average. In epidemics the mortality has been estimated at fifty per 
cent., and at least fifteen per cent, of the survivors pass into the defective classes, 
total deafness being the most common sequel ; total blindness, deafness of one ear, 
blindness of one eye, insanity, dementia, epilepsy and paralysis occur in a sufficiently 
large proportion of cases to make this disease the most baneful to survivors of the whole 
list of infectious diseases. So far as deaf-mutism is concerned, it will be seen from the 
annexed statistics that it outranks all other causes, producing, at the lowest estimate, 
fifteen per cent, of the cases, and probably, with due weight given to those cases reported 
as congenital, or unknown, to thirty per cent, of the cases. 
This disease, while occurring at all ages, is especially prevalent during infancy ; 
thus, out of 975 cases occurring in New York City in 1872 (see Smith, Diseases of 
Children, fifth edition, p. 334), nearly thirteen per cent, were under one year of age, 
and forty-seven per cent, were under two years of age ; in 83 cases of total deafness 
resulting from cerebro-spinal fever, which I have personally examined, fourteen per 
cent, were under one year of age, and forty-seven per cent, were under two years of age 
at the time when attacked by the disease. The census for 1880 shows that the propor- 
tion of deaf and dumb to the entire population is 66 to 100,000, 36 being males and 30 
females ; the distribution being very nearly uniform in all parts of the United States, 
the Eastern and Northern States exceeding the average slightly, and the very new States 
falling below-this would be expected. Race exerts an appreciable influence, the colored 
race having but 50 deaf-mutes to the 100,000. So far as I can conclude, cerebro-spinal 
fever is likewise uniformly distributed, or at least its effects in the production of deaf- 
ness vary but little in the different States ; not so, however, with scarlet fever, which 
apparently causes thirty per cent, of deafness in Rhode Island, twenty-two per cent, 
in Massachusetts, only seven per cent, in Illinois, and vanishes in Arkansas. It would 
appear that scarlet fever is not only more prevalent, but also more destructive in its 
effects, in the more densely populated parts of the country, especially in or near the 
large cities. 
The value of statistics is measured by the accuracy with which they are collected ; 
and judged by this standard, the reports of the superintendents of schools for the deaf 
and dumb are not as valuable as they should be, for, from the necessities of the case, 
the alleged cause of deafness is either directly obtained from the parent, or from a 
physician who obtains from the parent the supposed cause. It rarely happens that the 
report as to cause is from a physician who has full knowledge of the history of the 
child. In 8321 cases I have found "Fright" and "Teething" credited with six cases 854 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
each, and Cholera Infantum with ten, while nearly ten per cent, of the cases (825) are 
from unknown or not designated causes. Again, the lack of a well-understood and 
rational nosology materially obscures the tables published and renders careful study of 
each one necessary to its use in the aggregate ; for example, no one would hesitate to 
place together under the head of Cerebro-spinal Fever (which name is not used in any 
report that I have seen) both "Cerebro-spinal Meningitis" and "Spotted Fever." 
Difference of opinion might easily arise in regard to such terms as ' ' Meningitis, " " Brain 
Fever," " Spinal Meningitis, " "Spinal Disease," "Water on Brain," "Fits," "Con- 
vulsions," "Paralysis." Yet "Brain Fever," "Meningitis," "Spinal Meningitis" 
and "Spinal Disease" are used in many of the reports as synonymous with Cerebro- 
spinal Fever, and "Fits," "Convulsions," and "Paralysis," in some instances, at least, 
describe symptoms or sequelae of Cerebro-spinal Fever. 
Of the reports of thirteen of the leading institutions for deaf-mutes in this country, 
I find that in seven Meningitis is not mentioned as a cause, in five Spotted Fever is not 
mentioned, in six Cerebro-spinal Meningitis, and in one Brain Fever. Cerebro-spinal 
Meningitis and Spotted Fever occur separately in three, Brain Fever and Cerebro-spinal 
Meningitis occur separately in four, Meningitis and Cerebro-spinal Meningitis are sepa- 
rated in but one, indicating that these names are largely used synonymously. Nor are 
the reports of vital statistics from the State Boards of Health entirely free from the 
same kind of confusion. 
It has been suggested, and with great plausibility, that Cerebro-spinal Fever, so 
called, is an infectious fever, accompanied by local manifestations, no one of which is 
invariably present ; and that these local manifestations are most frequently found in 
the membranes of the brain and cord, together or separately, or in choroiditis of one or 
both eyes, or inflammation of the labyrinth of one or both ears. In this paper it is 
impossible to follow up the pathological considerations which intensify the belief that 
Cerebro-spinal Fever is of much more common occurrence than is indicated by present 
literature and statistics, and that its causative agent is correspondingly a more important 
factor in the production of deafness. Recovery from non-infectious, simple meningitis, 
whether idiopathic, traumatic, in connection with other febrile disturbance, or tuber- 
cular, is sufficiently rare to furnish strong ground for the belief that some other disease 
must have existed in the majority of forty-two cases of total deafness attributed to this 
cause, in a total of 338 cases reported from Minnesota, especially as the report from 
Illinois, with 1886 deaf-mutes, fails to mention simple Meningitis as a cause. 
The value of these reports is lessened also by the personal bias of the superintendents 
in many instances. The questions sent forth to be answered prior to admission, by their 
leading character, give an undue weight to certain apparent conclusions. The attempt 
to establish the influence of consanguineous marriages, in the production of mute 
offspring, has been the most prominent factor in devising questions to show cause for 
deafness ; for example, the questions are directly asked by the majority of institutions, 
"Was the applicant born deaf?" and, "What, if any, was the relationship of the parents 
before marriage?" As a result of the first question we have reported from the leading 
institution for the deaf and dumb of America forty-six per cent, of congenital mutes, 
and an average out of 8321 cases of 33.6 per cent. With a little care in sifting reports, 
I found out of 1111 cases in Iowa only 13.3 per cent, of congenital mutes, and I believe 
that a majority of those who have investigated the subject practically, will agree that 
even this percentage is too large. An illustration of the results of one-sided examina- 
tion of statistics in this respect is shown by the report of the Illinois institution, one 
of the most thorough that I have had access to ; it shows that out of 1886 cases, 110, 
nearly six per cent., were children of consanguineous marriages, ranging between 
incestuous conuection and intermarriage of fourth cousins and grandchildren of first SECTION XII-OTOLOGY. 
855 
cousins. Two families had four deaf children each. Careful examination shows that 
only 49 out of 110 were born deaf, and the deafness of the others was attributed to 
spotted fever, measles, cholera, cold, etc., causes showing no hereditary influence. 
The fact that, for teaching purposes, it has been customary in many institutions to 
class those who have never learned to articulate at all as " born deaf," or "congenital," 
also gives an undue prominence in older reports to the congenital numeration, as does 
also the fact that when at four or five months of age the parents discover a child to be 
deaf, they are prone to believe it was born so; however, I believe, for reasons to be given 
hereafter, that nasal disease, and, consequently, middle-ear disease of babes, has but 
little to do in the production of mutism, and that the great majority of cases of infantile 
deafness proceed from intra-cranial causes. Indeed, the appended tables show that only 
twenty-eight per cent, of deaf-mutes give a history indicating that their deafness flowed 
out of middle-ear disease. Personal inquiry has shown that four cases reported from 
the Iowra school as congenital were, in fact, the result of cerebro-spinal fever. Two 
cases reported as caused by scarlet fever were also found to have had their origin in 
cerebro-spinal fever, but it so seldom happens that these cases can be satisfactorily 
traced back, that I have only attempted it in a few instances when I was personally 
acquainted with the attending physician. 
The diagnosis of cerebro-spinal fever is difficult in the early part of life, when its 
occurrence is most common, and the most characteristic symptoms are, in malarial dis- 
tricts, frequently simulated by remittent fever, so that, unless epidemic, many physi- 
cians consider cases which recover as malarial. This was, perhaps, the case in the 
thirty instances where deafness was attributed to quinine, and I am certain that cerebro- 
spinal fever was the cause of deafness in one case personally examined, which was 
attributed to quinine. 
In the appended tables of causation of deafness compiled from the reports of differ- 
ent institutions, I have condensed the list of causes as much as possible without chang- 
ing anything that could be considered doubtful. For example, I have joined together 
" Diseases in the Head," " Sores in the Head," "Punning from the Head," "Rising 
in the Head," " Discharge from the Ears," "Running from the Ears," etc., the mean- 
ing being perfectly clear. 
The tables speak for themselves, showing that from central causes specified about 
eighteen per cent, of the cases of deafness proceeded, that if there be added to these 
those cases which are attributed to "fever," without specifying the kind, and those 
cases which are classed as of unknown origin, the percentage rises to about thirty per 
cent. 
If there be included in one group those cases which are (1) of a distinctly central 
origin, (2) those from unspecified fevers and unknown causes, and (3) all but ten per 
cent, of the alleged congenital, we shall have a series aggregating fifty-three per cent., 
in which the probability is very strong that the deafness is the result of intra-cranial 
disease, or, at least, of labyrinthine disease having its origin in early, and, in many 
cases, obscure, febrile conditions. I have not yet made a sufficient number of examina- 
tions to compare these series of cases, one with another, as to the amount and quality 
of hearing, the presence or absence of lesions of the middle ear or membrana tympani, 
and the ages at which deafness occurred; so far as my examinations have gone, they 
show a very striking similarity in the result of tests for bone conduction and the 
appearance upon inspection of the external auditory canal, and strong contrast with 
the appearances observed in those cases which were attributed to scarlet fever. It will 
be noticed that the non-eruptive fevers are credited with only about four per cent, of 
the cases, that the eruptive fevers, excluding scarlet fever, were the cause of but 2.5 
per cent, of cases, while including scarlet fever brings the ratio up to 20.8 per cent. 
The results obtained by personal examination differ so widely from those obtained 856 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
by Dr. Roosa (" Diseases of the Ear," Sixth Edition, p. 638), both in respect to appear- 
ances observed and results of tests for bone conduction, that I cannot explain the 
reasons for the discrepancy. For example, in twenty-seven cases of deafness from 
cerebro-spinal meningitis, fifty-four ears, he found pathological conditions of the mem- 
brane in every one that was well seen ; in my examinations, using reflected natural 
light, I found the membrane normal and the light spot in the proper position in 86 out 
of 166 ears, or in over fifty per cent, of cases, and pathological conditions present and 
seen in 61 ears, or about thirty per cent. He found bone conduction present in 39 out 
of 54 ears, or seventy-two per cent. ; I found bone conduction present in only 40 out of 
166 ears, or twenty-four per cent. 
Both the aerial conduction and the bone conduction were tested with the tuning 
fork (C2),the tests were in each instance repeated several times, and where there 
remained any doubt as to the mute's ability to distinguish between feeling and hearing, 
the credit was given to the hearing. The tuning fork was applied to the mastoid, to 
the vertex, to the wrist and hand and to the teeth. The vibration of the tuning fork 
applied to the hand produces pleasurable sensations to most mutes, but the sensation is 
not that of hearing. 
The result of the examinations would indicate that while a majority of those deaf 
from cerebro-spinal fever have had no severe form of middle-ear disease, yet that sup- 
purative inflammations of the middle ear frequently are suggested with the graver con- 
ditions that produce a total failure of appreciation of sound. Careful examination 
fails to show any relationship between the ability to appreciate sound in either of the 
ways and the presence or absence of pathology of the middle ear. 
So far as pathological considerations are concerned, I have made no observations 
upon the morbid anatomy of deaf-mutes, and can consider pathological questions only 
from clinical points of view. 
Clinical consideration of the cases observed suggests at once that the lesions pro- 
ducing deafness must involve the perceptive apparatus in the great majority of cases; 
sudden, complete, and symmetrical deafness cannot be attributed to middle-ear disease. 
I have, however, seen two cases in which severe deafness, apparently from middle-ear 
causes, followed Cerebro-spinal Fever, in both of whom the hearing became materially 
improved subsequently. 
In a disease characterized in some epidemics by tegumentary eruptions, not infre- 
quently accompanied by pharyngitis, middle-ear disease is likely to occur in a consid- 
erable proportion of cases. Is it not probable, then, that in those mutes (from cerebro- 
spinal fever) who show evidence of lesions of the membrane, or middle ear, the 
disease affecting the middle ear was coincident with, but not developed from, the dis- 
ease causing deafness? The rapidity with which deafness is produced, the comparative 
immunity of the facial nerve from simultaneous lesion, the analogy presented by lesions 
of the eye in cerebro-spinal fever, point to the labyrinth as the seat of the pathologi- 
cal processes destroying the hearing. I have notes of sixteen cases in which blindness 
resulted from Cerebro-spinal Fever, affecting twenty-eight eyes. In eight cases both 
eyes were lost from suppurative choroiditis, in six cases one eye of each was destroyed 
in the same manner, and in two patients both eyes were blind, showing white atrophy 
of the disk ; in both of these cases the blindness developed some time ( ' ' nearly a year ' ' ) 
after the sickness; in one of these, a female of eighteen, the circumference of the head 
was twenty-four and one-half inches. In two of the above cases of blindness of one 
eye, there was coincident deafness of both ears. I have seen, but failed to preserve 
notes, one case in which blindness of both eyes and deafness of both ears resulted from 
Cerebro-spinal Fever. 
From the foregoing considerations, and from the comparison of the annexed tables SECTION XII-OTOLOGY. 
857 
with each other, and their interpretation in the light of general observation and experi- 
ence, I think the following conclusions are warranted :- 
1. Cerebro-spinal fever is prevalent throughout the United States, and is a constant 
factor in the production of deafness. 
2. That, upon the surface, it appears equal in importance, as a cause for total deaf- 
ness, with scarlet fever. 
3. That when proper weight is given to the reports of causes of deaf-mutism, cerebro- 
spinal fever is the disease, above all others, producing total deafness, which the non- 
professional mind would class as " Fever," " Congenital," or " Unknown." 
4. That from reasons, some of which are specified above, and others of which are 
apparent to any physician who has studied the defective classes, it is probable that not 
more than ten per cent, of the cases of deaf-mutism are actually congenital. 
5. That with this assumption there appears upon the face of the reports thirty-five 
per cent, of cases of total deafness, for which no rational explanation is offered. 
6. That the greater part of this thirty-five per cent, result from intra-cranial causes, 
including under intra-cranial disease affections of the labyrinth. 
7. That it is important that more thorough investigation of cerebro-spinal fever be 
made, and especially of its relation to deaf-mutism, with the hope, in the light of more 
perfect knowledge of its cause and methods of dissemination, the production of deaf- 
ness from this cause may be diminished, as much as the sources of blindness were cut 
off by vaccination. 
The deaths from Cerebro-spinal Fever in 1880, 1881 and 1882, as shown by the reports of the 
State Board of Health of Michigan, are compared below with the deaths from allied diseases. 
A few of the cases reported as Meningitis should probably be excluded from the Cerebro-spinal 
total, but, on the other hand, many cases of Cerebro-spinal Fever are undoubtedly included 
under the titles "Convulsions," "Brain Disease," and "Dropsy of the Brain." 
Deaths from 
1880. 
1881. 
1882. 
Convulsions 
347 
377 
356 
Brain Diseases 
295 
370 
324 
Dropsy of the Brain 
34 
54 
35 
Cerebro-spinal Fever- 
Spinal Fever 
71 
136 
97 
Spotted Fever 
1 
9 
2 
Meningitis 
22 
21 
16 
Cerebro-spinal Meningitis 
5 
41 
84 
Spinal Meningitis 
58 
123 
84 
Total 
157 
330 
223 
Mean 
270 
This would indicate 16.5 deaths to 100,000 inhabitants, and extended to the whole United 
States would indicate a mortality from this cause of 8266 per annum. With the estimated mor- 
tality of epidemics, this would represent over 16,000 cases, but as it is well known that the 
fatality among sporadic cases is much less, and that many cases escape recognition, the total 
number of cases occurring must be much greater. 
CAUSES OF DEAF-MUTISM. 
Table I.-Report of Iowa Institution for 
Deaf and Dumb, 1885. 306 Cases. 
Per cent. 
Congenital 
53 
17.3 
Spinal Meningitis................. 
22 
Spinal Fever 
35 
Brain Fever 
19 
Cerebrospinal Meningitis 
26 
Spotted Fever 
13 
Cerebro-spinal Fever 
115 
37.5 
Scarlet Fever 
23 
7.5 
Cause unknown or not designated... 
52 
17. 
Remainder various causes 
63 
20.6 858 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Table II.-Aggregated Reports of 13 Institutions for the Deaf and 
Dumb (excluding Iowa). 8321 Cases. 
Per cent. 
Congenital 
2796 
33.6 
Meningitis 
173 
Spotted Fever.................... 
225 
C. S. Meningitis.................. 
504 
Brain Fever...................... 
464 
Cerebro-spinal Fever 
1366 
16.4 
Scarlet Fever 
1542 
18.5 
Causes unknown or not designated.. 
1008 
12.1 
Remainder various causes 
1609 
19.3 
Table III (Table II Extended).-8321 Cases from Reports of 13 Insti- 
tutions for the Deaf and Dumb. 
Congenital 2796 
Scarlet Fever 1542 
Meningitis 173 
Spotted Fever 225 
C. S. Meningitis 504 
Brain Fever 464 
Convulsions 57 
Hydrocephalus 44 
Paralysis 19 
Fever 210 
Unknown or not designated 798 
Typhoid Fever 166 
Typhus Fever 3 
Inflammatory Fever 18 
Catarrhal Fever 4 
Lung Fever 64 
Rheumatic Fever 10 
Nervous Fever 7 
Whooping Cough 67 
Intermittent Fever 13 
Mumps 20 
Diphtheria 34 
Discharge from Ears 343 
Scrofula 50 
Measles 201 
Smallpox 7 
Chicken Pox 8 
Burns 4 
Colds 110 
Croup 11 
Scattering 349 
Table IV.-Result of Examination of 83 Deaf-mutes, Deafness Attributed 
to Cerebro-spinal Fever. 
a. Age at which disease occurred. 
Under 1 year 12 14 per cent. 
Over 1 and under 2 years 27 33 " 
Between 2 and 5 years 31 37 " 
Over 5 years 13 16 " 
b. Hearing power. 
49 Failed to hear tuning fork. 
1 Heard T. F. through the air, but not through bone, with both ears. 
2 Heard T. F. through bone, but not through air, with both ears. 
3 Heard T. F. with both ears, both through air and bone. 
5 Heard through air with one ear, and not through bone. 
10 Heard through bone with one ear, and not through air. 
10 Heard through air and bone with one ear. 
3 Doubtful. 
c. Condition as shown by inspection. 
40 Cases, 80 ears-Membranes and Canals normal. 
6 Cases, 6 ears-Membranes and Canals normal on one side. 
16 Cases, 29 ears-Doubtful ; Canal obstructed by dirt or cerumen. 
24 Cases, 48 ears-Pathological both sides. 
3 Cases, 3 ears-Pathological on one side. 
Dr. L. Turnbull, Philadelphia, Pennsylvania, inquired if Dr. Hobby had em- 
ployed the hearing trumpet in testing his cases of deaf-mutism. Are there not 
epidemics of meningitis in the western countries ? Has not syphilis an important 
agency in the production of deaf-mutism in young children ? 
DISCUSSION. SECTION XII-OTOLOGY. 
859 
Professor G. E. Frothingham said his examination of the cases of deafness pro- 
duced by cerebro-spinal fever agreed with that of Dr. Hobby as stated in his paper. 
He had found, in a large majority of cases, a normal appearance of the drum- 
membrane. He had met with mixed cases, of which the history pointed to cerebro- 
spinal meningitis so positively that there could be no doubt that the patient had 
suffered from it ; there had also been inflammation of the middle ear, and, in such 
cases, the pharynx and nasal cavities had shown an inflammatory condition ; while 
these had been much benefited by treatment, those presenting normal drum membranes 
with pervious Eustachian tubes, he had found to be hopeless. He had heard of 
improvement in one instance only; the family of a child informed him that it had 
partially recovered its hearing. He had once seen an infant with double optic 
atrophy from cerebro-spinal meningitis. For three or four months its condition was 
such that its attention could not be attracted by light, while the optic papillæ were 
glistening white. It afterward recovered sufficient vision to reach for large objects, 
and seemed to delight in viewing them. These cases could be explained by suppos- 
ing that the destructive change had not involved all the nerve cells and fibres in the 
rapidly growing child, but had left a small number capable of future growth. 
Professor E. De Rossi inquired whether Dr. Hobby had made post-mortem ex- 
aminations in any of the cases. 
Dr. Hobby had not; his study of the cases had been purely clinical. Those who 
have been so fortunate as to have opportunity to examine those mute from this cause 
have found lesion of the labyrinth. 
RESEARCHES ON THE MICROORGANISMS IN THE EUSTACHIAN 
TUBE OF HEALTHY INDIVIDUALS. 
RECHERCHES SUR LES MICRO-ORGANISMES DANS LE TUBE D'EUSTACHE CHEZ 
LES SUJETS SAINS. 
UNTERSUCHUNGEN ÜBER DIE MIKROORGANISMEN IN DER TUBA EUSTACHII GESUNDER 
INDIVIDUEN. 
BY PROFESSOR DE ROSSI, 
Rome, Italy. 
When it was established that there existed in the saliva and in the follicles of the 
tonsils of healthy men, indisputable evidence of the presence of pathogenic microorgan- 
isms, and especially of the presence of the coccus pyogeneus aureus, it seemed to me 
desirable to undertake certain experiments to ascertain whether, or not, there existed 
microorganisms in the Eustachian tube, and if so, to ascertain their peculiarities. I 
fully realized the difficulties of obtaining positive and indisputable results. I assure 
you, however, that I have taken all the necessary precautions ; that I have observed all 
the indispensable minutiæ which present scientific observations exact. 
The method of procedure has been as follows : A fine platinum wire was fastened 
into a silver catheter. This wire was of such a length that it could be projected from 
the tubal end of the Eustachian catheter to the distance of one centimetre. The ter- 
minal end of the platinum wire was bent so as to form a loop in order to retain a suffi- 
cient quantity of the mucus collected from the inside of the Eustachian tube. 860 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Before sterilizing the instrument with the usual care, the wire was withdrawn into 
the interior of the sound, then the tubal extremity was sealed with a thin coating of 
celloidine, and every catheter so prepared was placed into the sterilizing tube. 
In introducing the catheter, it was passed as far as possible into the mouth of the 
Eustachian tube, and by pressing on the proximal end of the platinum wire, the thin 
coating of celloidine was broken and the looped end of the platinum wire projected to 
the distance previously determined. It was then withdrawn to the inside of the 
catheter. The loop of the platinum was immediately employed for the culture plates 
of gelatine, and later the colonies which were developed were cultivated in tubes. 
The experiments were begun on the 12th of April, with the assistance of Professor 
Guarneri, of the Institution of Pathological Anatomy in Rome. In that institution, 
through the kindness of Professor Marchiasafa, all the necessary appliances were at our 
service. 
The mucus was taken from the Eustachian tubes of twelve persons, at different 
times between the 12th and 30th of April. From each loop of wire two attenuations 
were used for plate culture. Positive results were obtained from only six of the cases 
-six out of twelve. 
Case 2 gave two successful cultivations. The planting took place on the 22d of 
April, and by the 1st of May the colonies were developed. In the plantings from cases 
1, 7, 8, 9 and 10, the colonies were developed on the 3d of May. The plates belonging 
to the other cases remained free from organisms. 
The examination of the colonies developed presented the following features :- 
Plate 2 in the first attenuation, the colonies were of a yellow color and the surround- 
ing gelatine was fluid. Examined under the microscope it revealed the streptococcus. 
Further from both the first and second cultivations a colony which was of a white color 
was developed, which revealed under the microscope the grape form (staphylococcus). 
Plate 1 exhibited two colonies, one gray, the gelatine remaining solid ; the other 
white, the gelatine liquefying. Under the microscope the white colony revealed tor- 
ules, and the gray colony, with the gelatine unchanged, gave the streptococcus. 
Plate 7 presented a round colony of a yellow color, the gelatine fluid. The micro- 
scope demonstrated the presence of short rods (bacilli) of a length varying from 0 mm. 
to 1 mm. and 0.5 mm. thick. 
Plate 8 gave two colonies, one round and of a yellow color, the other yellow, but 
irregular in form. In neither of these cases did the gelatine become fluid. The micro- 
scope revealed a staphylococcus from 1 to 1.5 mm. long. 
Plate 9 revealed a colony irregular in form and liquid gelatine. It was composed of 
filaments of different lengths ; some from ten to twelve mm., and others 1 mm. long. 
The thickness varying from 0.5 to 0.7 mm. 
Plate 10 revealed a colony of a yellow color and the surrounding gelatine fluid. It 
was composed of rods (bacilli) from one to three mm. long and from 0.6 to 0.8 mm. 
thick. 
From all these colonies pure cultures were made in gelatine tubes and their identity 
established after the culture. Cultures were also made on potatoes ; and finally from 
both the cultures in gelatine and the potato, transplantations were made to animal 
tissues. 
It would be useless here to detail the individual cases. Experiments were made in 
the peritoneum and subcutaneous tissue in the rabbit and guinea pig, but in no case 
was any pathological development manifest. We are not to infer from this that in the 
mucus of the Eustachian tube there never exists pathogenic organisms. It is necessary 
to investigate, and I present to the Congress these notes as an interesting study worthy 
of being pursued. SECTION XII-OTOLOGY. 
861 
DISCUSSION. 
Professor G. E. Frothingham said he had listened to Professor De Rossi's very 
interesting paper, presenting the result of his original researches in a field that had 
not been before investigated in this manner. The result of the investigations is such 
as confirms views he had for some time held from simple empirical observation. He 
had already expressed these views, and his reasons for them, and would not now 
repeat. When he had declared these views, he had no knowledge of any investiga- 
tion in this direction. It is peculiarly gratifying when scientific discovery harmonizes 
with facts learned empirically, as did Koch's discovery, that cholera bacilli cannot 
live in acid solutions, harmonize with the fact observed years ago, in the Pennsyl- 
vania Almshouse, that the use of sulphuric acid lemonade would sometimes prevent 
the spread of epidemic cholera. We cannot say the result is negative, because 
Prof. De Rossi discovered no pathogenic organism. He thinks the presence of these 
organisms in great numbers, whether pathogenic or not, serves to irritate the mem- 
brane, and, under certain conditions of atmospheric change, and of the constitution 
of the patient, will lead to inflammatory action, acute or chronic. We should not 
forget this effect, since in respiration of contaminated air such vast numbers of germs 
may be lodged upon the naso-pharyngeal spaces, and thus reach the ear. 
If it be urged that these are not pathogenic, who can say under what circum- 
stances they may not become so ? The virus of syphilis or gonorrhoea is not patho- 
genic for some individuals ; experimenters have bathed their eyes for hours with the 
secretion of Egyptian ophthalmia, and after exposure to wind and dust, for some 
hours afterward, had suffered no attack. He thinks no one now knows nearly all the 
conditions that determine the question, as to whether certain of these germs are 
always harmless. Investigation must be made to decide this. 
As the etiology of certain chronic diseases of the middle ear is so obscure, and 
the treatment of them so unsatisfactory that it constitutes a reproach to otology, it 
becomes us to hail with welcome every carefully conducted scientific investigation in 
this direction. Prof. De Rossi is a pioneer ; he has done good work and he is entitled 
to our thanks. 
Dr. R. Tilley, Chicago, Illinois, thinks it interesting to observe how different 
listeners get consolation and encouragement. While the previous speaker derived 
encouragement from the paper read in support of his views of the pathological 
influence of these organisms, I, on the other hand, derive encouragement from the 
paper in support of the idea that the influence of certain organisms is, at present, 
greatly over-estimated. I am glad the observations have been made and reported 
to us, notwithstanding their negative results, even after the germs were introduced 
into the peritoneal cavity and into the subcutaneous tissue. 
Dr. A. B. Thrasher, Cincinnati, Ohio.-I am much pleased to learn of the ad- 
mirable researches of Professor De Rossi in this direction. That he has found bacteria 
in this region only accentuates what we have heretofore pretty well known, viz. : that 
all mucous membranes in contact with the external air contain bacteria. But these 
microorganisms are by no means all pathogenetic. It appears to me that we are 
especially indebted to Prof. De Rossi for his endeavors to discover which are the 
pathogenetic germs in this region. When the pathogenetic bacteria or bacilli have 
been certainly recognized, then can we say that we have made some satisfactory 
advance in this direction. 
Dr. H. Gradle, Chicago, Illinois, remarked that the admirable researches of Pro- 
fessor De Rossi showed us an analogy between the Eustachian tube and other mucous NINTH INTERNATIONAL MEDICAL CONGRESS. 
862 
passages, like the Fallopian tubes, in which Fraenkel had found several pathogenic 
microorganisms; or the mouth, in which numerous harmless and virulent bacteria 
are known to exist. In otology it is necessary to distinguish accurately between 
exciting and predisposing conditions. The only exciting causes of suppuration are 
some microorganisms and, occasionally, chemical irritants. 
If ' ' taking cold, ' ' that is to say, temporary foreign circulatory disturbances, be 
accounted a cause of sudden inflammation of the middle ear, it is really an influence 
only, which permits the bacteria, already present in the tube, but yet outside of the 
tissues, to multiply and enter the tissues and produce disease. Similarly, the presence 
of these bacteria in the tube explains why a nasal douche can, at times, produce acute 
inflammation of the middle ear, by conveying infectious material into the ear. 
Water alone could not give rise to such consequences. 
Dr. Leartus Conner, Detroit, Michigan, stated that he is pleased to know a 
new method for the study of aural diseases. In normal conditions we find that the 
bacteria cause no harm ; it becomes important to study bacteria under such additional 
conditions as result in actual disease, and then we shall have light of added value. 
Professor De Rossi, in closing, said, "while the experiments I have narrated gave 
negative results, yet it is quite possible that under the depressing influence of cold 
draughts or other causes these organisms may contribute the determining influence 
which may result in some of those outbursts of inflammatory trouble, which some- 
times come on so unexpectedly. ' ' 
IS GENERAL ATROPHY OF THE CONDUCTING APPARATUS OF 
THE EAR IDENTICAL WITH PROGRESSIVE ARTHRITIS 
DEFORMANS ? 
L'ATROPHIE GÉNÉRALE DE L'APPAREIL CONDUCTEUR DE L'OREILLE EST-ELLE 
IDENTIQUE AVEC L'ARTHRITE DIFFORMANTE PROGRESSIVE? 
IST ALLEGEMEINE ATROPHIE DES LEITENDEN APPARATES DES OHRES IDENTISCH MIT 
FORTSCHREITENDER ARTHRITIS DEFORMANS? 
BY S. O. RICHEY, M.D., 
Of Washington, D. C. 
The name general atrophy of the conducting apparatus may not be better than the 
numerous other names by which this affection is designated, but it has the merit of 
describing the result of the process as we see it, instead of indicating it by some 
particularity of its course. Some attempt will be made, herein, to show its probable 
neurotic origin in the spinal system, by its similarity to a more general affection which 
has been supposed to find its source there. 
Atrophic degeneration of the conducting apparatus of the ear may not be, to any 
great extent, inflammatory in any part of its course, is not ' ' preeminently local in its 
character," is influenced by constitutional dyscrasia, probably begins at the cervico- 
spinal nervous centres, and is propagated through the sympathetic nervous system or 
the sensory spinal nerves, interfering with local trophic action. 
Many pathological changes have been observed in the cavity of the middle ear at SECTION XII-OTOLOGY. 
863 
its examination after death, but we are not assured thereby that any given structural 
variation has been a result of this affection alone, as we are denied the opportunity of 
observing it during the progress of the disease. For many reasons, we must think it 
has a broader pathogenesis than that usually accredited to it, in the exposition of 
which one may be aided by the processes of analogy and induction. 
Garrod says, of progressive arthritis deformans ("Reynolds System of Medicine," 
vol. I, page 555), "it is much easier to prove what rheumatoid arthritis is not, than 
to give the slightest clue to what it is . . . . ; it appears to result from a peculiar 
form of malnutrition of the joint textures, an inflammatory action with defective power 
. . . . ; it usually occurs in weakened subjects, and exposure to cold in many 
cases is the exciting cause of its development." Weber {Journal of Mental and Nervous\ 
Diseases, vol. vm, 1883, page 630) considers it of neurotic origin. In its entire history,1 
except in the functional peculiarities of the locality attacked, it is almost a complete 
analogue of atrophy of the middle ear, in causation, symptoms, progress, and thera- 
peutics. It would be an advantage to study the process, as we cannot, in the ear. 
Herewith is a parallel of the two affections- 
Progressive Arthritis Deformans. 
1. It is seldom fatal. 
2. At an early stage, swelling and the 
appearances of ordinary inflammation are 
prominent. 
3. When the effusion into the joint is 
absorbed, the capsule is commonly found 
thickened, the cartilages are sometimes ab- 
sorbed, and the ligaments so much lengthened 
as to allow unusual mobility and dislocation. 
4. At the commencement of the process, 
slow absorption of the cartilages takes place, 
often followed by fatty degeneration, and the 
formation of ligamentous bands. 
5. Heredity does not seem to influence the 
affection, for one member of a family may be 
affected, and the rest be free. 
6. Is frequent among women, and rare 
among men. 
7. It occurs at any age, and individuals of 
weak frames whose extremities are cold are 
most liable to the disease. 
8. Everything debilitating, as uterine 
hemorrhages, prolonged grief, persistent men- 
tal distress, loss of rest and dissipation, damp 
dwellings, poor food, and all rheumatic influ- 
ences, are supposed active causes. 
9. By test, no uric acid, or urate of soda, 
thus removing rheumatism and gout from con- 
sideration as causes : reduction of phosphoric 
acid in the urine. 
10. The disease is slowly but steadily pro- 
gressive. It may be stationary for a time, 
but exacerbations are sure to follow (Weber). 
There is slight remission, but no intermission, 
during the rest of the patient's life (Haygarth). 
Atrophy of the Conducting Apparatus. 
1. We do not know it ever to be fatal. 
2. At an early stage this may be the cause 
of symptoms of inflammation. 
3. When this happens it would be liable to 
cause tinnitus, or impaired hearing, or both : 
a flapping m. t., and disarticulation of the 
ossicula. 
4. The result of this change has been seen 
in anchylosis of the ossicles, especially of the 
stapes; retraction of the m. t., and bands of 
adhesion in the cavity. 
5. Complete correspondence. 
6. Is more frequent among women than 
among men. 
7. The symptoms are manifest at middle 
age, or just before, and at any later period. 
It may begin in the earache of children. Cold 
extremities are common. 
8. Idem. 
9. No tests, so far as I know. 
10 There are long intermissions in progress, 
judged by the impairment of function. 864 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Progressive Arthritis Deformans. 
Atrophy of the Conducting Apparatus. 
11. It usually begins as a subacute disease. 
12. It is very intractable. When the 
disease is not advanced, the affected joints few 
in number and progress slow, the prospect is 
more hopeful, especially if there is no disease 
to keep up the impairment of the general 
health. 
13. There is generally aching of the affected 
joints, prophetic of an increase of pressure in 
the atmosphere. 
14. Frequent mental depression without a 
known sufficient cause. 
15. It does not lead to suppuration, but 
to atrophy and more or less deformity. 
16. The treatment must be sustaining. 
Local treatment by blisters, iodine paint, and 
croton oil in the beginning. Later use counter- 
irritation ; later still, friction and slight 
motion. Living in a moderate winter climate, 
nutritious food, warm clothing, etc. 
11. An open question. 
12. Idem. 
13. Any existing impairment of hearing, 
or tinnitus, is increased under the same circum- 
stances. 
14. Idem. 
15. Idem. 
16. This general line of treatment is the 
best with which we are acquainted. 
Arthritis deformans begins in the smaller joints of the body, is symmetrical in 
appearance and progress, with lesions of the tissues surrounding the joints, atrophy of 
the muscular tissue, and, in old cases, a state of fatty and connective tissue degenera- 
tion (Weber). The Lilliputian joints of the ossicula auditûs are peculiarly exposed 
to atmospheric changes by their location, and are in one of the extremities of the body, 
for which reasons they would seem to be more liable to an attack of this affection than 
even the joints of the hand or foot. Rheumatoid arthritis, beginning in the small 
joints of the extremities, advances to the larger joints of the body, in which fact we 
may find an explanation of the pressure and pain about the head, and the diminution 
of intellectual apprehension, so common in cases of profound deafness in advanced 
aural atrophy. It may furnish a better demonstration of the deafness of boiler makers, 
ship caulkers, and locomotive engineers. Taking its symmetrical onset and advance as 
a point in evidence of its neurotic origin, it may also explain the change in voice so 
commonly met with among the profoundly deaf, who have become so by slow and 
progressive stages, for the recurrent laryngeal nerve makes the connection between the 
cerebro-spinal nerve centres and the vocal cords very intimate. The recurrent laryngeal 
is supposed to get its motive power from the pneumogastric, and irritation of the pneu- 
mogastric in the upper part of the neck has been proven by experiment to cause heat 
and tingling of the ear. Jewell {Journal of Mental and Nervous Diseases, 1874, 426) 
" looks upon articular rheumatism, as well as certain painful affections of the joints 
simulating rheumatism, as produced .... by disease of the nerve trunks or nerve 
centres, leading to decided local irritation at the peripheral termination of certain 
nerves," and Brown-Séquard has shown that nerve fibres going to the blood vessels of 
the various parts of the head come out chiefly from the spinal cord by the roots of the 
last cervical and first dorsal nerves. Leloir and Degerine * observe that, in a case of 
chronic rheumatism with considerable muscular atrophy and rapid eschars, they found 
the cutaneous nerves adjacent to the eschars affected with atrophic parenchymatous 
neuritis, which seemed to have existed previous to the eschars. Acute atrophy of the 
muscles has occurred without lesion of the cord. Those suffering with arthritis 
* Le Progrès Médicale, April 2d, 1881. SECTION XII-OTOLOGY. 
865 
deformans appear to be emaciated and neurasthenic, as a rule, complaining of pains 
over a great part of the body, associated with periodical failure of control or power in 
the muscles or tendons. The pain in the joints, weakness in the muscles and tendons, 
and some emaciation often precede the manifest changes in the size and formation of 
the joints. 
Women, according to Rosenthal, are more subject to prosopalgia in early life than 
men; neuralgia is most frequent between the thirtieth and fiftieth years of life; is some- 
times accompanied by inability to fix the mind on any subject or attend to business, and 
this effect is not due to pain. Arthritis deformans is often introduced by hemicrania, 
and lean persons have a more decided predisposition than the stout, as in neuralgia of 
the trigeminus. The temporo-maxillary and the upper cervical vertebræ are joints par- 
ticularly likely to be affected. No one questions the character of neuralgia, and arth- 
ritis appears to have a similar neuropathic origin and similar favoring causes. 
Weber-Liel * has seen thirteen persons affected by progressive deafness presenting 
the symptom of spontaneous pain over the tracks of the cervical and brachial 
plexus, associated with pain in the ears and disagreeable tinnitus, varying from 
that habitual to the case. Otalgia is often met with in the later stages of atrophy, 
generally uncomplicated with neuralgia elsewhere, but among individuals of the 
neurasthenic type. 
Arthritis deformans, nervous exhaustion and aural atrophy (progressive deafness) 
very greatly resemble each other. Each follows causes exhaustive in character; does not 
terminate fatally; most of the symptoms are subjective and functional, and often unac- 
companied with apparent structural variation. In each there is periodical hopelessness 
and discouragement. In nervous exhaustion and the ear affection there is diminished 
ability to fix thought on any subject (lack of mental control) and change in the voice; 
and Garrod claims that the irregular form of arthritis sometimes attacks the internal 
(middle ?) ear and the larynx, and causes hoarseness and a peculiar dry cough. 
Mr. R. W. Parkerf reports a case of rheumatoid arthritis; the girl, aged fifteen 
years, whose father died of phthisis and whose mother died of chalky rheumatism, 
had, in six months, become almost quite deaf. She had double keratitis and enlarged 
joints. No examination of the physical condition of the ears appears to have been 
made, unfortunately; only the reference above given to the disturbed function. C. H. 
Burnett f mentions a woman, aged twenty-six years, well nourished, who, six years 
before, had an attack of probable rheumatic facial paralysis. Two or three years later 
she noticed singing in her ears and impaired hearing. Lustre of the mtt. good; ett. 
pervious; when excited or fatigued there was a flush of the cheeks and neck and 
increased tinnitus. 
In the deafness of boiler makers, undisturbed control of equilibrium and the 
absence of vertigo argue against a theory of labyrinthine trouble. Buck {New York 
Medical Record, July 5th, 1875) thinks the peculiarities of these cases due to rigidity 
of the ligament at the base of the stapes, or to some change in the membrana secoudaria, 
which, to my mind, is the most natural explanation. The fact that individuals who 
have had acute or subacute catarrhal inflammation of the middle ear present the feature 
of hearing better in a din of some kind, does not invalidate Buck's theory, as, in even 
acute suppuration, the membrana secondaria may undergo changes calculated to pro- 
duce this effect; persistent thickening, calcareous deposits, adhesive secretions, etc., 
for which reasons some of these cases can be comparatively promptly improved. 
" Pathological alterations take place in the stapedio-vestibular articulation in the 
* Monats, für Ohrenheilk., Aug., 1874. 
f Transactions International Congress, 1881, Vol. i, p. 128. 
J " A Treatise on the Ear." 1st Ed., p. 391. 
Vol. Ill-55 NINTH INTERNATIONAL MEDICAL CONGRESS. 
866 
course of chronic inflammation of the middle ear, sometimes also with a perfectly normal 
state of the lining membrane. "* 
Among boiler makers the continuous action of the ossicula auditus renders them 
more liable to arthritis; and the exposure to draughts, lack of exercise of most of the 
other joints of the body, and irregularity in taking food, which is often less assimilable 
than it should be, furnish other sufficient factors in the causation of this affection. 
These same influences obtain among ship caulkers and locomotive engineers. That the 
disease may be manifest in no other joint is no sufficient reason against its attacking 
the ossicula when they are most used. It may extend to the sutures of the cranial 
bones and cause disturbance in their relation to each other, followed by a feeling of 
pressure or " weight on the head," or " as if there was an iron band around the head," 
or " as if there was an iron axle"between the ears," resulting from even slight distor- 
tion. It may thus so derange the cranial contents as to interfere with normal mental 
alacrity and the memory, of which some people with "progressive deafness" are so 
acutely conscious in the later stages. It may alter the size and shape of the cranial 
foramina to such an extent as to cause pressure upon the nerve thus finding an exit, and 
result in neuralgia in the region supplied by the nerve; this being one of the ways in 
which persistent neuralgia is supposed to be produced. 
Arthritis deformans may occur at almost any age; at first, in the most exercised 
small joints, and, if neglected, it will progressively attack every joint in the body. It 
would rarely be recognized in the ear before the age of thirty, when the true function 
of the ear begins to be impaired in the late stage of atrophy, though it might have 
existed from the age of four or five years, at which time it would have been in its 
inflammatory stage. This period of the affection would be marked by sudden onsets 
of pain of spasmodic or neuralgic character, causing at short intervals sharp, quick 
cries, followed by a period of ease and quiet. Though during the day there is entire 
comfort, the attacks are disposed to recur at night, the child sometimes waking from a 
sound sleep with a cry of distress, and falling to sleep again in a short time. These 
attacks of " earache " are supposed to be harmless because they do not result in sup- 
puration, immediate deafness, or any other material change in function or structure, 
for they pass off after several hours of intermitting pain, leaving some tenderness to 
touch, to recur again the next night, to follow much the same course. The mt. may be 
hyperæmic, but is not thickened; the et. is as patulous as usual, and there is no per- 
ceptible increase of secretion ; it may recur every evening of several days with entire 
subsidence of pain for the greater part of the twenty-four hours. 
These attacks differ in several particulars from the catarrhal affection resembling it, 
which causes almost continuous pain, thickening of the lining membrane, diminution 
or closure of the et., and increase of secretion with bulging of the mt. on this account. 
Sometimes suppuration occurs if the case is not promptly aûd properly handled ; 
nearly always there is more or less impairment of hearing from congestive thickening 
of the tissues or the presence of fluid in the cavity. After one catarrhal attack there 
may never be another. The same cause seems immediately productive of each, because 
each is more liable to happen at the change of the seasons, the child being more exposed 
to the cold and the damp air at these times. 
Thus, even in childhood a differential diagnosis might be made from the catarrhal 
affections, and we may reason that the disease at the foundation of the atrophic process 
may begin at any age, although the atrophy is a malum senilis. 
Von Triiltsch thought the disease without catarrhal symptoms should be given a 
different classification, but it is yet generally classed as a catarrh by authorities, though 
Pomeroy (" Diseases of the Ear," page 148), in a cursory way, says, " I believe that the 
* Politzer, " Diseases of the Ear." Am. Ed., p. 86. SECTION XII-OTOLOGY. 
867 
rheumatic diathesis, in many instances, has much to do with the obstinate character of 
this affection; the rheumatic inflammation, according to its well-known predilection 
for fibroustissues, finding a lodgment in the muco-periosteal lining of the drum." 
Whether or not atrophy of the middle ear is of the same origin as arthritis defor- 
mans it has a more extensive pathology than that allowed to it. 
TREATMENT. 
Arthritis is introduced by a chill (Bruce), followed often by hemicrania, indicating 
depression of the nervous and circulatory systems. This action may be induced by 
cold, emotional disturbance, or physical shock : it concentrates at the cerebro-spinal ner- 
vous centres, and radiates therefrom, to express itself in the organ of least resistance in 
an individual, in the form of pain and trophic changes. The views of the writer in 
regard to local treatment in aural atrophy may be found in the American Journal of 
Medical Sciences, April, 1887, pp. 413-423. Iodine vapor is our sheet-anchor for topical 
application, but our efforts may be materially aided by constitutional and hygienic 
influences, under which head come climate, clothing, food, and other items of general 
treatment. 
Climate should have special consideration in the choice of a winter residence. This 
should be moderate in temperature, and as dry as possible. The sudden changes of 
temperature in the higher latitudes are more deleterious, because they take place 
through a lower thermometric range, and passing from the inside to the outside of the 
house may produce violent circulatory disturbances during cold weather unless the 
cold is moderate. A climate distinguished by a decided difference in temperature 
between day and night is undesirable, unless this variation is guarded against by fire 
and clothing, which means thought and care on the part of the individual not likely to 
be taken. 
Clothing is very important, as it should be of such character as to afford protection 
against the depression of climatic variation, that next the body needing most thought, 
though generally it has least. 
Three areas of the body are especially sensitive to changes of temperature, and seem, 
to a great degree, to influence the comfort of the whole body. Such spaces are the 
cervical region of the spine, the posterior aspect of the arm just above the elbow, and the 
nates. 
The ordinary dress of men protects them very well, and the buttocks are most 
exposed ; from this region the body may be chilled or warmed. The exposure of this 
part of a chilled body to the grateful influence of radiated heat diffuses more general 
composure than warming the extremities, and every man will receive this suggestion 
feelingly. The effect is probably due to the superficial location here of the sciatic nerve, 
and to its short cutaneous branches. 
Among women the cervical region of the spine and the arms are least covered, espe- 
cially when in ' 'evening dress. ' ' When entering a cold bath the body may be more quickly 
adjusted to the lower temperature by dipping the elbows and the nates, than by wetting 
the head and neck, according to the usual custom ; and in this we may find some proof 
of the statement. Women, and especially neurasthenics, often complain at the men- 
strual period of cold on the posterior face of the arm just above the elbow. When one 
has his arms bared he may be seen to hold his elbows with his hands unconsciously, 
unless at work. This habit may be observed among workmen and washer-women, 
and sometimes among fashionable dames in bare arms. This part is supplied with 
cutaneous branches from the brachial plexus, and thus has more than local influence ; 
to protect it from cold is instinctive. Women ordinarily have one thickness of dress 
upon the arm and neck ; sometimes two on the arms ; and, in the coldest season, often 
none on arms or neck. The dress may be worn high, and covered with wraps during 868 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
the warmest part of the twenty-four hours, to be exchanged frequently, for a décolleté 
habit when the temperature is the lowest (slippers are not forgotten). May we not find 
in these facts some of the predisposing causes of the greater frequency of this aural affec- 
tion among women ? Fashion is without discretion, and is a Moloch to which health is 
unpityingly sacrificed (self-sacrifice). Intelligent advice may be given in regard to 
dress, but Fashion scorns it, and medication must be to little purpose without rational 
precautions on the part of the patient. 
GENERAL MEDICATION. 
Avoidance of shock, mental distress, damp cold, pregnancy, and whatever else tends 
greatly to disturb the balance of circulation, is to be advised. Nutritious food is to 
be taken regularly, and in such quantity as can be digested and assimilated. The 
moderate use of red wine is beneficial. Liq. potas. arsenit., in drop doses, taken for 
some months, promotes digestion and assimilation, in addition to its specific action upon 
the mucous membrane. In the same way it is probably useful in anaemia and certain 
forms of neuralgia. Syr. ferri iod. is serviceable in cases dependent upon impoverished 
blood, and may be associated with arsenic in the same prescription. Any gain from 
the administration of cod-liver oil has not been apparent to me. The salicylates have 
had manifest influence in some cases. Due attention should be given to the proper 
performance of its functions by every organ of the body, and particularly to the action 
of the bowels. A habit of constipation must be corrected, to aid nutrition. 
The above outline, taken with the local manipulations heretofore described, are of 
more certain value in the treatment of aural atrophy than any other known to me. It 
is needless to say that a number of cases exist in which the structural injury is of such 
character and so established that nothing short of re creation will restore to the organ 
the conditions necessary to its intended duties, as, for instance, osseous anchylosis or 
disarticulation of the ossicula. 
DISCUSSION. 
Dr. C. M. Hobby, Iowa City, Iowa.-I can recall seven cases of arthritis 
deformans in persons related to each other not more remotely than second cousins, 
and occurring in the ramifications of a large family, and among more than thirty 
members of this family that I can now recall there has been but one case of deaf- 
ness. 
Dr. L. Turnbull, Philadelphia, Pennsylvania, saw a case of this disease, arthritis 
deformans, on Canonicut Island this summer, every one of whose joints was immov- 
able; he was like a chalk man. When I called to treat him for ulceration of the 
cornea his hearing was perfect. In another case that I saw every joint was out of 
its natural position; the hearing was perfect. (Inquiry being made whether these 
gentlemen had examined the ears, and if they found any structural change, they 
answered they had not examined the ears. ) 
Professor G. E. Frothingham, Ann Arbor, Michigan, said he had listened to Dr. 
Richey's paper with much interest, and ail would admit that he had presented the 
theory with sufficient show of argument to challenge attention. While Professor 
Frothingham could not say that he is ready to accept the views presented, they are 
worthy of more careful consideration than could be given in an off-hand discussion of 
the subject, which, in the aspect in which Dr. Richey presented it, is new, at any 
rate to him. It is true, we have long acknowledged certain changes in the drum 
membrane and the articulation of the bones of the ear as due to a gouty or rheumatic 
condition, but the claims made in the paper he has not met with before. It is a 
subject upon which he must reserve his opinion until further consideration, as it SECTION XII-OTOLOGY. 
869 
does not fully accord with his present views. He is all the more glad, on that account, 
to hear this view presented, as progress is best made by interchange of views, and 
stimulation to research grows out of opposing theories. He will repeat, ' ' that man 
is a public benefactor who makes two blades of grass grow where one grew before. ' ' 
On the same principle, that man is a medical benefactor who gives us two ideas 
where we had but one before. 
In obscure subjects, like the disease under consideration, we should take into 
respectful consideration any plausible theory, and, for one, he is willing to devote to 
it careful study. 
Professor E. De Rossi, Rome Italy, inquired in what way Dr. Richey would 
distinguish between atrophy due to the cause suggested by his paper, and atrophy of 
the ear consecutive to hypertrophic processes. 
Dr. Richey stated that in the published abstract of his paper he had stated that 
the question of atrophy of the ear consequent to hypertrophy would not be raised 
in the paper. In answer to Professor De Rossi, however, he said the history of the 
case would suggest an antecedent hypertrophic condition, by increased secretion and 
diminution of the upper air passages at some time ; periods of greatly impaired 
function with relief, often without foreign agency; a subacute catarrhal condition, 
with thickening of the membrane involved, due to passive congestion, the impaired 
hearing being noticeable, especially during the exacerbations, and the absence of 
neuralgic pain. In atrophy following arthritis deformans, on the other hand, there 
is, if any, very slight thickening of tissue ; no perceptible increase in secretion ; 
very slow and progressive impairment of hearing, intractable in character ; and 
neuralgic pain. 
He did not anticipate immediate acceptance of the views offered. How can 
anchylosis, with prominence of the malleus and incus, be better explained ? Is dry 
catarrh an inflammation ? Mr. Henry Power, of London, England, in his remarks 
upon bacteria, in the Section on Ophthalmology, had intimated that the germs might, 
by migration, produce the joint affection, and Dr. Richey could not see that such a 
supposition would invalidate the theory of a neurosis, but, on the contrary, would do 
much to support it. He believes the bacterial theory, in explanation of this obscure 
affection, to be the other idea in Professor Frothingham's mind. 
As arthritis deformans begins in the smallest and most used joints in the body, it 
might exist in the ossicula auditus, and be absent elsewhere. Drs. Turnbull and 
Hobby had not examined the structures of the ears in the subjects mentioned by 
them; they did not notice impairment of hearing. Their observations are therefore 
negative, for how often do we see distortion of the malleo-incudal articulation, with- 
out perceptible impairment of hearing ? 870 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
PHYSIOLOGICAL RESEARCHES ON NASAL VOWELS. 
RECHERCHES PHYSIOLOGIQUES SUR LES VOYELLES NASALES. 
PHYSIOLOGISCHE UNTERSUCHUNGEN ÜBER NASENVOCALE. 
BY B. LOEWENBERG, M. D., 
Of Paris, France. 
A. ACOUSTIC RESEARCHES AND THEORY. 
Under the denomination of "nasal vowels," two kinds of phonemata are generally 
confounded, notwithstanding their considerable diversity with regard as well to the 
nature of their sonority as to the physiological conditions of their formation. 
In my book on "Adenoid Growths of the Upper Pharynx,"* I have been led to 
study this subject while examining the troubles of function caused by these vegetations. 
Among the perturbations they produce, by obstructing the posterior opening of the nasal 
fossæ, we find modified pronunciation of all the letters which implicate the free passage 
of the expired air and its resonance in the nasal cavities. 
After having first investigated the physiological formation of m and n and their 
transformation into b and d by the pathological obstruction of the naso-pharyngeal 
passage, due to these tumors, I then examined the changes undergone by the nasal 
vowels in the same affection, a subject which had not been studied before. 
I begun by investigating the physiological position of the phonetic organs while 
pronouncing these sounds, and expressed myself in the following way (translation of 
my book, by Professor M. Jones, page 362) :- 
" There now remains for our examination a group of phonetic sounds, . . . which 
have not been studied from this special point of view. These are the nasal vowels as 
they are pronounced in France f and in certain portions of Austria. 
" Here the narrowing (viz., the straightening through which the air escapes while 
we form these letters) is effected by the elevation of the base of the tongue, on the one 
hand, and on the other, the depression of the soft palate. The special aperture which 
produces the characteristic sound peculiar to each letter lies, for the nasal vowels, still 
further back than in the case of lingual letters (n, for instance). The nasal vowels are 
formed while the column of air dividing between the buccal and nasal channels escapes, 
partly through the aperture restricted by the soft palate and the back of the tongue, 
which approach one another, and partly at the same time through the nasal fossæ, thus 
giving rise to the characteristic resonance of French pronunciation. The vowels a, e, o 
and w,t pronounced in this position, become nasal, and are then an, ein, on and un. 
* B. Loewenberg. " Les Tumeurs adenoides du Pharynx nasal; leur influence sur l'Audition, 
la respiration et la phonation ; leur traitement." Paris, 1879. This work has been translated 
into English by Professor Macnaughton Jones, and published in The Medical Press and Circular, 
1879, and in an abridged way by my lamented friend, the late Dr. James Patterson Cassells, in 
the Edinburgh Medical Journal, same year. 
f Note of the Author.-We have been surprised to find that the so-called French nasal sounds 
are not peculiar to French pronunciation, as is generally believed (for instance, by M. Brücke, 
"Grundzüge der Physiologie der Sprachlaute," second edition, 1876). We have met with them 
in certain dialects of the South of Germany, among others in that of Frankfort-on-the-Main. 
J Note of the Author.-The vowels, after the French pronunciation, are written a, e, i, o, u, 
and un is considered to be the nasal sound of u ; but, according to my researches, the nasal sounds SECTION XII-OTOLOGY. 
871 
"We shall take this opportunity of referring to a subject which requires some expla- 
nation. We often confuse the nasal sounds of the French language (and which for this 
reason we shall call French nasal vowels) ("sons nasaux français ") with the sounds 
similarly called " nasal," but of a different sonority, which are contained in the other 
Latin languages (Spanish, Italian, Portuguese*). We may call these latter (ang, eng, ing, 
ong, ung) "foreign or not-French nasal vowels " (" sons nasaux non-français)." 
" The difference between these two classes of nasal sounds consists, as we think, in 
this : that in the above described narrowing the back of the tongue and the soft palate 
approach much more nearly to one another for the not-French nasal sounds than for the 
French pronunciation of these sounds . . . , the closure of the buccal cavity is more 
complete and the nasal aperture still more indispensable than in the case of French 
nasal sounds." 
The preceding remarks, though now of nine years' standing (the contents of my 
book having first been published in the Gazette des Hôpitaux, as early as in 1878), seem 
to have been entirely overlooked, as well by linguists as by physiologists. It may be 
that this omission arises from my observations having been inserted into a book of 
practical surgery, in which they form one of the scientific applications of the subject 
(I take the opportunity of reminding you that the same ill fate happened to other new 
points forming part of the same work, as, for instance, to a study on the part the sense 
of smell plays in that of taste). 
Since the publication of my book I have by different means corroborated and ampli- 
fied my researches on this subject. Having previously proceeded only, as mentioned 
above, by examining the different positions I gave to the vocal organs while pro- 
nouncing the different nasal sounds, I now resorted to more vigorously scientific methods, 
as, for instance, to the graphic one. The results of these, however, shall be published 
in a more exhaustive paper on the subject, their place not being in a short communica- 
tion as the present one must necessarily be. 
I actually intend to expose the results of the application to my subject of an acous- 
tic method intended to elucidate another point of this complicated study. 
Among the different problems this matter involves, arises the question of the 
musical notes belonging to or characteristic of each nasal vowel. In other terms, we 
must ascertain which is the sound or which are the sounds the vocal cavities are tuned 
to for each of these. 
Eesearches of an analogous kind are known to have been made with regard to the 
pure (not nasal) vowels by as eminent men as Bonders, Helmholtz, Koenig and others, 
and, as far as concerns the consonants, by Dr. O. Wolff. But no investigations, at 
least to my knowledge, have been made concerning the notes proper to the two distinct 
groups of nasal vowels, and I, therefore, have undertaken to study this point. 
of i and u do not exist in French, and what is generally spelt "un" is the nasal sound of "eu." 
I, therefore, shall write it " eun" and the corresponding pure vowel "eu." 
For those who may not have a thorough knowledge of foreign languages, I wish to add a 
COMPARATIVE TABLE OF PRONUNCIATION. 
French a corresponds to the English sound of a in "father;" German, a. 
" e (é) " " " " e in "get," "let," a in "fate;" " e. 
« ; « a a « ( i in "still; ( « ,• 
1 ee in "heel •" 1 ' 
" o " " ' " " o in "before;" . " o. 
" eu " " " " u in " curl ;" " œ or Ö. 
* Note of the Author.-I since ascertained, from a reliable medical friend, that in the Portu- 
guese language, especially patois, there exist other modifications of nasal vowels, still to be 
studied. f Dr. 0. Wolf. " Sprache und Ohr," Braunschweig, 1871. 872 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
Different methods have been employed in order to ascertain the notes peculiar to 
the buccal cavities when pronouncing the vowels a, e, i, o, ou (French pronunciation). 
The best way, in my opinion, is the one first followed by Prof. Helmholtz, and which 
consists in utilizing the phenomenon of resonance. A simple estimation of the musical 
note by the ear alone leads to errors, especially with regard to the octaves. This indeed 
happened to as eminent an observer as Prof. Donders, who noted the sounds produced 
by whispering the vowels. 
I therefore determined to employ the method of resonance, which leads to the end 
slowly, but surely. 
I happily was able to secure the use of an apparatus of the utmost perfection, belong- 
ing to and executed by the celebrated acoustician, Dr. R. Koenig (Paris). I gladly 
seize the occasion of publicly thanking my eminent friend for the devotedness with 
which he has placed his apparatus at my disposal. His tonometer, that I had the use 
of, consists of a great series of tuning-forks, differing from each other by only a few 
vibrations, tuned with the utmost precision. I was thus enabled to ascertain the dif- 
ferent sounds to which the vocal cavities are tuned in each case. 
I proceeded in the following manner: In order to get an approximate idea of the 
position of the nasal vowel sounds in the musical scale, I first pronounced a pure vowel 
and afterward one of the corresponding nasal ones (French or not-French) and tried to 
ascertain in an average way the interval between their two notes. Knowing from the 
above mentioned researches the exact sounds of a, e, i, etc., it was very easy immedi- 
ately to determine the average notes of the nasal vowels. Once these had been found, 
I pronounced one of these nasals, stopped, and maintained the position of the mouth 
which I had found necessary to produce this letter. I then placed in front of my 
mouth vibrating tuning-forks chosen above and beneath the average note previously 
ascertained, till I had found the one whose vibrations were the most reinforced by the 
resonance of the mouth. 
The results of these researches were as follows:- 
MUSICAL NOTES I FOUND FOR EACH NASAL VOWEL. 
PUPE 
VOWEL. 
NOTE FOUND. 
FRENCH 
NASAL 
VOWEL. 
NOTE FOUND. 
NOT- 
FRENCH 
NASAL 
VOWEL. 
NOTE FOUND. 
0 
B>8 (896 V.- S. *). 
on 
G3 (768 V. S.). 
ong 
B2 (480 V. S.). 
a 
Bb4 (1792 V. S.). 
an 
F #4 near G4 
(1470 V. S.). 
ang 
B3 (960 V. S.). 
e 
Bt>5 (3584 V. S.). 
en 
Beneath G5 
(3008 V. S.). 
eng 
B4 (1920 V. S.). 
eu 
f Between F#3 and G#3 
i (728 V. S.), besides C#4 
( (1100 V. S.,) was found. 
eun 
Toward A3 
(858 V. S.). 
eung 
E3 (640 V. S.). 
♦V. S. signifies "simple vibrations" (" vibrations simples," in French). The sounds found by me, 
and contained in this Table, may be expressed by the accompanying musical signs or notes, with the 
exception of a few vibrations. 
A glance at the preceding Table shows at once that the proper sounds of the French 
nasal vowels of the first three series are very nearly the minor thirds inferior to the 
notes for the corresponding simple vowels, while those of the not-French ones approach 
by about half a tone the lower octave of these. SECTION XII-OTOLOGY. 
873 
The results are different for the series: "en, eun, eung." This difference is extremely 
remarkable, and is perhaps due to the intermediate nature of eu, which, the same as 
the German ü or ue (French u) (a sound for which the English language has no equiva- 
lent), combines the lingual position of one vowel with the buccal one of another. For 
the latter reason one could call these two " mixed " or " intermediate " vowels (Vermitt- 
lungs vocale, as Lie vers calls them).* 
The results found with the not-French nasal vowels are still more striking, for we 
find the not-French nasal sound of a vowel to be distant by half a tone only from the 
proper sound of another simple vowel; for instance, the proper note of A is near Bb4, the 
one of O near Bb3, and we have found as the sound for the not-French nasal "ang" B3, 
and so on. 
The results of my preceding researches are not only veiy interesting themselves, but 
they open new fields to physiologists as well as to linguists. 
THE TECHNIPHONE SNAP-A SUBSTITUTE FOR THE WATCH, AS 
A TEST FOR HEARING. 
LA PERCUSSION DU TECHNIPHONE-UN SUPPLÉANT POUR LA MONTRE COMME 
UN CRITÉRIUM. 
DER TECHNIPHONSCHNAPP-EIN STELLVERTRETER DER UHR ALS GEHÖRPROBE. 
BY HENRY BYRD YOUNG, A.M., M.D., 
Burlington, Iowa. 
The insufficiency of the watch as a test for hearing is well known, and the desira- 
bility of something which will more nearly approach that point of excellence reached 
by Snellen's types as a test for vision, need not be discussed. This ground has been 
often traversed, and recently again in a very thorough manner by a special committee 
of the American Otological Society. It is, therefore, only necessary to say that such a 
test must be some device which will be simple of construction, cheap, easily managed 
and reasonably uniform. And combining these conditions very happily and completely 
is the little device herewith presented and known as the techniphone snap-the sounder 
of the strihgless piano called the techniphone. 
It is simple of construction. Consisting merely of a piece of strap steel about | mm. 
in thickness, 3 cm. in length and 1 cm. in width, dished (dented) slightly at its centre 
in such a way that the edges are not stretched. 
It is cheap. This is self evident. 
It is easily managed. Placing the ends of the strip against the thumb and a finger 
respectively, and preferably of the right hand, the centre is seized edgewise by the thumb 
and a finger of the other hand and made to spring against its concavity. When an 
excursion of about 2 mm. has been made, the part that is stretched reaches its point 
of reversal and changes with a distinct snapping sound. Released, it springs back and 
the sound is repeated. This sound can be produced rapidly, slowly or irregularly, as 
the operator may desire. If the sound is louder than necessary, it can be nicely and 
* Lievers. " Grundzüge der Lautphysiologie," Leipzig, 1876, p. 43. 874 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
definitely muffled by seizing the centre flatwise instead of edgewise-the thumb or 
finger resting on the point of greatest convexity. 
It is reasonably uniform. Experience has shown that in the manufacture of these 
snaps there is no appreciable difference, either in pitch or intensity, among those having 
identical measurements. To get a change of pitch there must be change of dimensions ; 
and, other things being equal, the longer strip usually means a lower pitch and the 
shorter a higher pitch. 
Taking it all in all, it is a more convenient test than the watch (a stop-watch), and, 
being just as good, should be substituted for it. That it does not fully reach that point 
of excellence found in Snellen's types as a visual test, is conceded. 
It is possible to show a relationship between the image of 5' angle and satisfactory 
vision by a careful computation of the retinal end organs involved. To establish a 
gauge of such mathematical exactness for the hearing power, a better knowledge of the 
acoustic nerve and its physiology is yet required. If, however, it is borne in mind that 
the test is not intended to decide how much a patient should hear, but merely how much 
is heard at one or another time, and that with trifling expense and little trouble the 
patient may be subjected to a number of tests by snaps of different dimensions writh 
their corresponding differences of pitch, the comparison with Snellen's type is not 
unwarrantable. 
One great advantage which it possesses over the watch is to be noted in the possible 
improvement of case reports; and for this, if nothing else, it should be generally 
adopted. How often, for instance, is it seen recorded that a patient's hearing, "as 
tested by the watch, was j J} in the diseased ear? and what real information is to be 
gotten from the statement ? It is supposed, of course, that the patient heard at twenty 
inches only that which had been heard at fifty. But the reader is uninformed as to the 
character of the sound, and is left to wonder whether the hearing must be extraordi- 
narily acute generally, or particularly susceptible to such sounds, to perceive it at the 
greater distance. 
With a snap of given measurements there goes a sound of definite pitch and inten- 
sity; and it becomes unnecessary to try a number of what may be estimated as normal 
ears with the watch (as recently advised by the committee of the American Otological 
Society) in order to get the so-called average maximum distance at which it can be 
heard. It only needs be noted that the patient heard the snap free at such a distance 
or muffled at such another distance; and the remote reader testing his own hearing by 
the same sound may form a judgment accordingly. 
In conclusion, the writer desires to say that his attention was called to this snap 
quite accidentally, through a personal meeting, at the house of a mutual friend, with the 
invention of the techniphone. Its adaptability for the purpose now proposed instantly 
suggested itself. The snap was procured, used, and found so satisfactory that it was 
deemed proper to call the attention of others to it. It is therefore before you. 
DISCUSSION. 
Professor E. De Rossi, Rome, Italy.-We have not, at present, any accurate 
tests for hearing, to determine the condition of the power of hearing. Not even the 
acoumeter of Politzer is as serviceable as the watch, which we always carry in our 
pockets, and the human voice. The watch constitutes a very fair test of the per- 
ception of sound, and the human voice is practically the most important sound that 
the patient desires to perceive. Until such time as we have some more nearly per- 
fect instrument, we must rely on the old instruments which have hitherto served us. 
Dr. S. 0. Richey thought improvement in any affection of the ear should be 
judged by structural changes, and that the surgeon should not rely on improvement SECTION XII-OTOLOGY. 
875 
in function alone to decide the more healthful condition of the ear. When the 
structure is made normal, proper functional activity follows. Tests are chiefly valu- 
able in differentiating the parts of the ear affected, and for indicating the final result, 
by comparison with the original indications by the same test. 
THE VALUE OF NITROGLYCERINE IN TINNITUS AURIUM. 
VALEUR DE LA NITRO-GLYCÉRINE DANS LE BOURDONNEMENT DES OREILLES. 
DER WERTH DES NITROGLYCERINS BEI OHRENSAUSEN. 
LOUIS J. LAUTENBACH, M.D., PH.D., 
Of Philadelphia, Pa. 
After the usual experience in ear-work, and a gradual accumulation of unimproving 
cases of tinnitus aurium, I began to study the general effects of nitroglycerine, and to 
use it in these cases. It had been used by others in tinnitus, both with and without 
success, but I knew of no way of recognizing the cases in which it would be most likely 
to prove serviceable. In order to learn when to use it, I began to give it, in private 
practice, to all cases of tinnitus in which I had found no improvement under other treat- 
ment, and, in public practice, in all cases of tinnitus. In some cases there was improve- 
ment, in others there was none. 
In the patients where improvement had occurred there was found to be present a 
similarity of conditions, and I soon satisfied myself that there was a class of patients in 
which the nitroglycerine treatment was valuable. I found it most Serviceable in patients 
having tinnitus aurium, without much impairment of hearing, and where but little 
change had occurred in the naso-pharynx, and where it was found, on examination, that 
some abnormal condition of the heart existed, either functional or organic. 
In many of these cases more or less structural changes, from catarrhal inflammation 
of the middle ear, were present, among them changes in the shape and translucency of 
the drumhead, with accompanying change in appearance or position of the triangular 
light spot. Follicular pharyngitis was present in some of the cases. The tinnitus was 
generally constant, or nearly so. It was not, as a rule, more marked when the patient 
was in a recumbent position ; occasionally there was some remission in that position. 
The thermometric and barometric conditions of the atmosphere influenced the tinnitus. 
Damp weather, with low barometer, usually increased it. 
Dull, heavy headache, more or less persistent, and most frequently located in the 
parietal regions, though sometimes located in the frontal region, was of frequent 
occurrence. 
In these cases I used the nitroglycerine in pill form, and in doses of one hundredth 
of a grain. At first but one pill a day was given, generally in the morning. The 
amount given later was increased, enough of the pills being given to diminish the 
tinnitus, or to cause headache. As many as six of these pills were given in a day, 
though usually two were found to produce a beneficial effect. Improvement sometimes 
was manifest within a day or two after beginning the use of the remedy. In cases of 
long standing the remedy was sometimes continued for a period varying from one to 
three months before a satisfactory result was obtained. Cases, in which there was 
recurrence of the tinnitus, seemed to yield more readily on resuming the treatment than 876 
NINTH INTERNATIONAL MEDICAL CONGRESS. 
when the remedy was first administered. The conclusion which I reached, àfter a fair 
trial of this remedy, was, that it is of value in certain cases of tinnitus aurium, especially 
in those where cardiac lesion exists, functional or organic, and where there is little or 
no loss of hearing. 
EXHIBITION OF COLORED PLATES, 
PREPARED BY PROFESSOR ADAM POLITZER, 
Of Vienna, Austria, 
SHOWING VIEWS OF THE MEMBRANOUS LABYRINTH. 
EXHIBITION OF INSTRUMENTS AND APPARATUS. 
EXPOSITION D'INSTRUMENTS ET D'APPAREILS. 
AUSSTELLUNG VON INSTRUMENTEN UND APPARATEN. 
CLOSING REMARKS BY THE PRESIDENT. 
It becomes my duty to announce that the hour for final adjournment of the 
Section has arrived. 
Before doing so, I wish to return thanks to the colleagues who have contributed 
to the work of the Section, and who have so fully cooperated in the endeavor to have 
the occasion one which might result in substantial progress in the general effort that 
is being made for the advancement of otology. 
We all share in the regret at the absence of many eminent otologists who expected 
to have been present, and whose letters of regret have been presented here, in which 
they express their continued interest in otology, and their wish to have been present, 
and to have participated actively in the work of the Section, but who, from various 
and unavoidable causes, have been prevented from doing so. 
The time allotted for the work of this Section has not afforded opportunity for 
full discussion of some of the questions in otology which, as announced at the open- 
ing session, it was designed to have presented during the progress of the work, and 
to have invited full consideration of them. The active interest which has been 
awakened in the whole subject of otology in the last few years, and of which this 
occasion has given further evidence, is justification for the expectation that before 
the time for the meeting of the Tenth Triennial Congress, at least some of the ques- 
tions will have emerged from the uncertainty which yet surrounds them. 
With thanks to all who have aided in the work of the Section, and especially to 
those honored confrères who have come from distant lands to do so, I now announce 
the final adjournment of this Section. INDEX TO VOLUME III. 
Abadie, Dr. Charles, 681, 684, 704, 730, 749. 
Acetonuria in children, 596, 597. 
Acid, hydrobromic, dilute, formula for, 74. 
Address by Pres, of Sec. VI (Dr.Traill Green), 2. 
VII (Dr. Wm. H. Pan- 
coast), 122. 
VIII (Dr. J. H. Callen- 
der), 232. 
IX (Dr. A. B. Palmer), 
352. 
X (Dr.J.Lewis Smith), 
438. 
XI (Dr. J. J. Chisolm), 
656. 
XII (Dr. S. J. Jones), 
802. 
Agencies, natural, inhibiting pathogenic organ- 
isms, therapeutic employment of, 396. 
Alcohol in medicine and disease, 91. 
Allyn, Dr. George W., 785, 810, 841. 
"American" hip-splint, 642. 
Ametropia in schools, 787. 
table of cases of, 790. 
Anæmia, pancreatic, 409. 
Anatomico-mechanical treatment in spinal dis- 
eases, 211. 
Anatomy and pathology, photo-micrography 
in, 432. 
human, didactic teaching of, 147. 
methods of teaching, 224. 
pathological, of laryngeal diphtheria, 
508. 
of superior maxillaries, 416. 
(Section vu), officers, list of, 121. 
Andeer, Dr. Justus, 100, 102. 
Ankle joint, retro-calcanean bursæ in amputa- 
tion, 175. 
Appliance for reduction of contracted knee- 
joint, 646. 
Arteries, main, surgical, collateral branches of, 
194. 
Artery, middle thyroid (anomalous), 165. 
Arthritis deformans, identity with atrophy of 
conducting apparatus of ear, 862. 
Artificial vitreous, use of the, after eviscera- 
tion, 762. 
Ashby, Dr. Henry, 583. 
Aspiration in detachment of retina,, 747. 
Atkinson, Dr. George A., 57. 
Aural furuncles, bacteriology and treatment of, 
811. 
Bacteria in dejecta of summer diarrhoea, 598. 
Baginsky, Dr. Adolph, 596, 597. 
Baker, Dr. A. R., 707, 765, 774. 
Baldwin, Dr. B. J., 685. 
Dr. D. J., 735. 
Balkwill, Mr. Wm. E., 623. 
Baratoux, Dr. J., 827, 839, 850. 
Bermann, Dr. Isidore, 662. 
Beyer, Dr. H. G., Ü.S.N., 62, 70, 102. 
Bilharzia haematobium, 420. 
Bishop, Dr. Seth S., 804, 839. 
Blackburn, Dr. I. W., 407. 
Blitz, Dr. A., 681, 841. 
Blood, comparison of coagulation in rigor mor- 
tis, 251. 
red corpuscle, function of, 285. 
Boenning, Dr. H. C., 178, 246. 
Bone, embryonic, development of, 151. 
Booker, Dr. William D., 598. 
Botany, medical, in the United States, synop- 
sis of, 7. 
Bouchut, Dr. E., 513, 515, 552. 
Brackett, Dr. John E., 18, 43, 50, 55, 63. 
Bradford, Dr; E. H., 646. 
Brain, basal ganglia of, as psychic centres, 238. 
Brains, etc., preparation of, for anatomical and 
pathological demonstration, 407. 
Brown, Dr. Dillon, 531. 
Brazil, hereditary syphilis and rachitis in, 575. 
malaria of children in, 580. 
Brugsch-Bey, Dr. A., 752. 
Bull, Dr. Ole, 663, 745. 
Burnett, Dr. Swan M., 708, 779, 785, 795. 
Bursæ, retro-calcanean, in amputation through 
ankle-joint, 175. 
Bush, Dr. Lewis P., 381. 
Calcium sulphite in diphtheria, 574. 
Calhoun, Dr. A. W., 681, 751. 
Callender, Dr. J. H., 232, 251. 
Calomel, antiseptic action of, 51. 
Cannes, France, treatment of scrofula by sea 
baths at, 620. 
Canton, Dr. Richard, 246. 
Carter, Dr. J. M. G., 734. 
Cascara sagrada, 43. 
Cataract, extraction of without iridectomy, 692. 
extractions and iridectomies, best 
after treatment of, 698. 
operation for, 695. 
operations, methods of, 688. 
Cerebral function, 339. 
gray matter, electrical phenomena of, 
246. 
irritation in young children, 452, 454. 
Cerebro-spinal fever aS a cause of deafness, 852. 
Charlton, Dr. S. IL, 455. 
Chemical philosophy in remedy, 19. 
Chlorosis, pigmentation of skin in, 436. 
Children, acetonuria in, 596, 597. 
diseases of (Sec. X), 437. 
hallucinations in, 552. 
877 878 
INDEX TO VOLUME III. 
Children, headaches in, 490. 
rate of growth in, 446. 
tables of growth and weight in, 450- 
452. 
weight in, 447, 448. 
young, cerebral irritation in, 452, 
454. 
Chisolm, Dr. Julian J., 655, 656, 662, 708, 714. 
Cholera, supplemental respiration in, 108. 
Cities, milk supply of, 477. 
Clark, Dr. Daniel, 238. 
Club foot, congenital, treatment of, 623. 
Cobra De Capello, venomous secretion of, 63. 
Cohen, Dr. J. Solis, 24. 
Coghill, Dr. J. G. 8., 9, 23. 
Collinsonia canadensis, 76. 
Conner, Dr. Leartus, 673, 862. 
Contraetured tissues, section of, 624. 
Convulsions, infantile, etc., 540. 
Coomes, Dr. M. F., 842. 
Cornea, abscess and ulceration of, jequirity in, 
781. 
Corson, Dr. Hiram, 79. 
Coutts, Dr. J. A., 540. 
Cranium, skin-grafting upon, 166. 
Cross, Dr. Richardson, 750, 764, 770, 780, 785. 
Curtis, Dr. Lester, 381. 
Cystotomy, suprapubic, 181. 
Dacryocystic fistula, lachrymal drainage in,796. 
Danforth, Dr. I. W., 394. 
Davis, Dr. N.S., 389, 395. 
Day, Dr. W. H., 490, 503. 
Deafness, caused by cerebro-spinal fever, 852. 
Deformity, congenital, of spinal column, 160. 
Dennett, Dr. Wm. S., 503, 506. 
De Rossi, Dr. E., 809, 827, 839, 859, 862, 869, 
874. 
D'Espine, Dr. Adolph, 559. 
Diarrhoea, bacteria in dejection of, 598. 
Dibble, Dr., 713. 
Dickinson, Dr. Fannie, 780. 
Dr. William, 662. 
Dickson, Dr. Jos. N., 175. 
Digestion, cellular, its utility in pathological 
processes, 389. 
Dight, Dr. C. F., 420. 
Diphtheria, laryngeal, pathological anatomy of, 
508. 
turpentine and sulphite of calcium 
in, 574. 
water pollution, sewerage, influ- 
ence on, 440. 
Dissecting room offal, disposal of, 178. 
Doses, maximum, of medicine, 67. 
table of, 69, 70. 
Dott, Dr. D. B., 47. 
Dronke, Dr. F., 103. 
Drugs, action on kidney, 35. 
progress in science of, 10. 
Duncan, Dr. A. M., 55. 
Ear, atrophy of conducting apparatus, identity 
with arthritis deformans, 862. 
diseases of, in negro, 817. 
diseases, statistical report of, 804. 
internal, inherited syphilis in, 850. 
middle, inherited syphilis in suppuration 
of, 844. 
Earle, Dr. C. W., 409, 440. 
Eckhard, Dr. C., 342. 
Edson, Dr. Cyrus, 477. 
Electrical phenomena of cerebral gray matter, 
246. 
stimulation of mammalian heart, 
253. 
Electrolysis in erectile tumors, 577. 
Elliott, Dr. George R., 363. 
Embryo, human, cerebral vesicle in, 138. 
Embryonic bone, development of, 151. 
Entropium, treatment of, 715. 
Ergot of rye in ophthalmic practice, 760. 
Eustachian tube, microorganisms in, 859. 
Everts, Dr. 0., 339. 
Evisceration, use of artificial vitreous after, 
762. 
Eye diseases, hot water in, 673. 
microbes in, 682. 
troubles, in relation to occipital disease, 
658. 
Fats, crystallography of, in health and disease, 
361. 
Fermentation, alcoholic, of hepatic sugar, 293. 
Fibres, elementary, physiology of, 290. 
Fistulas, urinary, anatomy and surgery of, 192. 
Force, organic, transmutation in psychic, 339. 
Ford, Dr. W. H., 293. 
Frothingham, Dr. G. E., 714, 715, 808, 810, 
815, 824, 828, 843, 852, 859, 861, 868. 
Fulton, Dr. J. F., 728, 735, 810, 825. 
Furuncles, aural, 811. 
Galezowski, Dr., 686, 687, 692, 747, 752, 759, 
765, 779, 782. 
Ganglia, basal, of brain, as psychic ce .très, 238. 
Gerlach, Dr. Jos. V., 138. 
Dr. Leo, 144. 
Gifford, Dr. Harold, 766. 
Glands, sudoriferous (twin), 144. 
Glaucoma in the negro, 755. 
predisposition to, 752. 
Glioma of retina, etc., 756. 
Gnezda, Dr. Julius, 55, 63, 66. 
Gradle, Dr. Henry, 662, 861. 
Grauer, Dr. Frank, 591. 
Green. Dr. Traill, 2, 6, 19, 34, 55, 67, 119. 
Growth, rate of, in children, 446. 
Gubb, Dr. A. S., 119. 
Halliburton, Dr. W. D., 243, 251. 
Hallucinations in children, 552. 
Hamilton, Dr. Hugh, 19. 
Hare, Dr. H. A., 33. 
Headaches in children, 490. 
Hearing, techniphone snap, test for, 873. 
Hemorrhage, post-partum, supplemental res- 
piration in, 108. 
Herdman, Dr. W. J., 223. 
Heyl, Dr. A. G., 672, 684, 738, 745. 
Hip-splint, American, 642. 
Hobby, Dr. C. M., 809, 823, 840, 852, 868. 
Holcombe, Dr. Wm. Fred., 751, 843. 
Hot water in eye diseases, 673. 
Hotz, Dr. F. C., 681, 710, 714, 840. 
Huckins, Dr. P. T., 681. INDEX TO VOLUME III. 
879 
Hull, Dr. Geo. S., 50, 51, 55, 56. 
Hypodermic injection of sterilized cultures, 
production of immunity by, 403. 
Ice and cold water in inflammations, 79. 
Infancy, formation of tumors in, 568. 
tumors, mediastinal, non-congenital, 
in, 568. 
Infantile convulsions and later neurotic ten- 
dencies, 540. 
marasmus, 617. 
pneumonia, 559. 
Infants, use of cows' milk in, 485. 
Inoculation, preventive of rattlesnake venom, 
388. 
International pharmacopoeia, necessity for, 103. 
Intubation, in laryngeal diphtheria, 508. 
of larynx, history of, 531. 
in croup, etc., 513, 516, 527. 
tables of, 529, 530. 
Iridectomies, etc., best after treatment of, 698. 
Jackson, Dr. S. K., 396. 
Dr. Edward, 785. 
Jennings, Dr. C. G., 538. 
Jequirity in abscess, etc., of cornea, 781. 
physiological action of, 97. 
Joint affections, anatomical points in, 199. 
Jones, Dr. S. J., 713, 800, 802, 876. 
Judson, Dr. A. B., 635, 642. 
Keyser, Dr. P. D., 672, 680, 685, 686, 706, 714, 
745, 749, 758, 765, 798. 
Kidney, action of certain drugs on, 35. 
Knee-joint, contracted, appliance for, 646. 
Knight, Dr. James, 641. 
Lachrymal drainage in dacryocystic fistula, 
796. 
Landolt, Dr. Edmund, 685, 704, 718, 750, 785, 
787. 
Langdon, Dr. F. W., 147. 
Larynx, intubation of, 516, 527. 
history of, 531. 
in croup, etc., 513. 
tubage of, in stricture and croup, 515. 
Lateral curvature of spine, treatment of, 640. 
Lautenbach, Dr. Louis J., 875. 
Lee, Dr. Benjamin, 160. 
Leeds, Dr., 484. 
Lenses, necessity for reform in manner of des- 
ignating, 783. 
Leuf, Dr. A. H. P., 224. 
Lewin, Dr. L., 66, 67, 101. 
Liell, Dr. Edward N., 91. 
Love, Dr. I. N., 244, 283, 285, 475, 617. 
Loewenberg, Dr. B., 811, 870. 
Magruder, Dr. G. L., 34. 
Malaria in children in Brazil, 580. 
Mammalian heart, electrical stimulation of, 
253. 
Manganese preparations, emmenagogue action 
of, 71. 
Manolescu, Dr. N., 684, 695, 733. 
Marasmus, infantile, 617. 
Marmion, Dr. Wm. V., 662, 705. 
Martin, Dr. Sydney, 97. 
Mastoid cells, acute primary inflammation in, 
825. 
process, perforation of, artificial, §28. 
Materia medica, history of progress in the United 
States, 2. 
investigation of, by U. S. Gov- 
ernment, 10. 
Matthews, Dr. Joseph M., 140. 
McWilliam, Dr. J., 253. 
Medicines, maximum doses of, 67. 
Memoriam, in, Dr. Alonzo B. Palmer, 350. 
Microbes in eye diseases, 682. 
Microorganisms in Eustachian tube, 
Milk, cows', use of, in infants, 485. 
supply of cities, 477. 
Moncorvo, Dr., 546, 575, 580. 
Mooren, Dr. Albert, 658, 662, 688. 
Morphia, pharmacology of bodies derived from, 
47. 
Motility, ocular, derangements of, 730. 
Moura, Dr., 755. 
Mules, Dr. P. H., 762, 
Murrell, Dr. T. E., 698, 817. 
Dr. William, 9, 22, 34, 41, 46, 50, 61, 
62, 63. 
Muscles, ocular, insufficiency of, 723. 
recti, insufficiency of, 732. 
Nasal vowels, physiological researches on, 
870. 
Negro, diseases of the ear in, 817. 
glaucoma in, 755. 
Nephritis, scarlatinal, 583. 
anatomical characters of, 591. 
Nerve and muscle, physiological doctrines in, 
255. 
Nervous system, trophic influence of, 249. 
Newman, Dr. Robert, 460. 
Nitrites and nitroglycerine, pharmacology of, 
57. 
Nitroglycerine, value of in tinnitus aurium, 
875. 
North, Dr. John, 424. 
Northrup, Dr. Wm. P., 508, 539. 
Nutrition, teeth as indicators of, 335. 
« 
Occipital disease in relation to eye troubles, 
658. 
Ocular muscles, insufficiency of, 723. 
motility, derangements of, 730. 
O'Dwyer, Dr. Jos., 516, 540. 
Ophthalmia, sympathetic, 766. 
Ophthalmology (Sec. XI), officers, list of, 655. 
Ophthalmoscope, new pattern of, 798. 
Organisms, pathogenic, inhibition of, by natu- 
ral agencies, 396. 
Orthopædic surgery, 623. 
principles of progress in, 
637. 
Otology (Sec. XII), officers, list of, 800. 
Paddack, Dr. H. Clay, 760, 843. 
Palmer, Dr. A. B., 350, 352, 412. 
Pancoast, Dr. Wm. H., address of, 122. 880 
INDEX TO VOLUME III. 
Pancreas, cirrhosis of, 409. 
Parker, Dr. M. G., 432. 
Pathological demonstration, preparation of 
brains, etc., for, 407. 
Pathology of retinal vessels, 663. 
(Sec. IX), officers, list of, 351. 
Pelvis, male, frozen sections, showing relations, 
etc., 181. 
Peritoneum, relations of, 181. 
Pharmacology of bodies derived from morphia, 
47. 
Pharmacopoeia, international, necessity for, 
103. 
Phillips, Dr. C. D. F., 2, 6, 9, 35, 41, 42, 46, 
62, 63, 66, 119, 
Photo-micrography, in anatomy and pathology, 
432. 
Physiological doctrines in inter-relations of 
nerve and muscle, 255. 
researches on nasal vowels, 870. 
Physiology (Sec. VIII), officers, list of, 231. 
Pitner, Dr. T. J., 538. 
Pitts, Dr. Barton, 715. 
Pneumonia, infantile, 559. 
Points, anatomical in joint affections, 199. 
Politzer, Dr. Adam, 876. 
Pollock, Dr., 34. 
Poole, Dr. Thomas W., 255. 
Potash, chlorate of, 23. 
Pott's disease, pressure paralysis of, 363. 
Poussié, Dr. Emile, 574. 
Pouzet, Dr. Paul, 436. 
Power, Dr. Henry, 680, 682, 703, 734, 752, 759, 
762, 765, 787. 
Prepuce, narrow, and preputial adhesions, 461. 
Preputial dilatation, 457, 458. 
President of Sec. VI (Dr. Traill Green), resolu- 
tion of thanks to, 119. 
Pressure paralysis of Pott's disease, 363. 
Prince, Dr. A. E., 796. 
Ptomaines and leucomaines, pathological rela- 
tions of, 424. 
Ramsey, Dr. W. M., 55. 
Randolph, Dr. R. L., 759. 
Rattlesnake venom, preventive inoculation of, 
388. 
Raynaud's disease, pathology of, 412. 
Recti muscles, insufficiency of, 732. j 
Rectum, anatomy of, in reflexes, 140. 
Redard, Dr. P., 577. 
Red blood corpuscle, function of, 285. 
Reflex secretion, salivary, 342. 
Remedy, chemical philosophy in, 19. 
Resorcin and preparations, 100. 
Retina, detachment, curability of, 747. 
glioma of, etc., 756. 
Retinal vessels, pathology of, 663. 
Retinoscopy, 770, 774. 
Reynolds, Dr. D. S., 685, 705, 735, 759, 783. 
Rhoads, Dr. J. N., 161. 
Richey, Dr. S. 0., 810, 823, 827, 841, 869, 874. 
Roberts, Dr. M. G., 211. 
Rockwell, Dr. A. D., 460. 
Riickhard-Rabl, Dr., 136. 
Rusby, Dr. H. IL, 18. 
Saint-Germain, Dr., 457, 458. 
Salmon, Dr. D. E., 403. 
Sayre, Dr. Louis A., 461, 476, 624. 
Scarlatinal nephritis, 583. 
anatomical characters of, 
591. 
Schaefer, Dr. F. C., 167. 
Scrofula, treatment of, by sea baths, 620. 
Secretion, salivary, reflex, 342. 
Section VI, Therapeutics and Materia Medica, 
officers, list of, 1. 
VII, Anatomy, officers, list of, 121. 
VIII, Physiology, officers, list of, 231. 
IX, Pathology, officers, list of, 351. 
X. Diseases of Children, officers, list 
of, 437. 
XI, Ophthalmology, officers, list of, 655. 
' XII, Otology, officers, list of, 800. 
of contracted tissues, 624. 
Servais, Dr. L., 416. 
Sewall, Dr. Henry, 388. 
Sewerage, etc., influence on diphtheria, 440. 
Shakespeare, Dr. E. 0., 373, 381, 395, 732, 734. 
Shoemaker, Dr. John V., 76. 
Simon, Dr. J., 452, 454. 
Sinclair, Dr. A. G., 756. 
Skin grafting on cranium, 166. 
Skin, pigmentation of, in chlorosis, at phalan- 
geal articulations, 436. 
Smith, Dr. Eugene, 681, 686, 708, 751, 765, 
781, 782. 
Dr. J. Lewis (President. Sec. X), 437, 
438, 445, 456, 475, 489, 506, 512. 
Dr. Theobald, 403. 
Mr. Noble, 637. 
Souchon, Dr. Edmond, 194. 
Spinal column, congenital deformity of, 160. 
Spine, anatomico-mechanical considerations in 
diseases of, 211. 
treatment of lateral curvature of, 640. 
Stamm, Dr. M., 199. 
Statistical report of ear diseases, 804. 
Stellwagen, Dr. T. C., 335. 
Stevens, Dr. Geo. T., 723, 735. 
Stephenson, Dr. Wm., 446. 
Sterilized cultures, production of immunity by 
hypodermic injection of, 403. 
Stern, Dr. Max J., 165. 
Stewart, Dr. F. E., 9, 34, 41. 
Stockman, Dr. Ralph, 22, 41, 47, 50, 57, 71, 
242. 
Strabismus, advantage of operating early for, 
728. 
operation for, 718. 
Stricture, anatomy of, 161. 
Strong, Dr. Albert B., 181. 
Sudduth, Dr. W. X., 151. 
Sudoriferous glands (twin), 144. 
Sugar, hepatic, alcoholic fermentation of, 293. 
Summers, Dr. T. 0., 249. 
Superior maxillaries, pathological anatomy of, 
416. 
Supplemental respiration in cholera, etc., 108. 
Surgery, orthopædic, 623. 
principles of progress in, 
637. 
Sympathetic ophthalmia, 766. 
Syncope, local (Raynaud's disease), 412. 
Synechia posterior, operative treatment of, 686. 
Syphilis, hereditary, and rachitis, in Brazil, 575. 
inherited, in suppuration of middle 
ear, 844. 
in internal ear, 850. INDEX TO VOLUME III. 
881 
Tarsal border in trichiasis, restoration of, 710. 
Taylor, Dr. Thomas, 361. 
Techniphone snap as a test for hearing, 873. 
Teeth, indicators of nutrition, 335. 
Tetanus, table of cases, 374-378. 
traumatic, infectious nature of, 373. 
Therapeutics and Materia Medica, officers, list 
of, 1. 
Thompson, Dr. Jas. L., 680, 707, 713, 785. 
Thrasher, Dr. A. B., 861. 
Thyroid artery, middle (anomalous), 165. 
Tiffany, Dr. F. B., 787. 
Tilley, Dr. R., 809, 815, 823, 841, 844, 861. 
Tinnitus aurium, value of nitroglycerine in, 
875. 
Toeplitz, Dr. M., 842. 
Tonsils, ignipuncture of, 457, 458. 
Torus longitudinalis in teleostians, develop- 
ment and homology of, 136. 
Trichiasis, restoration of tarsal border in, 710. 
Trophic influence of nervous system, 249. 
Tubage of larynx in stricture and croup, 515. 
Tumors, erectile, electrolysis in, 577. 
formation of, in infancy, 568. 
mediastinal, non-congenital, in chil- 
dren, 568. 
Turnbull, Dr. L., 816, 823, 858, 868. 
Turpentine in diphtheria, 574. 
Tyrotoxicon, nature, chemistry and action of, 
on animals, 382. 
Upshur, Dr. John N., 55, 62, 71. 
Urinary fistulæ, anatomy and surgery of, 192. 
Valcourt, Dr. De, 620. 
Valk, Dr. F., 708. 
Vaughan, Dr. Victor C., 382, 485, 489. 
Vesicle, cerebral, in human embryo, 138. 
Visual axis, 738. 
Vitreous, artificial, after evisceration, 762. 
Vowels, nasal, physiological researches on, 870. 
Wade, Dr. DeWitt C., 18, 62, 63, 74. 
Ward, Dr. William, 108. 
Water, cold, and ice, in inflammations, 79. 
Waxham, Dr. F. E., 444, 527, 540. 
White, Dr., 734. 
Whooping cough, nature and antiseptic treat- 
ment of, 546. 
Wile, Dr. Wm. C., 192. 
Willard, Dr. DeF., 473. 
Wiltshire, Dr. J. G., 505. 
Woodbury, Dr. Frank, 10, 34, 42, 47, 63, 67, 
70, 119. 
Wyss, Dr. Oscar, 568. 
Wythe, Dr. J. H., 243, 290. 
Young, Dr. H. B., 809, 824, 827, 842. 
Vol .111-56 TRANSACTIONS 
OF THE 
International Medical Congress. 
NINTH SESSION. 
EDITED FOR THE EXECUTIVE COMMITTEE 
BY 
JOHN B. HAMILTON, M. D., 
Secretary-general. 
VOLUME III. 
WASHINGTON, D. G., U. S. A. 
1887.